What the patients think … about RT + ADT

Well here’s a good idea! Let’s actually ask patients what they think about the pros and cons of long- and short-term hormone therapy in association with radiation!

The use of long-term androgen deprivation therapy (LT-ADT) in combination with radiation for men with regionally advanced prostate cancer has been proven to convey a prostate cancer-specific survival advantage over short-term androgen deprivation (ST-SADT) and radiation. In 2009, Bolla et al. published data showing that the survival benefit of radiation + LT-ADT (for 3 years) compared to radiation + ST-ADT (for 6 months) was an increase in survival of 3.8 percent. However, there has always been a question about the relative merits of the additional survival compared to the adverse effects of LT-ADT.

Wilkie et al. decided that asking patients about their preferences might be a good idea! So they did. Their paper talks in terms of statistically complex issues such as “the probability trade-off method” and “time trade-off utilities” for erectile dysfunction and osteoporesis, and we aren’t going to try to get down into this level of detail. The two core findings of the study are as follows:

  • All participants were willing to risk a shortened overall survival in order to avoid LT-ADT compared with ST-ADT.
  • The average (mean) minimal increase in prostate cancer-specific survival that would convince a patient to have LT-ADT compared to ST-ADT was 8.2 percent.

The patient viewpoint appears to be very clear. Before they are willing to accept LT-ADT in combination with radiation as a treatment for locally advanced prostate cancer, they want to know that they are going to get a significantly higher survival benefit than anything currently available in order to make up for the losses in quality of life associated with LT-ADT!

The radiation oncology community would be well advised to take notice of this interesting study!

6 Responses

  1. This is very interesting since I am now at the point where I must decided if I should continue my ADT after one year (including IMRT and HDR). I will have had 8 months of ADT following radiation.

    So, just how would one go about calculating the survival benefit?

  2. Dear Curt:

    There is no way for you to be able to “calculate the survival benefit” for yourself as an individual.

    What the Bolla study (mentioned above) showed is that, at 5 years of follow-up, 15.2% of the men who stayed on hormones for 3 years had died as compared to 19% of the men who only had hormones for 6 months.

    What YOU need to do is have a conversation with your doctor about how long YOU want to stay on hormone therapy. The greater your interest in the length of your life compared to the quality of your life, the greater the need to stay ON the hormones.

    However, no one is going to be able to tell you exactly how long you are going to live. There are too many variables (assuming that at present your PSA is stable and low and that you have no other signs of progressive disease).

  3. Sitemaster,

    I think it might be helpful if you could explicitly differentiate between “prostate-cancer-specific” and “all-cause” when you give mortality rates. Your wording here seems to be clear (and the Bolla abstract confirms it is all-cause), but I can see people getting confused when they come from other sites that tend to omit the all-important “prostate-cancer-specific” qualifier when advertising the benefits of particular aspects of care. (The “20% reduction in mortality” claims regarding the European screening trial come to mind.) You give the number here that most men would likely consider more important when making a decision, but I think it is important to make sure that everyone understands that.

    A minor nitpick of an excellent resource. Thanks for your work here.

  4. Dear Jim:

    I do do my best to make those distinctions, but I am dependent on the source material. Abstracts are often not entirely clear, and I do not always have access to the full text of the paper to get clarity.

    However, you have encouraged me to try to do better!

  5. For those of us with Gleason scores of 8 to 10, it’s probably worth noting that in the discussion section the authors state, “In a subset analysis of the randomized study, among patients who had high-grade tumors (Gleason score, 8-10) the reported benefit in prostate cancer-specific survival was 11.4% (93.4% vs 82%; P=0.0078). In that instance, 65.7% of participants in the study would accept LTAD [long term AD] over STAD [short term AD].”

    Translation: The higher the Gleason score the more willing one is to trade off survival for a diminished QOL. Certainly consistent with how I (Gleason 8) feel personally, anyway.

    Thanks for bringing this study to our attention.

  6. I agree with Craig, numerous studies come to the same conclusion about benefit of ADT for high-grade cancer treated with RT. However, a fairly large study by the respected Alvaro Martinez at Beaumont Hospital from 2005 showed clouds the issue nicely. Also, it is clear from other studies that, beyond your Gleason score, the amount of cancer in the biopsy cores is a strong predictor of outcome. So is a lot of 3 + 4 better or worse than a little 4 + 4?


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