It has been a long-term debate about whether one should start ADT as soon as one’s PSA starts to climb or wait until it reaches a higher threshold. The case for waiting is that it reduces the time that the patient is burdened with ADT side effects. The case against waiting is that it might allow the disease to progress faster. A new study out of Korea looks at this question in a retrospective analysis of 69 patients with non-metastatic prostate cancer, who received radiotherapy along with ADT after a radical prostatectomy.
All the men were selected because they ultimately developed distant metastases. The authors, however, divided them into two groups. Men in one group started on ADT when their PSA was less than 2 ng/ml. Men in the other group started on ADT when their PSA was greater than 2 ng/ml. The patients were then followed for a median of 6.5 years (range ~4.5 to ~9.5 years).
The study authors come to a clear conclusion that early ADT—when PSA level is less than 2ng/ml—confers a cancer-specific survival benefit in patients who have biochemical progression after a radical prostatectomy.
In truth, though, the question is not completely resolved for a couple of reasons. For one thing, the population is strictly Korean and there may be racial differences in the pattern of PSA progression. A more serious problem is the small sample size. Of the two groups in this study, one had only 31 men and the other had 38.
Nevertheless this is a nice study and one that suggests some benefit in starting on ADT early, when there is a clear sign of a rising PSA after a primary treatment. The study deserves to be reproduced with a much larger sample size and a more diverse patient population.
To read the full article, see: https://www.eymj.org/DOIx.php?id=10.3349/ymj.2020.61.8.652
Ahn HK, Lee KS, Kim D, et al. Optimal PSA Threshold for Androgen-Deprivation Therapy in Patients with Prostate Cancer following Radical Prostatectomy and Adjuvant Radiation Therapy. Yonsei Med J. 2020;61(8):652-659.