Well, yes there is compelling evidence. It just came out this year, so maybe he hasn't yet seen it. It wouldn't hurt to share the journal reference with him and ask for his comments.
www.thelancet.com/journals/lanonc/article/PIIS1470-2045(16)00107-8/fulltextThis was a major randomized clinical trial.
Immediate treatment cut mortality by about half compared to delayed treatment - a stunning finding. It is the only randomized clinical trial on this subject, and it provides the highest level of evidence we now have. This doesn't mean that immediate hormone therapy is for everyone, but it does mean that everyone faced with the decision after curative options have been exhausted should be discussing this study with his oncologist. For some, the side effects or QOL may be overriding factors.
It's also worth reading her comments:
Dr. Duchesne said...
The results delivered by this trial have been both unexpected and thought-provoking. Despite the fact that the trial recruitment was prolonged and fell well short of its target, the results are clinically and statistically in favour of immediate intervention when survival and disease progression end points are considered, with hazard ratios around the 0.5 mark. The key clinical point is that we can now advise men what likely lies ahead of them, who is at greater risk if delaying treatment, and what delays they might achieve if that is their choice.
The results also add further weight to the hypothesis that treating small volume or occult disease is more effective than treating overt disease. This trial was predominantly for patients who had failed curative treatments, but who had only microscopic disease at randomization. This concept obviously underpins the use of adjuvant therapy, but here we are treating only those known to have disease, rather than the whole population most of whom would not benefit from adjuvant therapy. PSA as an early harbinger of relapse is useful indeed.
Where the unexpected results are concerned, we have the following: firstly that the effects on overall survival are not just from a reduction in prostate cancer deaths but also from deaths from other causes. Other trials have also shown this, which suggests a real finding, the causes of which remain unclear. Secondly, the effects on global health-related quality of life, at least over the first two years, showed no major difference between immediate and delayed therapy, meaning that men may choose to start relatively early without major detriment. This may relate to the use of intermittent schedules for two thirds of both arms, which did not appear to have an impact on disease control (data not shown in the publication), despite the lack of firm evidence supporting its use. An exploratory unplanned analysis in fact suggested that the highest survival rate was seen in men treated with immediate intermittent therapy.
One of the most thought-provoking findings was that the development of the castration-resistant phase occurred significantly earlier in the men who started treatment after a delay, a counter-intuitive finding. This may again be linked to treating low volume disease before it grows resistant clones.
We are undertaking two further major analyses, the long-term detailed quality of life, and the combined analysis with the Canadian ELAAT trial, to add further evidence in this arena.
Also, there are a lot of recipes for hormone therapy, GnRH agonist, GnRH antagonist, antiandrogen, estrogen patch, orchiectomy, or any of the new hormonals are all possibilities.