Radiotherapy in the conservative treatment of operable and locally inoperable carcinoma of the prostate.

Abstract

For a considerably long time, most cases of prostatic cancer have been considered as invariably hopeless, and only palliative measures have been instituted in an attempt to help the patient. In 1962, we stated that there was evidence, not then sufficiently sanctioned by time, that cobalt 60 and supervoltage radiotherapy could achieve control of moderately advanced, inoperable carcinomas of the prostate (1). Today, we have convinced ourselves of the veracity of this assertion, and, moreover, we feel certain that radiotherapy will rapidly become the treatment of choice of all carcinomas of the prostate, operable or inoperable, which remain confined to the pelvis. Because cancer of the prostate usually attacks the elderly, its relatively high incidence is not often dramatized: 120 cases per 100,000 males over thirty-five years of age. In the early part of the century, Young demonstrated that the radical perineal prostatectomy afforded a possibility of surgical control when the carcinoma is confined within the prostatic capsule (22). Yet, because of the unavailability of surgical skills, or enthusiasm, very few patients (less than 5 per cent) have been offered the operation (12). In recent years, earlier diagnosis of cancer of the prostate has not brought about a greater utilization of the radical surgical procedure (20). The work of Huggins (11) brought us the orchiectomy and hormone therapy as means of palliation of advanced cases of cancer of the prostate. An apparently logical extension of this palliative approach has been advocated and found general acceptance: the systematic orchiectomy and/or hormone therapy in cases not eligible for prostatectomy; these procedures are carried out almost routinely in the belief that the patient's life expectancy is elongated and his eventual discomfort diminished. The Veterans Administration Co-operative Urological Research Group has recently reported the results of a most interesting study (19); a total of 1,764 cases of inoperable carcinoma of the prostate were judiciously randomized into 4 categories of treatment: orchiectomy plus estrogens, orchiectomy plus placebo, estrogens alone, and supportive measures only. The four groups were compared for enlargement of tumor, elevation of acid phosphatase, pain, appearance of osseous metastases, and survival rates. The only statistically significant difference observed among the groups was the greater mortality from intercurrent cardiovascular disease in the patients receiving estrogens (5 mg of Stilbestrol daily). The results for 992 patients with Stage III carcinoma of the prostate are illustrated in Figure 1; in all the carcinoma was no longer confined within the prostatic capsule, but there was no elevation of acid phosphatase or evidence of distant metastases. The conclusions of this study emphasize the advantage to the patient when orchiectomy is kept in reserve for the time when symptoms appear and definite, though temporary, palliation is afforded.