Hormonal Therapy for Prostate Cancer

First-Line Hormonal Therapy Options

The European Society for Medical Oncology recommends androgen suppression using bilateral orchiectomy or an LHRH agonist/antagonist alone as the first-line hormonal therapy for metastatic prostate cancer, without routine addition of anti-androgens 1, 2
Bilateral orchiectomy and LHRH agonists are equally effective as initial palliative treatments for metastatic prostate cancer, with equivalent survival rates 3
LHRH agonists, such as goserelin, are equally effective as bilateral orchiectomy, but may cause an initial testosterone surge, which can be prevented with a short-course anti-androgen 3, 1
The American Urological Association suggests that LHRH antagonists offer equivalent testosterone reduction without the initial testosterone surge seen with LHRH agonists, eliminating the need for anti-androgen coverage during initiation 1

The European Association of Urology recommends that when starting LHRH agonists, a short-course anti-androgen should be used to prevent disease flare due to initial testosterone surge 2, 4

The European Society for Medical Oncology does not recommend combined androgen blockade (adding an anti-androgen to surgical or medical castration) for routine first-line treatment, due to minimal survival benefit and increased side effects 1, 5
Meta-analyses show only a minimal survival benefit with CAB, with a 5-year survival of 25.4% with CAB vs. 23.6% for androgen deprivation alone, and a strength of evidence rated as low 1

The American Society of Clinical Oncology states that nonsteroidal anti-androgens, such as flutamide, nilutamide, and bicalutamide, as monotherapy show equivalent survival to castration in some studies, but with different side effect profiles 3, 6
The National Comprehensive Cancer Network recommends that steroidal anti-androgens are not recommended as monotherapy due to inferior outcomes compared to nonsteroidal anti-androgens 3

The American Heart Association recommends that patients should undergo comprehensive cardiovascular risk assessment before starting ADT, especially those over 65 with pre-existing cardiovascular conditions, with a strength of evidence rated as moderate 8

The European Society for Medical Oncology recommends that for castration-resistant prostate cancer, patients should continue androgen suppression and be considered for additional hormonal therapies, such as abiraterone acetate and enzalutamide, with a strength of evidence rated as high 1, 9
Enzalutamide has shown superior progression-free survival compared to bicalutamide in CRPC, with a median progression-free survival of 15.7 vs. 5.8 months, and a strength of evidence rated as high 9, 1

The American Society for Radiation Oncology recommends that for high-risk localized disease, androgen deprivation therapy should be given before, during, and after radiotherapy for a minimum of 6 months, with a strength of evidence rated as moderate 2, 4
The National Comprehensive Cancer Network suggests that for patients at high risk for recurrence, androgen deprivation therapy for at least 2 years with 3D radiation therapy is recommended, with a strength of evidence rated as moderate 7