Over-use of neoadjuvant and concurrent ADT in combination with radiation therapy

As anyone who has had long-term androgen deprivation therapy is well aware, this type of treatment may be able to delay the onset or relieve the metastases and bone pain associated with progressive prostate cancer, but it is far from being benign — and comes with a wide spectrum of side effects that affect some patients very seriously.

A newly published study by Quon et al. has just reported data comparing the “real world” use of neoadjuvant and concurrent use of ADT among Medicare-eligible patients in the USA with the recommended uses (which are limited to men with high-risk but not low-risk disease and not for men with short life expectancies). The study evaluated “patterns of care” data in men diagnosed with prostate cancer between 2004 and 2007 who all received first-line radiation therapy for treatment of localized prostate cancer. To do this, the authors used the information collected in the joint Surveillance, Epidemiology, and End Results (SEER)-Medicare database and they stratified the patients by tumor risk group and by life expectancy.

Here are the key study findings:

  • The study sample included 10,686 patients.
    • The average (mean) age of these men was 74.2 years.
    • 83.4 percent of the patients were white.
  • When caterogorized by risk group, neoadjuvant or concurrent ADT was administered in combination with radiation therapy to
    • 80.7 percent of high-risk patients
    • 54.1 percent of intermediate-risk patients
    • 27.8 percent of low-risk patients
  • Men with a life expectancy < 5 years had higher rates of use of neoadjuvant or concurrent ADT + radiation therapy than men with life expectancy ≥ 10 years across all risk groups.
  • Within each risk group, advancing age was associated with higher likelihood of receiving of ncAD.
    • For high-risk patients, the odds ratio (OR) for men aged 80-84 compared to 67-69  was 1.93.
    • For intermediate-risk patients the OR for men aged 80-84 compared to 67-69 was 1.51.
    • For low-risk patients the OR for men aged 80-84 compared to 67-69 was 1.71.

Quon et al. conclude that the use of neoadjuvant and concurrent ADT in combination with radiation therapy was certainly not consistent with guideline recommendations in the period from 2004 to 2007, was more frequent among men who were older, had shorter life expectancies, and were less likely to benefit from therapy.

What we do not know, obviously, is whether there has been any significant change to this pattern of use of neoadjuvant and concurrent ADT over the ensuing 6 years, but for older men with a limited life expectancy and men with low- and intermediate-risk disease, if ADT is suggested as part of the treatment for localized prostate cancer, you may wish to ask your doctor exactly why s/he thinks this is appropriate in your case.

4 Responses

  1. From what I have observed, it seems to me that the use of a number of combination treatments, including ADT, has increased over the last several years. I also believe that the increased use of ADT is not limited to radiation therapy but is found with surgery as well.
    The real question is then: are the guidelines used during 2004-2007 obsolete and should they be replaced by more recent practices, provided a change in guidelines can be justified.

  2. “is not limited to radiation therapy is” should be replaced with “is not limited to radiation therapy but is”


    I’m just looking for explanations here and not trying to justify what appears to be overuse of ADT in support of radiation for some patients. If we understand the problem better, we will be in a better position to do something about it. With this in mind, here goes. I’m responding as a now savvy patient who has been on intermittent triple ADT for 13+ years, including a fourth round in support of radiation for my high-risk case; I’ve paid a lot of attention to ADT research over the years.

    I’m thinking of two possible reasons for greater use of ADT for men in their *0s: less impact on sex life, and a lower “burden” on the patient from hot flashes and sweats. Both of these side effects of ADT are major problems for some men, especially when countermeasures are not used. (My impression is that many doctors and patients are still not even aware of the need for countermeasures.)

    The study compared men in the first half of their 80s to men in the latter years of their 60s. It seems likely that a large proportion of men in their 80s would not care much about sex (though some of us will still care). In contrast, many of us in our late 60s still care about our sex life. Therefore, a major impact on sex life would not be perceived by many doctors as an issue in prescribing ADT for men in their 80s, I suspect.

    Similarly, my impression is that hot flashes and sweats due to ADT are much milder for most of us as we grow older. Anecdotally, that has been true in my own case over three rounds of intermittent ADT and has been true for several friends. Clearly there are exceptions, but I suspect flashes and sweats too are no longer a major issues for men for whom they would have been issues at younger ages. While it’s clearly a small minority at any age that suffers a major burden from flashes and sweats, I’m thinking that many doctors would consider that there would be minimal burden for men in their 80s, and this perception could make them more likely to prescribe ADT. However, I haven’t checked research to confirm the lower burden of flashes and sweats for much older men.

  4. Thanks for posting this article Mike. It supports the point you made to me last week that ADT is over-prescribed to older men.

    What is not indicated in your summary is the length of time the ADT is prescribed. I wonder if this is pretty much per protocol …. <= 4 months for low to intermediate risk, 4-8 months for intermediate risk, and 18 to 36 months for high risk?

    The abstract does not indicate, but this is important information — the average period used in each risk category.

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