Go Early or Delay?

Life – Terror. Ecstasy. Fight. Denial. Flight. Failure. PAIN. Forgiveness. Reconciliation. Hope. Love. Peace – Death.

Prostate cancer is a leading cause of cancer death in men. Best case for men with advanced (metastatic) prostate cancer is ten years tops. Treatment goals for men with advanced prostate cancer include prolonging survival, preventing or delaying symptoms due to disease progression, improving and maintaining quality of life, reducing treatment related morbidity.

Androgen suppression therapy is considered a mainstay of treatment for men with advanced prostate cancer. However it is not clear whether early androgen suppression for men with locally advanced disease or asymptomatic metastases improves length and quality of life compared to androgen suppression deferred until signs and symptoms of clinical progression.

I am on that cusp; I have to make that choice. To go early or delay?

Make no mistake, it is ‘your’ choice. No doctor will make this choice for you. They might advise you, one way or the other, but it is completely up to you (the patient) must decide?

Maybe it’s a no brainer for most? Go early, live longer? Even if it is just a few months?

However, an early choice brings with it side effects, potentially huge quality of life decisions? Who wants to live longer if life is shit, pain, substantial (perpetual) discomfort, a life not worth living’?

A prostate cancer friend of a friend recently ceased all treatment. He had reached the difficult decision that he preferred a (final) period of side effects free life, a period of no-treatment for the final months of his life.

A recent systematic review assessed the efficacy and adverse effects of primary therapy with early versus deferred androgen suppression therapy in men with advanced prostate cancer (me).

Randomized controlled trials were searched in general and specialized databases (MEDLINE, EMBASE, CancerLIT, Cochrane Library, VA Cochrane Prostate Disease register) and by reviewing bibliographies including those of the Blue Cross and Blue Shield Association Technology Evaluation Centre/Evidence-based Practice Centre of the Agency for Healthcare Research and Quality (BCBS/TEC-AHRQ) report No.4.

All published randomised trials were eligible for inclusion provided they: randomised men with advanced prostate cancer to early versus deferred androgen suppression; reported overall, progression-free, and cancer-specific survival, and/or adverse events; did not utilise androgen suppression as adjuvant therapy to radiation treatment.

An independent reviewer using a standardised form extracted information on trial characteristics, interventions, and outcomes. Results were reviewed for accuracy and discrepancies resolved by discussion. The main outcome measure for comparing effectiveness was the overall survival at 1, 2, 5 and 10 years. 

Four trials involving 2,167 patients were included in this review. All of the trials were conducted prior to use of prostate specific antigen (PSA) testing.

There was variability between studies regarding the treatments used and the requirements for initiation of treatments. However, the percent overall survival at 1, 2, 5, and 10 years for the early treatment group was 88%, 73%, 44%, and 18%.

For the deferred therapy group the percent overall survival was 86%, 71%, 37%, and 12%. Significantly less across the board?

The pooled estimate for the difference in overall survival favoured early therapy but was significant only at 10 years when few patients had survived. The pooled estimate of prostate cancer specific survival at 2, 5, and 10 years favoured early therapy though the confidence intervals were wide and the results not statistically different. The risk differences at 2, 5, and 10 years were 2.7%, 5.8%, and 4.6%.

All studies found progression free survival was consistently better in the early intervention group at all time points. 

Conclusions

Available information suggests that early androgen suppression for treatment of advanced prostate cancer reduces disease progression and complications due to progression.

Early androgen suppression may provide a small but statistically significant improvement in overall survival at 10 years. There was no statistically significant difference in prostate cancer specific survival but a clinically important difference could not be excluded.

These outcomes need to be evaluated with the evidence suggesting higher costs and more frequent treatment related adverse effects with early therapy.

Additional studies are required to evaluate more definitively the efficacy and adverse effects of early versus delayed androgen suppression in men with prostate cancer.

In particular trials should evaluate patients with advanced prostate cancer diagnosed by PSA testing and men with persistent or rising PSA levels following treatment options (e.g. radical prostatectomy, radiation therapy or observation) for clinically localised disease.

Early or later?

The idea of additional symptoms/side effects from Hormone and or Chemotherapy on top of symptoms – side effects due to underlying medical conditions (chronic psoriasis, diabetes, peripheral neuropathy, metabolic syndrome, arthritis, damaged rotator cuffs, worn discs, sciatica), does not appeal.

Thanks for Reading

Peace

https://pubmed.ncbi.nlm.nih.gov/12787718/

https://pubmed.ncbi.nlm.nih.gov/11098244/

https://pubmed.ncbi.nlm.nih.gov/15046683/

Published by Riff

Husband to my inspirational, (long suffering) wife, father of two amazing (adult) children, teacher, former guitarist (now guitar owner), recent 'granda(r) to my beautiful grandson who I am yet to meet. I Love people. I love my family, my friends, I love(d) what I do (my Job), I love Music, Cars, Everton .... I love many things, most of all I fucking love 'life'.

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