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Controversies in Internal Medicine
March 24, 2003

Rebuttal by Drs Oottamasathien and Crawford

Author Affiliations
 

FARRELL J.LLOYDMD,MPH

Arch Intern Med. 2003;163(6):665-666. doi:10.1001/archinte.163.6.665

THERE IS certainly a heated controversy surrounding prostate cancer screening with PSA and DRE. Dr Hoffman makes a fair argument against screening, but the key issue is that we as physicians need to routinely discuss and educate our patients to the risks and benefits of screening. Once again, knowledge is power.

Dr Hoffman is correct that there is no good method to prevent prostate cancer, but it is not entirely true that men with advanced cancers can be treated only from a palliative standpoint. Traditionally, hormone therapy has been used in prostate cancer with locally advanced disease and/or metastatic disease. Currently, several trials indicate a survival advantage with the use of early hormonal intervention for prostate cancer. For example, the Medical Research Council study1 randomized patients with nonmetastatic locally advanced disease (stage T3) to 1 of 2 study arms: #11) early, lifelong hormonal therapy in conjunction with either orchiectomy or therapy with a luteinizing hormone–releasing hormone agonist, or #12) delayed therapy begun at the appearance of symptoms. Early hormonal intervention was associated with a decreased incidence of comorbid events and a significant survival advantage. In another study, conducted by the Eastern Cooperative Oncology Group (ECOG),2 patients who had undergone radical prostatectomy and pelvic lymphadenectomy and who were found to have nodal metastases (D1) were randomly assigned to either immediate treatment with antiandrogen therapy or to observation until disease progression was noted. The median duration of follow-up was 7.1 years (range, 3-10 years). Patients receiving immediate antiandrogen therapy demonstrated improved survival, reduced risk of recurrence, and decreased morbidity compared with the patients who were merely observed.2 These studies illustrate that men with advanced cancers can be treated in a palliative fashion and have a significant survival advantage.

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