Which patients with intermediate and high risk prostate cancer should not receive androgen deprivation therapy?

Based on randomized trials that didn't exclude patients with cardiac risk factors, an overall survival benefit has been observed for intermediate and high risk localized prostate cancer. Review of RTOG studies has not detected an increase in cardiovascular events. That said, appropriate management of cardiac risk factors and hyperglycemia is beneficial for all patients. One must be careful to withhold a treatment with a known survival benefit due to theoretical concerns.

RTOG 0815 is currently testing whether short term androgen deprivation therapy is needed for patients who receive contemporary high-dose RT, given with EBRT or brachytherapy. Until this study or others is complete, one must consider short term androgen deprivation standard ...

For men with intermediate risk disease, the jury’s still out pending RTOG 0815 as to which men will benefit most from ADT. Retrospective data suggest that a ‘favorable’ intermediate risk group can be identified, that behave similarly to low risk disease and hence may not benefit as much from ADT. In our practice, percent positive cores is the largest determinant of disease outcome after dose escalated RT, so if we are treating a man off protocol we consider this factor (along with age, and comorbidity) in deciding whether to add ADT to RT.

For men with high risk disease, I would hesitate to exclude ADT for most men. Although retrospective data suggest a detriment in time to MI, diabetes, and cardiovascular events, I would not consider ...