Maximal androgen blockade

According to the representative data of the Tumor Registry Munich, 38.1% of prostate cancer patients received a primary androgen deprivation, whereas 20.5% had an adjuvant hormonal treatment. Following surgical castration bei ng the most common form of androgen deprivation, 5 alpha-dihydrotestosteron e is still present in prostate cancer tissue. Therefore, a maximal androgen blockade (MAB) consisting of a chemical or surgical castration plus a pure or antigonadotropic antiandrogen, has been proposed. Indeed, MAB lowers th e dihydrotestosterone-androgen-receptor complex and suppresses the growth-f actor dominated signal transduction. This leads to a measurable increase of apoptosis. New is the finding that LHRH as well as LH (for example followi ng surgical castration) are bound by the prostate cancer cell. In 30 phase-III trials, MAB has been tested against monotherapy and a cance r-specific survival advantage of 3 to 6 months and a approximately 6-month delay of progression was demonstrated. The most effective form of MAB is th e combination of a LHRH agonist - in contrast to surgical castration - with a well-tolerated pure antiandrogen. The quality of life during MAB is low, if a pure antiandrogen such as flutamide is used which leads to rather ser ious side-effects. At the present time, special indications for MAB are patients with minimal metastases, bone pain at the time of diagnosis, a neoadjuvant or adjuvant a pplication in combination with a radical prostatectomy or radiotherapy and particularly intermittent androgen deprivation which is tested at the prese nt time in at least 5 international studies. An endocrine withdrawal syndro me is observed in approximately 30 % of patients, if, following a PSA-relap s, the antiandrogen is discontinued. Little notice has been given to the us e of prognosticators for the decision, whether a MAB is useful or not. Pati ents with good prognostic factors as defined by Sylvester have a clear adva ntage, if MAB is compared to monotherapy, whereas patients with a pure prog nosis did not benefit. In addition to these prognostic factors up-front, th e PSA dynamics under an initial MAB may be employed for the decision, if th is form of androgen deprivation is to be continued or not. In essence, in contrast to a general use of MAB a more differential applica tion based on quality-of-life issues and prognosis should be preferred.