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[Treatment of metastatic prostate cancer: certainty and doubts].

HIGH MORTALITY: Despite progress in early diagnosis, mainly due to prostate specific antigen (PSA) assay, metastasic cancer of the prostate remains an important health problem; more than 40,000 men died from prostate cancer in 1996 in the USA. More than 50 years after the hormone sensitivity of prostate cancer, antiandrogen therapy remains the cornerstone of treatment protocols. Although this is only a palliative therapy, it does delay disease progression for several years before the tumor inevitably escapes from hormone control. STAGE D1 DISEASE: In patients with microscopic nodal metastases (stage D1) it is classical to propose early or delayed hormone therapy which gives a 5-year survival rate in the 77-85% range. Certain teams also associate radical treatment (radical prostatectomy or pelvic prostate radiotherapy) with the hormone therapy, basically with the aim of better local control despite the lack of proven gain in survival rate. STAGE D2 DISEASE: Medical or surgical castration is the gold standard when the disease reaches stage D2. Specific treatments for urinary, neurological or bone complications may also be associated. Median survival is approximately 3 years. ASYMPTOMATIC PATIENTS: There remains a certain controversy about the best time to initiate treatment. Some advocate treatment immediately upon diagnosis while others propose delaying treatment until the onset of symptoms. There is a trend towards early treatment, but the beneficial effect in terms of survival and quality of life has not been proven. STAGE D3 DISEASE: When the tumor escapes hormone control (stage D3) mean survival is less than one year. Castration should be maintained and antiandrogens, which may have been given initially in combination with castration to achieve total androgen blockade, should be withdrawn (antiandrogen withdrawal syndrome) before assessing the need for second intention hormonal or other treatment. Such second intention regimens usually have a temporary and symptomatic effect. Their indication depends on side effects which may have a deleterious effect on quality of life. Symptomatic treatment plays a predominant role at this stage, combining analgesics, external or metabolic radiotherapy for bone pain, transurethral excision and/or urinary tract derivations for neurological or urological complications, and psychological care which requires the combined efforts of the radiotherapist, oncologist, urologist, and general practitioner.