The evidence is strong that adding ADT to radiotherapy can improve survival for patients with medium to advanced prostate cancer. But does it help to slow down the progression of the disease or improve overall survival to start ADT either before one’s prostatectomy or immediately thereafter? This new meta-analysis digs into the literature to find out.
Concerning neoadjuvant ADT (i.e., ADT before one’s prostatectomy), the authors found 11 relevant studies involving collective data on 2,322 men. The patients’ post-operative pathology reports showed that starting ADT before the prostatectomy led to down-staging of the prostate tumors. That sounds good. However in terms of what really matters, the meta-analysis found no evidence that the early treatment with ADT in advance of surgery delayed cancer recurrence or improved overall survival.
In contrast, initiating ADT immediately after surgery showed some evidence of slowing the time to biochemical recurrence and possibly overall survival. This was particularly true for patients with evidence of PCa in the lymph nodes and a climbing PSA.
The authors acknowledged a multitude of limitations in their analysis. Most of the studies they included in their meta-analysis are quite old (i.e., studies that started over two decades ago) and the drugs used then are not necessarily the drugs now commonly in use. That’s a case for revisiting the topic, specifically with the newer ADT agents.
There’s also an interesting context for this work that is not mentioned in the paper. It relates to the COVID pandemic, which has forced delays in surgery for patients awaiting a prostatectomy. Some guidelines came out this past year in both North America and Europe suggesting that patients in the queue for a prostatectomy, who had their surgery delayed, could go instead on ADT short term as a “holding strategy”. That brings a new reality to this meta-analysis. Previous to this review, results of the individual papers had already suggested that there wasn’t any long term advantage in starting on ADT before a prostatectomy. But what is nice and timely about this review is that it suggests that patients are not worse off in terms of cancer control for having gone on ADT short term while awaiting surgery.
As for going on ADT immediately after a prostatectomy, this paper reviews data that already show a benefit for patients with high risk disease.
To read the study abstract, see: https://pubmed.ncbi.nlm.nih.gov/33443481/
Ref: Nayak AL, Flaman AS, Mallick R, Lavallée LT, Fergusson DA, Cagiannos I, Morash C, Breau RH. Do androgen-directed therapies improve outcomes in prostate cancer patients undergoing radical prostatectomy? A systematic review and meta-analysis. Can Urol Assoc J. 2021 Jan 8. doi: 10.5489/cuaj.7041. Epub ahead of print. PMID: 33443481.