I prefer antagonist in patients with bone metastases and PSA more tan 100. The antagonist blokcs testosterone since the first aplication.

The antagonist takes more time to block testosterone production (30 days or more).

I think that the only difference is at the beginning of the treatment.

...Thereby avoiding testosterone flare-ups if the antagonist is used. OK, so you are making a decision based on the PK-Profile of testosterone suppression. Thank you very much.

With best regards from Germany,

Niels

Dear Niels, first of all a general remark: The decision regarding the timing and indication of hormonal treatment in prostate cancer patients should be based on guidelines (eg. S3 Leitlinie of the German Urological Association or the European Association www.uroweb.org/guidelines, also commenting on your question). Short and long term side effects should be considered in comparison to the impact on survival and QoL and should be discussed with the patient.

Based on available data LHRH antagonists are preferable in symtomatic metastatic patients when a rapid testosterone decline will result in pain relief. This is the only patient group with a strong indication for antagonists. Progression free survival may be better compared to Leuprorelin. Data on overall survival are not available. At present only a 1 month injection is available.

Much more data on LHRH agonists with depots up to 1 year are available, but testosterone decline will need up to 2 weeks, testosterone and symtoms flair must be avoided by a concomitant 2 weeks administration of an androgen receptor blocker. Especially in advanced but asymptomatic cases some patients will nevertheless suffer from flare symptoms. In all other patients LHRH agonists are still preferable because of more solid data and practcability in dayly life.

Best regards

Walter

Diego you are totally right with your comment given you mean the agonists taking a longer time to lower testosterone levels. Also for me the target patient is a symptomatic metastatic patient who formerly got bilateral orchidectomy. The main reason antagonists are not generally used is the lack of long acting depot injections.

you could start win LHRH blockers and afret 3 or 4 months you could change for an antagonist without flare.

at the begining of the treatment I prefer to see the patient monthly and watch the PSA kinetics. Once the PSA is low and the testosterone is at castrated level y prefer to see the patient trimestrally.

Dear all,

thank you very much for these interesting insights in clinical practice. Do you use 0.5 ng/mL or 0.2 ng/mL Testosterone plasma levels as castration concentration? Guidelines (as far as I know) still use 0.5 ng/mL despite numerous papers and clinical trials nowadays suggest to lower it to 0.2 ng/mL.

Best regards, Niels

According to the guidelines I still believe in 0.50. If you read Morotes publication carefully, he is stating that the clinical advantage of lowering the castration level is still unknown. I fear changing therapy too often makes more harm to our patients.

Best regards

Walter