Overuse of neoadjuvant androgen deprivation in low risk prostate cancer

Background: Evidence has emerged that androgen deprivation (ADT) use prior to radical prostatectomy or radiation therapy in low risk prostate cancer patients does not provide a survival benefit and may subject patients to adverse side effects and clinical outcomes. We examined trends and factors associated with ADT use prior to definitive therapy in low and very low risk prostate cancer. Methods: We identified men diagnosed with low or very low risk prostate cancer in the National Cancer Database from 2004-2013 who elected definitive treatment with radical prostatectomy (RP), external beam radiation (EBRT) or brachytherapy (BT). Neoadjuvant ADT use was defined as receipt of ADT prior to definitive treatment. Trends in neoadjuvant ADT use were assessed and multivariable logistic regression was used to evaluate associations between treatment, age, race, insurance status and urban/rural status and receipt of neoadjuvant ADT. Results: Of 199,933 patients with low or very low risk prostate cancer, neoadjuvant ADT use decreased from 14.6% in 2004 to 2.7% in 2013 (23.0% to 8.8% for BT, 20.6% to 6.0% for EBRT and 2.3% to 0.5% for RP; each p for trend <0.001). Controlling for covariates and year, we found increased odds [OR (95% CI)] of neoadjuvant ADT use in patients undergoing BT [12.01 (11.23-12.83)] or EBRT [8.75 (8.16-9.39)], African Americans [1.08 (1.02-1.14)] vs. whites, patients 75 or older [1.93 (1.80-2.06)] and 65-74 [1.52 (1.44-1.60)] vs. less than 65, patients in communities less than 250,000 [1.28 (1.23-1.34)] vs. metropolitan areas and patients with Medicare or Medicaid [1.22 (1.16-1.29)] vs. private insurance. Conclusions: Use of ADT prior to definitive prostate cancer treatment has declined over the past decade. However, patients receiving radiotherapy, African Americans, patients of older age, rural location, and insured by Medicare or Medicaid more frequently received neoadjuvant ADT. Since this treatment is unlikely to provide a survival benefit and may subject patients to adverse side effects or clinical outcomes, strategies to minimize overuse of ADT in low or very low risk patients prior to definitive therapy may help limit overtreatment and its associated harms.