According to a group of urologists in Italy, the answer is “yes”.
Residing in Europe, the authors reached that conclusion based on the formal guidelines for the use of ADT set out by the European Association of Urology. Those guidelines are clear that with no sign of systemic disease, and with a low PSA and a long PSA doubling time, there is no benefit in putting elderly patients on ADT. These guidelines also state that it is inappropriate to put such men on ADT, if they have not yet received, but could safely receive, treatment for localized disease.
Following those guidelines, the researchers found that out of 427 elderly patients, who were treated with ADT, 66 (15.5%) started on ADT when they shouldn't have. These were all elderly men. Many were identified as “old old”; i.e., over 75 years old.
The paper rigorously reviews the serious cardiovascular side effects that can come from ADT, such as a heart attack and osteoporosis, as well the most bothersome ones, such as fatigue and hot flashes. Given the potentially dangerous side effects of ADT in the elderly population, a case can be made to avoid ADT when there is little sign that the patients will benefit from the treatment.
Although the paper does not go into this, one might imagine that these men are not good candidates for a radical prostatectomy, but that would not rule out external beam radiation, which could be an alternative to starting them prematurely or unnecessarily on ADT. The authors also point out that excessive use of ADT has a large financial cost on the health care system.
There is no reason to suppose that excess use of ADT is a problem specific to Italy. We have personally seen men with a very low and slow climbing PSA well over 75 anxious to start ADT. Given their climbing PSA, they fear that they must start ADT as soon as possible…regardless of other factors that could influence their overall survival. It would be interesting to survey such patients and find out why they are more worried about prostate cancer than having a heart attack, a stroke, or falling down and breaking a hip from osteoporosis. Although this is only a speculative guess, we suspect that the word “cancer” is interpreted as more threatening to the men then many of of the health risks associated with the side effects of ADT.
This paper is a great review of the side effects of ADT, but it also raises the question of why a large percentage of men are started on this treatment when they don't benefit from it. Are the clinicians recommending it excessively or are the patients demanding it excessively? To be clear, although we see great benefit in the appropriate use of ADT for extending the lives of men with advanced prostate cancer, we know of no great benefit for older men to start on it without clear evidence that the benefits out rank the risks.
Reference:
Oderda M, Bertetto O, Barbera G, Calleris G, Falcone M, Filippini C, Marquis A, Marra G, Montefusco G, Peretti F, Gontero P. Appropriateness and complications of androgen deprivation therapy for prostate cancer: Can we do better? A retrospective observational analysis from a referral center. Urologia. 2023 Jan 26:3915603221149502. doi: 10.1177/03915603221149502 Epub ahead of print. PMID: 36703243.