COMMENTARY

Implications of Early Versus Delayed Androgen Deprivation Therapy on Quality of Life in Patients With Prostate Cancer

Gerald Chodak, MD

Disclosures

September 22, 2017

Hello. I'm Dr Gerald Chodak for Medscape. Today's topic is the implications of early versus delayed androgen deprivation therapy (ADT) in men who have a rising prostate-specific antigen (PSA) after local treatment or who had noncurable asymptomatic cancer at diagnosis.

Duchesne and colleagues[1] recently reported the results of a randomized multicenter trial conducted in Australia, New Zealand, and Canada. In the study, patients had a rising PSA following definitive treatment or, in a small subset, had noncurable localized disease. The study participants were given ADT initially or were given the option to delay therapy by up to or more than 2 years.

Initial results of this study were reported previously in terms of overall survival[2]; the investigators now have median follow-up data of 5 years. Duschesne and colleagues found that the men in the immediate-therapy group had a statistically significant better overall survival rate, with a difference of approximately 5%, meaning that for every 20 men treated with ADT, only one had improved survival.[2]

The recent study data by Duchesne and colleagues[1] reported on patient quality of life (QOL). The authors used validated surveys to assess QOL factors of all participants prior to the start of the study and again at 6, 12, 18, and 24 months after the study began. The authors found that participants in the early-ADT group had significantly worse sexual function and hot flashes at 6 and 12 months compared with participants in the delayed-therapy group.[1] Overall QOL, however, was similar between the two groups.

There are a couple of small problems with this trial. Number one, not all of the men in the study were homogeneous in terms of status, meaning that some men were receiving ADT because they had noncurable disease, and therefore didn't fail local therapy prior to receiving this treatment. Another problem with this study is that the decision to treat patients with ADT was left entirely to the discretion of each investigator. This was very nonhomogeneous in that some participants received ADT and others received various forms of medical or surgical castration.

Nevertheless, this study is well done, and it does provide doctors with an opportunity to have a reasonably good conversation with patients about the trade-offs they might expect if their PSA begins to rise after local therapy.

Although immediate therapy does slightly improve patient survival, it comes at a cost to QOL in terms of worsening sexual function and hot flashes. For men who are not concerned about sexual function or who have lost the ability to function sexually due to local therapy, the choice might be easier. If men are maintaining their QOL in terms of those two factors, then delaying therapy comes at a relatively small cost.

The bottom line is, as with most therapies for prostate cancer, patients have to weigh the pros and cons of the various trade-offs that they're going to face from the different options available. Our job as physicians is to make sure that they're well informed and that they can make a good choice.

I look forward to your comments. Thank you.

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