The original form of androgen deprivation therapy, which won Charles Huggins, MD, the Nobel prize, was surgical castration. Although that may seem like excessive treatment compared to the injectable LHRH agonist and antagonist drugs now used for ADT, it remains as effective for PCa control and less expensive in the long term. In poverty-stricken parts of the world, surgical castration is still offered to patients who cannot afford the more expensive LHRH agonist and antagonist drugs.
But what about in a country like Turkey?
In a new study, researchers asked 217 urologists and 170 medical oncologists in Turkey, if they offered surgical castration as an ADT option to their advanced PCa patients. Only 7.5% offered this option. Surgeons were statistically more likely to offer it than medical oncologist, but that is hardly surprising since surgical castration is a surgical procedure performed by surgeons.
We have two comments on this study.
In the discussionof their findings, the authors take it as a given that patients consider surgical castration detrimental to their body image. This may be true, but the literature documenting this is very limited. There is remarkably little data on patient preference for different forms of ADT, where the patients were confirmed to be fully informed of the costs and benefits of all the treatment options. One would suppose that patient choice would be influenced by their knowledge about the effectiveness of the treatment against the side effects that might occur.
A common argument against surgical compared to pharmacological castration is that surgery is not reversable. However, this argument is not particularly relevant for older, patients with a advanced disease and do not desire to father children. Patients in that class, who start on ADT, are likely to stay on treatment for the rest of their life.
A couple of studies have found that PCa patients, who elected surgical castration for ADT, were significantly less anxious overall than patients on injectable depot LHRH medications. Now, with so many different ways to suppress testosterone’s influence on PCa cells, it might be worth exploring how much patient comfort or discomfort—with any form of treatment—is influenced by their knowledge of treatment options.
If less than 10% of physicians present all the options to their patients, it would not be surprising that patients may not be making well-informed decisions about their treatments. Are few advanced PCa patients in Turkey (or elsewhere) considering surgical castration for ADT because they feel it will negatively impact their self-image or because they are not being told about that option by their physicians?
This is more than an academic discussion. There are increasingly data showing that the effectiveness in cancer control for patients on the standard ADT drugs can be enhanced with the newer androgen receptor targeting agents (ARTAs). But ARTAs are not cheap drugs. When patient’s financial status is limited, ADT via surgical castration remains a credible option. It certainly should remain an option offered to patients, who might benefit from both standard ADT plus an ARTA, but can’t afford both.
To read the full paper, see: https://www.turkishjournalofurology.com/Content/files/sayilar/206/287-293.pdf
Reference:
Semiz, H. S., Kisa, E., Yildirim, E. C., Atag, E., Arayici, M. E., Muezzinoglu, T., & Karaoglu, A. (2022). What Is Your Choice for Androgen Deprivation Therapy in Metastatic Prostate Carcinoma: Surgical or Medical?. Turk J Urol, 48(4), 287-293.