We are approaching 40 years since Lupron, the first LHRH drug used to treat prostate cancer, came on the market. Lupron was an expensive drug back then and still is. It became a bit cheaper once it had competition, but many newer drugs have become available to treat advanced prostate cancer and they are all expensive.
Before there were any ADT drugs, androgen deprivation could be achieved by surgical removal of the testes in a procedure called an orchiectomy. This surgical procedure is still common in low-income countries where many men can‘t afford the drugs.
In the wealthier world, both the healthcare providers and the patients have accepted the argument that the drugs are preferable to surgery because their castrating effects are reversible. If they are stopped, the testosterone levels start to recover. That is clearly an advantage when patients are candidates for intermittent ADT. But patients with metastatic disease typically go on the drugs and stay on them for the rest of their lives. For these patients, the reversibility argument favoring the drugs becomes irrelevant.
The other argument commonly floated in favor of the drugs is that genital surgery is emotionally traumatic for men and thus means a lower quality of life (QoL). However, when one looks into the literature, it is hard to find a well-designed study showing that the psychological distress of an orchiectomy, as a single procedure, is greater than the cumulative distress of having to get depot injections of ADT drugs multiple times a year. In the absence of good data, one might suppose that clinicians who tell patients that the surgery is more stressful may be projecting their own feelings about the procedure onto their patients.
Now, finally, a research team in Los Angeles has gone back and looked at the actual QoL of patients who elected to have an orchiectomy versus an LHRH drug for ADT. What is nice about their study, which had not been done before, is that they carefully matched the two populations on socio-economic status.
The sample size was small, with just 27 patients who had an orchiectomy, compared to more than 10 times that number who had the depot injections. To their credit, the authors realized that the socioeconomic status of the patient may be a big variable that had not been previously controlled in such studies.
With several years of follow-up, the researchers found no difference in either physical or mental measures of QoL in the two populations.
From a cost perspective, depending on what drugs one is on and where one lives, about two years of the ADT drugs ends up costing more than the single surgical procedure. That favors the surgery for those who have limited financial reserves. The authors also make the argument that the surgery is ecologically better (has a lower carbon footprint) because the orchiectomy patients don’t have to come back to the clinic repeatedly for depo injections.
To be clear, we are not endorsing the surgery over the drugs. But at the same time, the best available data do not show that ADT with the more expensive ADT drugs means a better QoL in the long run than ADT with an orchiectomy.
To read the study abstract, see: https://pubmed.ncbi.nlm.nih.gov/35581122/
Ref:
Gaither TW, Kwan L, Villatoro J, Litwin MS. Quality of life in low-income men after surgical castration for metastatic prostate cancer. Urol Oncol. 2022 May 14:S1078-1439(22)00118-1. doi: 10.1016/j.urolonc.2022.04.009. Epub ahead of print. PMID: 35581122.