Abstract
Bicalutamide is approved as an adjuvant to primary treatments (radical prostatectomy or radiotherapy) or as monotherapy in men with locally advanced, nonmetastatic prostate cancer (pca). However, this treatment induces gynecomastia in most patients, which often results in treatment discontinuation. Optimal therapy for these breast events is not known so far. We undertook a meta-analysis to assess the efficacy of various treatment options for bicalutamide-induced gynecomastia. The medline, cancerlit, and Cochrane library databases were searched and the Google search engine was used to identify prospective and retrospective controlled studies published in English from January 2000 to December 2010 comparing prophylactic or curative treatment options with a control group (no treatment) for pca patients who developed bicalutamide-induced gynecomastia. Radiotherapy-induced cardiotoxicity was also evaluated. The search identified nine controlled trials with a total patient population of 1573. Pooled results from prophylactic trials showed a significant reduction of gynecomastia in pca patients treated with prophylactic tamoxifen 20 mg daily (odds ratio: 0.06; 95% confidence interval: 0.05 to 0.09; p = 0.09), and pooled results from treatment trials showed a significant response of gynecomastia to definitive radiotherapy (odds ratio: 0.06; 95% confidence interval: 0.01 to 0.24; p < 0.0001). Aromatase inhibitors and weekly tamoxifen were not found to be effective as prophylactic and curative options. For the radiotherapy, skin-to-heart distance was found to be an important risk factor for cardiotoxicity (p = 0.006). A funnel plot of the meta-analysis showed significant heterogeneity (Egger test p < 0.00001) because of low sample size. Our meta-analysis suggests using prophylactic tamoxifen 20 mg daily as the first-line preventive measure and radiotherapy as the first-line treatment option for bicalutamide-induced gynecomastia. Aromatase inhibitors and weekly tamoxifen are not recommended.
Highlights
In patients with locally advanced nonmetastatic prostate cancer, bicalutamide 150 mg (Casodex: AstraZeneca Pharmaceuticals, Wilmington, DE, U.S.A.) is increasingly being used to reduce the risk of disease progression
Pooled results from prophylactic trials showed a significant reduction of gynecomastia in pca patients treated with prophylactic tamoxifen 20 mg daily, and pooled results from treatment trials showed a significant response of gynecomastia to definitive radiotherapy
Our meta-analysis suggests using prophylactic tamoxifen 20 mg daily as the first-line preventive measure and radiotherapy as the first-line treatment option for bicalutamide-induced gynecomastia
Summary
In patients with locally advanced nonmetastatic prostate cancer (pca), bicalutamide 150 mg (Casodex: AstraZeneca Pharmaceuticals, Wilmington, DE, U.S.A.) is increasingly being used to reduce the risk of disease progression. Despite the reduced toxicity profile of bicalutamide, one meta-analysis of 8 trials involving 2717 patients suggested that nonsteroidal antiandrogen is associated with lower overall survival in metastatic pca[4]. In the Early Prostate Cancer program, the incidence of gynecomastia was 68.3%–73.6%, with symptoms developing within the first 6–9 months of bicalutamide use in most cases. Development of this side effect resulted in treatment discontinuation in 16.7% of patients, with the risk of compromising their treatment outcome[5]. Results have been promising[6], but controversy about the optimal therapy for bicalutamide-induced gynecomastia remains[7]
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