Stage III Prostate Cancer
Current Clinical Trials
Note: Some citations in the text of this section are followed by a level of
evidence. The PDQ editorial boards use a formal ranking system to help the
reader judge the strength of evidence linked to the reported results of a
therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more
information.)
Stage III prostate cancer is defined by the following staging systems:
- American Joint Committee on Cancer's TNM classification system: T3, N0, M0, any G.
- Jewett staging system: stage C.
External-beam radiation therapy (EBRT), interstitial implantation of radioisotopes, and
radical prostatectomy are used.[1] The results of radical prostatectomy in
stage III patients are greatly inferior compared with results in patients with stage II
cancer. Interstitial implantation of radioisotopes is technically difficult in
large tumors. EBRT using a linear accelerator is the most
appropriate treatment for most patients with stage III prostate cancer, and large series support its success in achieving local disease control
and disease-free survival.[2,3] Prognosis is greatly affected by whether
regional lymph nodes are evaluated and proven not to be involved. The
patient’s symptoms related to cancer, age, and coexisting medical illnesses
should be taken into account before deciding on a therapeutic plan. In a
series of 372 patients treated with radiation therapy and followed for 20
years, 47% eventually died of prostate cancer, but 44% died of intercurrent
illnesses without evidence of prostate cancer.[3]
Hormonal therapy should be considered in conjunction with radiation therapy, especially in men who do not have underlying moderate or severe comorbidities.[4,5] Several
studies have investigated its utility in patients with locally advanced
disease. The Radiation
Therapy Oncology Group (RTOG) performed a prospective, randomized trial (RTOG-8531) in patients with T3, N0, or any T,
N1, M0 disease who received prostatic and pelvic radiation therapy and then
were randomly assigned to receive immediate adjuvant goserelin or observation with
administration of goserelin at time of relapse. In patients assigned to
receive adjuvant goserelin, the drug was started during the last week of the
radiation therapy course and was continued indefinitely or until signs of
progression. The actuarial overall 10-year survival rate for the entire
population of 945 analyzable patients was 49% on the adjuvant arm versus 39% on the observation arm P = .002.
There was also an improved actuarial 10-year local failure rate (23% vs.
38%, P < .001).[6][Level of evidence: 1iiA]
A similar trial was performed by the European Organization for Research and
Treatment of Cancer (EORTC). Patients with T1, T2 (World Health Organization grade 3), N0–NX or T3,
T4, N0 disease were randomly assigned to receive either pelvic/prostate radiation therapy, or
identical radiation therapy and adjuvant goserelin (with cyproterone acetate for 1
month) starting with radiation therapy and continuing for 3 years. The 401 patients
available for analysis were followed for a median of 66 months. The Kaplan-Meier estimates of overall survival (OS) at 5 years were 78% on the adjuvant arm and 62% on the radiation alone arm (P <.002). Similarly, 5-year disease-free
survival (74% vs. 40%, P <.001) and local control (98% vs. 84%, P <.001)
favored the adjuvant arm.[7][Levels of evidence: 1iiA,1iiDii] Two smaller
studies, with 78 and 91 patients each, have also shown similar results.[8,9]
The role of adjuvant hormonal therapy in patients with locally advanced disease
has been analyzed by the Agency for Health Care Policy and Research (AHCPR) (now the Agency for Healthcare Research and Quality). Most patients had more advanced disease, but patients with bulky T2b
tumors were included in the study. Randomized
clinical trial evidence comparing radiation therapy to radiation therapy with prolonged
androgen suppression (with a luteinizing hormone-releasing hormone [LHRH] agonist or orchiectomy) was evaluated. The meta-analysis found a difference
in 5-year OS in favor of radiation therapy plus continued
androgen suppression compared with radiation therapy alone (hazard ratio [HR] = 0.631;
95% confidence interval [CI], 0.479–0.831).[10][Level of evidence: 1iiA]
Additionally, the RTOG did a study (RTOG-8610) in patients with bulky local disease (T2b,
T2c, T3, or T4), with or without nodal involvement below the common iliac
chain: 456 men were evaluable and were randomly assigned to receive either radiation
therapy alone or radiation therapy with androgen ablation started 8 weeks before radiation therapy
and continued for 16 weeks.[11] At 10 years, OS was not statistically
significantly different; however, disease-specific mortality (23% vs. 36%) and disease-free survival (11% vs. 3%) favored the combined arm.[12][Level of evidence: 1iiA] This trial assessed only short-term hormonal therapy, not long-term
therapy, as the studies analyzed by the AHCPR did.
A subset analysis of this trial and RTOG 85-31 with 575 patients with T3, N0, M0 disease concluded that long-term hormones compared with short-term hormones resulted in improved biochemical disease-free survival and cause-specific survival.[13]
Likewise, a meta-analysis of seven randomized controlled trials comparing early (adjuvant or neoadjuvant) to deferred hormonal treatment (LHRH agonists and/or antiandrogens) in patients with locally advanced prostate cancer, whether treated by prostatectomy, radiation therapy, or watchful waiting, showed improved overall mortality (RR=0.86; 95% CI, 0.82–0.91).[14][Level of evidence: 1iiA]
Bicalutamide has not been shown to improve OS in patients with localized or locally advanced prostate cancer. The Early Prostate Cancer (EPC) program is a large, randomized, placebo-controlled, international trial that compared bicalutamide (150 mg orally per day) plus standard care (radical prostatectomy, radiation therapy, or watchful waiting, depending on local custom) with standard care alone for men with nonmetastatic localized or locally advanced prostate cancer (T1–2, N0, NX; T3–4, any N; or any T, N+).[15] Less than 2% of the 8,113 men had known node disease. At a median follow-up of 7.4 years, there was no difference in OS between the bicalutamide and placebo groups (about 76% in both arms (HR = 0.99; 95% CI, 0.91–1.09; P = .89).[15][Level of evidence: 1iA]
In patients who are not candidates for or who are unwilling to undergo radical prostatectomy or radiation therapy, immediate hormonal therapy has been compared with deferred treatment (i.e., watchful waiting with hormonal therapy at progression). Initial results from a randomized study of immediate hormonal treatment
(orchiectomy or LHRH analog) versus
deferred treatment in
men with locally advanced or asymptomatic metastatic prostate cancer showed
better OS and prostate cancer-specific survival with the
immediate treatment. This subsequently lost statistical significance as was recorded in abstract form.[16] The incidence of pathologic fractures, spinal cord
compression, and ureteric obstruction were also lower in the immediate
treatment arm.[17][Level of evidence: 1iiA]
In another trial, 197 men with stage III or stage IV prostate cancer were randomly assigned to receive bilateral orchiectomy at diagnosis or at the time of symptomatic progression (or at the time of new metastases that were deemed likely to cause symptoms). No statistically significant difference in OS was seen over a 12-year period of follow-up.[18][Level of evidence: 1iiA]
In the EORTC-30891 trial, 985 patients newly diagnosed with prostate cancer, stage T0–4, N0–2 M0, and a median age of 73 years were randomly assigned to receive androgen deprivation, either immediately or on symptomatic disease progression.[19] The study was designed to demonstrate the noninferiority of deferred treatment compared with immediate treatment in relation to OS. At a median follow-up of 7.8 years, approximately 50% of the patients in the deferred treatment group had been started on androgen deprivation. The median OS in the immediate treatment group was 7.4 years and in the deferred treatment group was 6.5 years, corresponding to a mortality HR of 1.25 (95% CI, 1.05–1.48), which failed to meet the criteria for noninferiority.[19][Level of evidence: 1iiA]
Antiandrogen monotherapy has also been evaluated in men with locally advanced prostate cancer as an alternative to castration. In a randomized equivalence study involving 480 men with locally advanced (T3 and T4) disease, those who were treated with castration had a median OS of 70 months, while those treated with bicalutamide (150 mg/day) had a median OS of 63.5 months (HR = 1.05; 95% CI, 0.81–1.36); these results failed to meet the prespecified criteria for equivalence.[20][Level of evidence: 1iiA]
Patients with locally advanced nonmetastatic disease (T2–T4, N0–N1, M0) are at risk for developing bone metastases, and bisphosphonates are being studied as a strategy to decrease this risk. However, a placebo-controlled randomized trial (MRC-PRO4) of a 5-year regimen of the first generation bisphosphonate clodronate in high oral doses (2,080 mg per day) had no favorable impact on either time to symptomatic bone metastasis or survival.[21][Level of evidence: 1iA]
Standard treatment options:
- EBRT.[2,3,22-24] Hormonal therapy (LHRH agonist or orchiectomy) should be considered
in addition to EBRT.[4,5,10,12,25,26] Although the RTOG 9413 trial showed an increased progression-free survival at 4 years for patients with a 15% estimated risk of lymph node involvement receiving whole-pelvic radiation therapy as compared with prostate-only radiation therapy, OS, and prostate-specific antigen (PSA) failure rates were not significantly different.[27,28][Level of evidence: 1iiDiii] Definitive radiation therapy
should be delayed until 4 to 6 weeks after transurethral resection to reduce
incidence of stricture.[29] Radiation therapy designed to decrease exposure of
normal tissues using methods such as computed tomography (CT)-based 3-D conformal
treatment planning is under clinical evaluation.[30]
- Hormonal manipulations (orchiectomy or LHRH agonist).[17][Level of evidence: 1iiA]
- Radical prostatectomy, usually with pelvic lymphadenectomy (in highly selected
patients).[31] Since about 40% to 50% of men with clinically organ-confined disease are found to have pathologic extension beyond the prostate capsule or surgical margins (i.e., pathologic stage III disease), the role of postprostatectomy adjuvant radiation therapy has been studied. In a randomized trial of 425 men with pathologic T3, N0, M0 disease, postsurgical EBRT (60 Gy–64 Gy to the pelvic fossa over 30–32 fractions) was compared to observation.[32] The primary endpoint was metastasis-free survival, an endpoint that could be affected by serial PSA monitoring and resulting metastatic work-up for PSA increase. This could have biased the primary endpoint in favor of radiation therapy, which was associated with a lower rate of PSA rise. Nevertheless, metastasis-free survival was not statistically different between the two study arms (P = .06). After a median follow-up of 10.6 years, the median survival was 14.7 years in the radiation therapy group versus 13.8 years in the observation group (P = .16).[32][Level of evidence: 1iiA] Although the survival rates were not statistically different, complication rates were substantially higher in the radiation therapy group: overall complications were 23.8% versus 11.9%, rectal complications were 3.3% versus 0%, and urethral stricture was 17.8% versus 9.5%, respectively. The role of
preoperative (neoadjuvant) hormonal therapy is not established.[33,34] Also, the morphologic changes induced by neoadjuvant androgen
ablation may even complicate assessment of surgical margins and capsular
involvement.[35]
- Careful observation without further immediate treatment.[36]
Symptomatic treatment:
Since many stage III patients have urinary symptoms, control of symptoms is an
important consideration in treatment. This may often be accomplished by
radiation therapy, radical surgery, transurethral resection of the prostate, or
hormonal manipulation.
- Radiation therapy.[2,3,22,23] EBRT designed to
decrease exposure of normal tissues using methods such as CT-based 3-D conformal treatment planning is under clinical evaluation.
- Hormonal manipulations effectively used as initial therapy for prostate
cancer:
- Orchiectomy.
- Leuprolide or other LHRH agonists (goserelin) in daily or depot
preparations. (These agents may be associated with tumor flare.)
- Estrogen (diethylstilbestrol [DES] is no longer available in the
United States).
- Nonsteroidal antiandrogen (e.g., flutamide, nilutamide,
and bicalutamide) or steroidal antiandrogen (cyproterone acetate).
A meta-analysis of randomized trials comparing various hormonal monotherapies
in men with stage III or stage IV prostate cancer (predominantly stage IV) came to
the following conclusions:[37][Level of evidence: 1iiA]
- OS at 2 years using any of the LHRH agonists is
similar to treatment with orchiectomy or 3 mg per day of DES (HR = 1.26; 95% CI, 0.92–1.39).
-
Survival rates at 2 years are similar or worse with nonsteroidal
antiandrogens compared to orchiectomy (HR = 1.22; 95%
CI, 0.99–1.50).
- Treatment withdrawals, used as a surrogate for adverse effects,
occurred less with LHRH agonists (0%–4%) than with nonsteroidal
antiandrogens (4%–10%).
When used as the primary therapy for patients with stage III or stage IV prostate cancer, androgen suppression with hormonal therapy is usually given continuously until there is disease progression. However, some investigators have proposed intermittent androgen suppression as a strategy to attain maximal tumor cytoreduction followed by a period without therapy to allow tumor repopulation by hormone-sensitive cells. Theoretically, the strategy might provide tumor hormone responsiveness for a longer period of time. However, a systematic review of all five randomized trials addressing this issue found no reliable data on the relative effectiveness of intermittent versus continuous androgen suppression for OS, prostate cancer specific survival, disease progression, or quality of life.[38][Level of evidence: 1iiA] All five trials were small and had short follow-up. Intermittent therapy therefore remains under evaluation, pending further analysis of results from clinical trials, including the CAN NCIC PR7 trial and the SWOG 9346 trial.
- Palliative surgery (transurethral resection).
- Interstitial implantation combined with EBRT is
being used in selected T3 patients, but little information is available.[39]
- Clinical trials employing alternative forms of radiation therapy. A
randomized trial from the RTOG reported improved local control and survival
with mixed-beam (neutron/photon) radiation therapy compared with standard photon
radiation therapy.[40] A subsequent randomized study from the same group
compared fast-neutron radiation therapy with standard photon radiation therapy.
Local-regional control was improved with neutron treatment, but no difference in
OS was seen, though follow-up was shorter in this trial.
Fewer complications were seen with the use of a multileaf collimator.[41]
Proton-beam radiation therapy is also under investigation.[42]
- Other clinical trials such as the SWOG-8794 trial, for example.
- Ultrasound-guided percutaneous cryosurgery is under clinical evaluation. Cryosurgery is a surgical technique under development that involves destruction of prostate
cancer cells by intermittent freezing of the prostate tissue with cryoprobes,
followed by thawing.[43][Level of evidence: 3iiiC];[44,45][Level of evidence: 3iiiDiv] Cryosurgery is less well
established than standard prostatectomy, and long-term outcomes are not as well established as with prostatectomy or radiation therapy.
Serious toxic effects include bladder outlet injury, urinary incontinence,
sexual impotence, and rectal injury. The technique of cryosurgery is under
development. Impotence is common. The frequency of other side effects and the probability of cancer control at 5 years' follow-up have varied among reporting centers, and series are small compared with surgery and radiation therapy.[44,45]
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage III prostate cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
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