MDT (multi-disciplinary team) guidance for managing prostate cancer

Table 6: Effect of immediate versus deferred hormonal treatment 85
Combined (maximum) androgen blockade
• There is debate over the use of combined androgen blockade (CAB). In 2000, the Prostate Cancer
Trialists’ Collaborative Group published a meta-analysis of the available trials of CAB versus
monotherapy. The analysis included 27 trials, which incorporated 8275 men, representing 98%
111, 112
of men ever randomised in trials of CAB versus monotherapy.
o The 5-year survival for all patients receiving CAB was 25.4%, compared with 23.6% for
patients receiving monotherapy.
o In subgroup analyses, patients treated with CPA seemed to fare slightly worse than those
treated with flutamide or nilutamide, mostly secondary to non-prostate cancer-related
deaths.
• If the CPA studies were excluded, the results were as follows: 111
Immediate Deferred
Distant progression 26% 45%
Mortality due to prostate cancer M0 disease 31.6% 48.8%
M1 disease No significant No significant
difference difference
o CAB with flutamide alone was associated with an 8% reduction in the risk of death (95%CI:
0.86−0.98; p=0.02), which translates to a small but significant improvement in 5-year survival
over castration alone.
o CAB with flutamide plus nilutamide was associated with an 8% reduction in the risk of death
(95%CI: 1.00−1.27; p=0.005), which translates to a small but significant improvement in 5-year
survival of 2.9% over castration alone.
o Conversely, CAB with CPA is associated with an increased risk of death of 13% (95%CI:
1.00−1.27; p=0.04), which translates to a small but significant reduction in 5-year survival
of 2.8% over castration alone.
• It can be concluded that the choice of anti-androgen used for CAB has an impact on outcome, and
that CAB with a non-steroidal anti-androgen may offer a small but significant survival benefit.
45