1. Neadjuvant Hormonal Therapy in Men Being Treated with Radiotherapy for Localized Prostate Cancer Mack Roach III, MD Professor, Radiation Oncology & Urology University of California, San Francisco UCSF/Mt. Zion NCI-Designated Comprehensive Cancer Center San Francisco, California

3. All Patients Pilepich et al. Proc Am Soc Clin Oncol . 2003;22:381(Abs1530). 0.0053 22% 13% 17% 9% Prostate Cancer Death 0.0043 38% 71% 47% 76% Absolute Survival <0.0001 22% 44% 36% 62% NED Survival <0.0001 39% 29% 25% 15% Distant Failure <0.0001 39% 30% 23% 15% Local Failure P 10 yr 5 yr 10 yr 5 yr RT+HT at Relapse (n=468) RT+ Adj LHRH (n=477)

4. Absolute Survival Central Gleason 7 Years from Randomization Percent (%) 0 3 6 9 12 RT+Immediate Hormones RT+Hormones at Relapse P =0.042 Pilepich et al. Proc Am Soc Clin Oncol . 2003;22:381(Abs1530). 0 25 50 75 100

5. Absolute Survival Central Gleason 8-10 P =0.0061 Pilepich et al. Proc Am Soc Clin Oncol . 2003;22:381(Abs1530). Years from Randomization Percent (%) 0 3 6 9 12 RT+Immediate Hormones RT+Hormones at Relapse 0 25 50 75 100

12. Randomized Trials Using NHT Progression-free survival advantage with short follow-up 23 ng/mL 28% NR NR 33% NR NR 646 / 0 0 1291 / 645 Roach (2003) RTOG 9413 Disease-specific survival and Overall for GS = 8-10. 20 ng/mL 40% 35% 26% 0 45% 55% 0 / 753 0 1514 / [761 vs 753 (+adjuvant)] Hanks (2003) RTOG 9202 Survival advantage for GS <7, Included N+ patients 26 ng/mL - - 28% 0% 30% 70% 0 / 0 230 456 / 226 Pilepich (2001) RTOG 8610 Comments: PreTx PSA (Med)^ GS# 2-6 7 8-10 T-Stages T1-2b T2c T3-4 Short / Long Term Adjuvant HT (no.) No HT Total / No. patients with NHT +/- concurrent HT First Author (Year)

13. Phase III RTOG Trial 8610 of Androgen Deprivation Adjuvant to Definitive Radiotherapy in Locally Advanced Carcinoma of the Prostate 0 10 20 30 40 50 60 70 80 90 100 0 1 2 3 4 5 6 7 8 RT + NHT RT alone Survival (%) Gleason 2-6 Years P =0.015 Pilepich MV et al. Int J Radiat Oncol Biol Phys 2001; 50(5): 1243-52.

14. RTOG 92-02 Arm 1: goserelin and flutamide 2 months before and during standard RT (STAD) Arm 2: goserelin and flutamide 2 months before and during standard RT, followed by goserelin alone for 24 months (LTAD) T2c-T4 PreRx PSA <150 ng/mL R A N D O M I Z E

15. Overall Survival All Patients RTOG 9202 Years since randomization Survival rate STAD+RT LTAD+RT 0 . 0 0 . 2 0 . 4 0 . 6 0 . 8 1 . 0 0 1 2 3 4 5 6 7 8 159 22 169 28 P =0.73

16. 9202 Prostate Cancer Survival 0 . 0 0 . 2 0 . 4 0 . 6 0 . 8 1 . 0 0 1 2 3 4 5 6 7 8 Failed/Total STAD+RT 87/762 LTAD+RT 55/755 Years Since Randomization Survival Rate P =0.006

17. RTOG 9413 Scheme: Timing First Month HT T HT HT HT none none EBRT EBRT none none HT HT HT HT EBRT EBRT Arms 1 & 2 Arms 3 & 4 2 months different Rx duration Second Month Third Month Fourth Month Fifth Month Sixth Month

18. Progression-Free Survival Arm 2 vs Arm 4 (RTOG 9413) Years since randomization Approximately two months N&CHT+PO RT 0 . 0 0 . 2 0 . 4 0 . 6 0 . 8 1 . 0 0 1 2 3 4 5 Non-failure rate PO RT+AHT

19. Progression-Free Survival Arm 1 vs Arm 2 (RTOG 9413) Years since randomization 0 . 0 0 . 2 0 . 4 0 . 6 0 . 8 1 . 0 0 1 2 3 4 5 Non-failure rate N&CHT+WP RT N&CHT+PO RT

20. Randomized Trials Using NHT Overall no difference in PSA failure rates ~10 ng/mL 50% 38% 11% ~52% ~35% 13% 0 0 378 / 378 (3 vs 8 months) Crook (2004) Princess Margaret Overall & disease specific survival advantage 11 ng/mL 35% 59% 15% 100%, 0% 0 / 0 102 206 / 104 D’Amico (2004) Harvard Study PSA failure rates higher with EBRT alone, otherwise no difference s 10 ng/mL 12 ng/mL (7-10) = 26%^ (7-10) = 28% NA NA 30% NA NA 13.5% 55 / 0 148 / 0 43 0 161 / 63 296 / 148 (3 months) Laverdeire (2004) Quebec Trials Comments: PreTx PSA (Med) GS# 2-6 7 8-10 T-Stages T1-2b T2c T3-4 Short / Long Term Adjuvant HT (no.) No HT Total / No. patients with NHT +/- concurrent HT First Author (Year)

21. Laverdiere Scheme: Timing of Hormonal Therapy (HT) Arm (no.) Group 1 Study 1 EBRT EBRT none none none none Group 2 Study 1 HT HT H T EBRT EBRT none Group 3 Study 1 HT HT HT HT EBRT HT EBRT HT* Maximum field size 10 x 10 cm to 64 Gy. *HT = Combined Androgen Blockade with a LHRH & Flutamide *10 months. Laverdiere J et al. J Urol 2004; 171(3): 1137-40. First Month Second Month Third Month Fourth Month Fifth Month Sixth- Tenth

22. The Efficacy and Sequencing of Short Course of Androgen Suppression on Freedom from Biochemical Failure When Administered with Radiation Therapy for T2-T3 Prostate Cancer 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 Months bNED Survival (%) 3 month NHT N&CHT+Adj (10 months) EBRT Alone Laverdiere J et al. J Urol 2004; 171(3): 1137-40.

23. Laverdiere Scheme: Timing of Hormonal Therapy (HT) Group 1 Study 2 HT HT HT HT EBRT HT EBRT none Group 2 Study 2 HT HT HT HT EBRT HT EBRT HT* *HT = Combined Androgen Blockade with a LHRH & Flutamide Maximum field size 10 x 10 cm to 64 Gy. *10 months. Laverdiere J et al. J Urol 2004; 171(3): 1137-40. Arm (no.) First Month Second Month Third Month Fourth Month Fifth Month Sixth- Tenth

24. 6-Month Androgen Suppression Plus Radiation Therapy vs Radiation Therapy Alone for Patients with Clinically Localized Prostate Cancer 0 10 20 30 40 50 60 70 80 90 100 0.0 1.0 2.0 3.0 4.0 5.0 6.0 3D-CRT + Hormones 3D-RT alone Survival (%) Years P =0.04 D’Amico et al. JAMA. 2004;292:821-827.

27. Model and Literature on the Impact of Short-Term NHT and EBRT on Outcome in Treatment of Clinically Localized from Prostate Cancer RTOG 9413 RTOG 9202 RTOG 8610 Princess Margaret Quebec Studies Harvard Study Relative Extent of Disease -50 -40 -30 -20 -10 0 10 20 30 40 Low Risk Intermediate High Risk Very High Risk Dz Impact of Short Term NHT on Survival Impact of Disease on survival Net Impact of Dz & HT