- Email: [email protected]
Re: Urs E. Studer, Laurence Collette, Peter Whelan, et al. Using PSA to Guide Timing of Androgen Deprivation in Patients with T0–4 N0–2 M0 Prostate Cancer not Suitable for Local Curative Treatment (EORTC 30891). Eur Urol 2008;53:941–9
european urology 55 (2009) e43–e44
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Letter to the Editor Re: Urs E. Studer, Laurence Collette, Peter Whelan, et al. Using PSA to Guide Timing of Androgen Deprivation in Patients with T0–4 N0–2 M0 Prostate Cancer not Suitable for Local Curative Treatment (EORTC 30891). Eur Urol 2008;53:941–9 We read the article by Studer et al [1] with great interest. The timing for androgen deprivation therapy (ADT) in prostate cancer (PCa) is crucial and remains largely unclear. In this study, the authors set out to assess whether serum levels of prostate-specific antigen (PSA) might be used as a guide for when to best initiate ADT. While this question is of significant interest, in light of their findings, we feel that the authors have made certain bold assertions. The statement, ‘‘Our analyses suggest that patients with a baseline PSA >50 ng/ml are likely to die of PCa and therefore are good candidates for immediate ADT,’’ is slightly misleading. Additionally, when assessing the paper and its data, one might come to the following conclusions: Patients with PSA levels <8 ng/ml have a very low risk of dying of PCa within 7 yr of first diagnosis. Patients with PSA levels 8–20 ng/ml might derive some benefit for approximately 4–6 yr with immediate ADT; however, with time, this benefit wears off on longer follow-up. This closely reflects the results of a previous Medical Research Council trial [2]. Patients with baseline PSA levels >50 ng/ml are likely to die of PCa and have poor prognosis (both in immediate and deferred ADT arms). Baseline PSA levels are good guides to tumour behaviour and progression. PSA doubling time (PSA DT) is a useful tool. It is difficult to judge from this paper and from the original EORTC 30891 study [3] whether immediate
ADT confers a survival advantage to patients. It is quite possible that there may be a delay or slowing in symptom progression in the immediate ADT arm; however, such details are absent from the current paper. The current literature does not strongly suggest that immediate ADT would confer a survival advantage in locally advanced PCa patients; thus, it remains difficult to determine the best timing for initiating ADT. Perhaps this is a consequence of the fact that androgens predominantly play a role in PCa progression, while oestrogens might be the initiating agents [4]. Therefore, novel targeting strategies may have to evolve in the chemoprevention and treatment of PCa. Conflicts of interest: The authors have nothing to disclose.
References [1] Studer UE, Collette L, Whelan P, et al. Using PSA to guide timing of androgen deprivation in patients with T0–4 N0–2 M0 prostate cancer not suitable for local curative treatment (EORTC 30891). Eur Urol 2008;53: 941–9. [2] The Medical Research Council Prostate Cancer Working Party Investigators Group. Immediate versus deferred treatment for advanced prostatic cancer: initial results of the Medical Research Council trial. Br J Urol 1997;79: 235–46. [3] Studer UE, Whelan P, Albrecht W, et al. Immediate or deferred androgen deprivation for patients with prostate cancer not suitable for local treatment with curative intent: European Organisation for Research and Treatment of Cancer (EORTC) trial 30891. J Clin Oncol 2006; 24:1868–76. [4] Singh PB, Matanhelia SS, Martin FL. A potential paradox in prostate adenocarcinoma progression: oestrogen as the initiating driver. Eur J Cancer 2008;44:928–36.
DOI of original article: 10.1016/j.eururo.2007.12.032 0302-2838/$ – see back matter # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2008.08.061
e44
european urology 55 (2009) e43–e44
Narasimhan Ragavana,b,* University Hospital Aintree, Liverpool, UK b Lancaster University, Lancaster, UK
a
Paras B. Singh Francis L. Martin Lancaster University, Lancaster, UK Andrew D. Baird University Hospital Aintree, Liverpool, UK
*Corresponding author. SpR Urology, Mersey Deanery, Liverpool, United Kingdom. Tel. +44 1617074681 E-mail address: [email protected] (N. Ragavan) August 22, 2008 Published online on September 1, 2008
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Letter to the Editor Re: Urs E. Studer, Laurence Collette, Peter Whelan, et al. Using PSA to Guide Timing of Androgen Deprivation in Patients with T0–4 N0–2 M0 Prostate Cancer not Suitable for Local Curative Treatment (EORTC 30891). Eur Urol 2008;53:941–9 We read the article by Studer et al [1] with great interest. The timing for androgen deprivation therapy (ADT) in prostate cancer (PCa) is crucial and remains largely unclear. In this study, the authors set out to assess whether serum levels of prostate-specific antigen (PSA) might be used as a guide for when to best initiate ADT. While this question is of significant interest, in light of their findings, we feel that the authors have made certain bold assertions. The statement, ‘‘Our analyses suggest that patients with a baseline PSA >50 ng/ml are likely to die of PCa and therefore are good candidates for immediate ADT,’’ is slightly misleading. Additionally, when assessing the paper and its data, one might come to the following conclusions: Patients with PSA levels <8 ng/ml have a very low risk of dying of PCa within 7 yr of first diagnosis. Patients with PSA levels 8–20 ng/ml might derive some benefit for approximately 4–6 yr with immediate ADT; however, with time, this benefit wears off on longer follow-up. This closely reflects the results of a previous Medical Research Council trial [2]. Patients with baseline PSA levels >50 ng/ml are likely to die of PCa and have poor prognosis (both in immediate and deferred ADT arms). Baseline PSA levels are good guides to tumour behaviour and progression. PSA doubling time (PSA DT) is a useful tool. It is difficult to judge from this paper and from the original EORTC 30891 study [3] whether immediate
ADT confers a survival advantage to patients. It is quite possible that there may be a delay or slowing in symptom progression in the immediate ADT arm; however, such details are absent from the current paper. The current literature does not strongly suggest that immediate ADT would confer a survival advantage in locally advanced PCa patients; thus, it remains difficult to determine the best timing for initiating ADT. Perhaps this is a consequence of the fact that androgens predominantly play a role in PCa progression, while oestrogens might be the initiating agents [4]. Therefore, novel targeting strategies may have to evolve in the chemoprevention and treatment of PCa. Conflicts of interest: The authors have nothing to disclose.
References [1] Studer UE, Collette L, Whelan P, et al. Using PSA to guide timing of androgen deprivation in patients with T0–4 N0–2 M0 prostate cancer not suitable for local curative treatment (EORTC 30891). Eur Urol 2008;53: 941–9. [2] The Medical Research Council Prostate Cancer Working Party Investigators Group. Immediate versus deferred treatment for advanced prostatic cancer: initial results of the Medical Research Council trial. Br J Urol 1997;79: 235–46. [3] Studer UE, Whelan P, Albrecht W, et al. Immediate or deferred androgen deprivation for patients with prostate cancer not suitable for local treatment with curative intent: European Organisation for Research and Treatment of Cancer (EORTC) trial 30891. J Clin Oncol 2006; 24:1868–76. [4] Singh PB, Matanhelia SS, Martin FL. A potential paradox in prostate adenocarcinoma progression: oestrogen as the initiating driver. Eur J Cancer 2008;44:928–36.
DOI of original article: 10.1016/j.eururo.2007.12.032 0302-2838/$ – see back matter # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2008.08.061
e44
european urology 55 (2009) e43–e44
Narasimhan Ragavana,b,* University Hospital Aintree, Liverpool, UK b Lancaster University, Lancaster, UK
a
Paras B. Singh Francis L. Martin Lancaster University, Lancaster, UK Andrew D. Baird University Hospital Aintree, Liverpool, UK
*Corresponding author. SpR Urology, Mersey Deanery, Liverpool, United Kingdom. Tel. +44 1617074681 E-mail address: [email protected] (N. Ragavan) August 22, 2008 Published online on September 1, 2008