Despite the evidence against survival benefit in low-risk disease, and the lack of guidelines recommending its use in this setting, primary ADT remains a commonly used approach to treating early-stage or low-risk PC, especially in the elderly.3 A large US study found that 7% of men overall and 42% of men aged 75 years and older with low-risk PC were treated with ADT.3,6

In SEER data from 1991 to 2005, 17.9% of men with low-risk PC received primary ADT; another analysis of Medicare data found that 14.9% of patients with low-risk PC received ADT against guideline recommendations, and that men aged 75 years and older or those with multiple comorbidities were the most likely to be so treated.9,10

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For these patients, ADT leads to indirect costs in quality of life detriments and side effects, as well as direct economic costs for treatment. The issue of overtreatment of low-risk PC is of current interest, with some models suggesting that 42% of men with cancers detected through PSA screening receive unnecessary treatments.3

When asymptomatic disease is discovered through screening, comprehensive risk assessment, including Gleason score, PSA, and clinical staging, should be performed and used to guide treatment decisions.

Patients should have a thorough understanding of the potential benefits and risks of each option, including active surveillance.1,3 Improvements in diagnosis and treatment have the practical effect of men living for many years, even decades, after initial PC diagnosis. Because most men with low-risk PC will have excellent outcomes with treatment other than ADT or with active surveillance, the odds are good that harm from ADT in terms of side effects will outweigh any benefit for these men in terms of cancer control.10,11

In summary, although ADT remains an important and effective treatment option for some men with intermediate-risk PC and those with high- or very high-risk disease,3 the use of ADT as primary therapy in low-risk PC seems increasingly ill advised. With no long-term survival benefit but many potential side effects of long-term consequence, clinicians and patients would do well to follow guidelines and reserve primary ADT only for those low-risk PC patients who truly have no alternative.

References

  1. American Cancer Society. Cancer Facts & Figures 2014. Atlanta, GA: American Cancer Society; 2014.
  2. Lu-Yao GL, Albertsen PC, Moore DF, et al. Fifteen-year survival outcomes following primary androgen-deprivation therapy for localized prostate cancer. JAMA Intern Med. 2014;174(9);1460-1467.
  3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer. V2.2014. Available at www.nccn.org. Accessed July 28, 2014.
  4. Ahmadi H, Daneshmand S. Androgen deprivation therapy for prostate cancer: long-term safety and outcomes. Patient Relat Outcome Meas. 2014;5:63-70.
  5. Allan CA, Collins VR, Frydenberg M, McLachlan RI, Matthiesson KL. Androgen deprivation therapy complications. Endocr Relat Cancer. 2014;21(4):T119-T129.
  6. Agency for Healthcare Research and Quality. Treatments for Localized Prostate Cancer: Systematic Review to Update 2002 US Preventive Health Services Task Force Recommendations. AHRQ Pub. 12-05161-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
  7. Lu-Yao GL, Albertsen PC, Moore DF, et al. Survival following primary androgen deprivation therapy among men with localized prostate cancer. JAMA. 2008;300(2):173-181.
  8. Potosky AL, Haque R, Cassidy-Bushrow AE, et al. Effectiveness of primary androgen-deprivation therapy for clinically localized prostate cancer. J Clin Oncol. 2014;32(13):1324-1330.
  9. Gilbert SM, Kuo YF, Shahinian VB. Prevalent and incident use of androgen deprivation therapy among men with prostate cancer in the United States. Urol Oncol. 2011;29(6):647-653.
  10. Kuykendal AR, Hendrix LH, Salloum RG, et al. Guideline-discordant androgen-deprivation therapy in localized prostate cancer: patterns of use in the Medicare population and cost implications. Ann Oncol. 2013;24(5):1338-1343.
  11. Mohler JL. Kantoff PW, Armstrong AJ, et al. Prostate cancer, version 1.2014. J Natl Compr Canc Netw. 2013;11(12):1471-1479.

Topics:

Male Reproductive Cancers Prostate Cancer