What is the background of the difficulties between urologists and medical oncologists in the treatment of prostate cancer and how can we root out prejudice? Until some years ago, at least in Italy, few medical oncologists were interested in patients with prostate cancer because their role was considered negligible both by the urologists and the patients. This is true because their advice was often sought at the end of the patient history and the possible usefulness of chemotherapy to increase, at least in hormone-refractory patients, their quality of life or survival was based, until ASCO 2004, on very few well-conducted, randomised, prospective studies, in terms of statistically significant numbers of accrued patients and clear definitions of the primary and secondary aims.

This reality has been always astonishing for the oncologists accustomed to the enormous number of well-done trials in other types of frequently occurring cancers, such as breast or colon cancer. This opinion has been strengthened by a very recent clinical study reported by Collins and coworkers [2]. At the Centre for Reviews and Dissemination of the University of York, United Kingdom, they performed a systematic review to evaluate the clinical and cost effectiveness of docetaxel and prednisone versus other chemotherapy regimens or versus active supportive care or placebo for the treatment of metastatic hormone-refractory prostate cancer, on behalf of the National Institute for Clinical Excellence in the United Kingdom. From inception to April 2005, 1065 titles and abstracts were screened through 21 electronic resources: 267 records were full papers. Among these, only seven reported the results of randomised, controlled trials that met their inclusion criteria, but only one, the TAX 327 trial, docetaxel plus prednisone versus mitoxantrone plus prednisone [3], was identified as the unique large, well-conducted, randomised, controlled trial that assessed the clinical effectiveness of docetaxel plus prednisone.

On these grounds, it is easy to understand the strong impression that arose from the presentation of the final data of TAX 327 and SWOG 9916 to the thousands of oncologists attending the 2004 ASCO meeting in New Orleans. Even more impressive was the moment when the chairman of the session, Bruce J. Roth of the Vanderbilt-Ingram Cancer Center, discussing the data under the title “Survival benefit of chemotherapy in advanced prostate cancer” showed what were the predictions, in the early 2000s, of the results of the two trials:

It is unbelievable, but all these expectations were wrong! In particular, the modest but statistically significant survival advantage with docetaxel versus mitoxantrone linked with a significant improvement in the quality of life was really a new event for men with hormone-refractory prostate cancer. The rapid approval by the Food and Drug Administration in the United States and EMEA in Europe made docetaxel every 3 weeks plus prednisone the standard tolerable treatment in these patients. The “standard” treatment does not mean the “gold standard” treatment! We are far from the gold mine, but the number of ongoing or designed studies, with the cooperation of urologists and medical oncologists, through the creation of “prostate cancer units,” bodes well for a rapid increase in positive results in every step of the natural history of prostate cancer.

The present paper on the current indications for chemotherapy in prostate cancer patients by Calabrò and Sternberg is an excellent review on the up-to-date state of the art of this important topic [4]. Presentation and discussion of ongoing studies in the early stages of high-risk prostate cancer patients, which could clarify new problems concerning the optimal timing to introduce active chemotherapy drugs and possible active target therapies, is noteworthy. Moreover, as a medical oncologist who follows patients with hormone-refractory prostate cancer, I wish to stress the forthcoming data on second-line chemotherapy regimens, particularly those that will emerge from the SPARC trial. Now patients who obtained clinical benefit from the well-tolerated docetaxel treatment and who usually after 6 months relapsed, ask insistently to have an available second-line treatment.

In the future, it will be important to consider the possible usefulness of combining hormone therapy with the continuous administration of very low doses of chemotherapy (the so-called metronomic therapy), in the light of the recent interesting results obtained in patients with breast cancer [5].

The last 2 yr have changed part of the natural history of advanced prostate cancer and introduced a new era. My statement is easy to understand when you consider what Cora Sternberg wrote today and what she wrote in a review on what is new in the treatment of advanced prostate cancer, published exactly 3 yr ago [6]:

References

Please log-in or register in order to submit comments.

Powered by AkoComment!