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).[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. At 10 years, OS was not statistically significantly different; however, disease-specific mortality (23% vs. 36%) and DFS (11% vs. 3%) favored the combined arm.[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 the RTOG-8531 trial with 575 patients with T3, N0, M0 disease concluded that long-term hormones compared with short-term hormones resulted in improved biochemical DFS and cause-specific survival. This finding was confirmed by RTOG-9202, which reported that radiation therapy plus 28 months of androgen deprivation resulted in longer 10-year disease-specific survival (23% vs. 13%; P < .0001) but not OS (53.9% vs. 51.6%; P = 0.36). An unplanned post hoc-subgroup analysis reported increased OS with longer androgen deprivation (28 months vs. 4 months) (45% vs. 32%; P = .0061) in men with high-grade cancers and Gleason scores of 8 through 10.
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).[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+). 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).[Level of evidence: 1iA]