Science behind total androgen blockade: from gene to combination therapy.

Probably the most important finding in the endocrine therapy of prostate cancer is that the testicles and adrenals contribute approximately equal amounts of dihydrotestosterone (DHT), the active androgen that stimulates normal and cancerous prostatic cell growth and function. Structure of the cDNAs and genes encoding most of the enzymes responsible for the transformation of the adrenal precursor dehydroepiandrosterone (DHEA) into DHT have recently been elucidated, namely 3 beta-hydroxysteroid dehydrogenase/delta 5-delta 4 isomerase, 17 beta-hydroxysteroid dehydrogenase, and 5 alpha-reductase. With the action of these enzymes, DHT is then made locally in the prostate from circulating DHEA of adrenal origin. Given such an important role of the adrenals, it is essential to use a pure antiandrogen for maximal blockade of the interaction of DHT with the androgen receptor while the testicles are blocked by orchiectomy or treatment with a luteinizing hormone-releasing hormone (LHRH) super-agonist. This combination therapy was first developed to treat advanced prostate cancer. The multicenter clinical data recently obtained confirm our original data and demonstrate the major importance of the intracrine or in situ formation of androgens in the human prostate from the inactive adrenal steroid precursors. Combination therapy thus permits, for the first time, to prolong life in advanced prostate cancer and, most importantly, offers the possibility of a major improvement in the efficacy of a curative therapy, namely, radical prostatectomy in early stage disease.