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DR ROACH: I recently treated a gentleman who underwent a radical prostatectomy and had positive nodes on imaging. The question is what further treatment he needs, and I suspect most urologists would administer hormone therapy. A retrospective study from Spain compared postprostatectomy patients who received hormone therapy and radiation therapy to those who received only hormones. The abstract was presented at the AUA meeting, and the patients who received both therapies fared better.

Also, MD Anderson published a paper a number of years ago on a nonrandomized trial examining patients found to have positive nodes on radical prostatectomy, which also reported that patients who received hormones and radiation therapy fared better than patients who received hormones alone (Sands 1995).

Extrapolating from the definitive treatment studies with hormones and radiation therapy and from the adjuvant trials, such as SWOG and EORTC, I favor the more aggressive approach of using hormones and external beam radiation therapy for patients with node-positive disease.

DR LOVE: How long should patients with node-positive disease receive hormones?

DR FREEDLAND: I believe the urologist’s usual mantra for node-positive disease is lifelong hormonal therapy. However, for me, node-positive prostate cancer doesn’t necessarily mean lifelong hormones.

I worked with Yu-Ning Wong and Katrina Armstrong on a retrospective, observational study examining the SEER-Medicare database for men who had node-positive disease after radical prostatectomy (Wong 2007). The primary analysis compared men who received hormones within four months of surgery to those who did not. In our analysis, we observed no benefit to immediate hormone therapy.

In data from the Messing study and from Hopkins with patients who received no hormone therapy, 15 percent were cured by radical prostatectomy alone (Messing 2006). Therefore, it may be reasonable to add radiation therapy and a short course of hormones but not necessarily commit the patient to lifelong therapy until we detect the PSA rising and know the doubling time.

DR ROACH: I believe patients with positive nodes should receive hormone therapy early. If I have a patient with positive nodes postprostatectomy — even if the PSA is undetectable or very low — I generally use hormone therapy for two or three years. There seems to be something different about the biology of prostate cancer if you wait too long to initiate hormone therapy.

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