Editorial Comment.

Abstract

Open AccessJournal of UrologyAdult Urology1 Sep 2021Editorial CommentThis article comments on the following:Timing of Androgen Deprivation Treatment for Men with Biochemical Recurrent Prostate Cancer in the Context of Novel Therapies David VanderWeele, and Maha Hussain David VanderWeeleDavid VanderWeele Division of Hematology/Oncology, Department of Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois More articles by this author , and Maha HussainMaha Hussain Division of Hematology/Oncology, Department of Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001797.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Many patients with prostate cancer (PCa) with biochemical recurrence (BCR) post-definitive therapy receive androgen deprivation therapy (ADT) before developing metastasis, despite lack of prospective data to support its routine use. The TOAD trial concluded overall survival (OS) improves with immediate ADT. However, it had several limitations, including inclusion of patients who did not receive definitive therapy; incomplete accrual (293 patients vs 750 planned); short followup (5 years); and a larger decrease in death from other causes than from PCa.1 Several retrospective studies have shown no benefit for ADT in BCR. A study utilizing the CaPSURE™ database found little difference in outcome when initiating ADT within 3 months of BCR vs delaying ADT at least 2 years or until progression, defined multiple ways.2 Another observational study including 5,804 patients found no improvement in all-cause or PCa-specific mortality from salvage ADT, though subset analysis suggested some benefit for patients with high risk disease.3 The question of how best to manage BCR remains controversial. Marshall et al contribute to this debate by examining outcomes for patients with high risk BCR (defined as PSA doubling time <10 months after radical prostatectomy) from 2 large institutions and who did not receive ADT until developing metastasis. They contrast outcomes with data from phase III trials of androgen receptor-targeted therapy in nonmetastatic castration resistant PCa (nmCRPC). Although different populations, outcomes of high-risk BCR patients who delayed treatment compared favorably to nmCRPC on intensified therapy; median metastasis-free 192 months and OS 204 months from time of local treatment. These data provide context for patients with BCR and providers on whether to undergo ADT for years despite unproven benefit and quality of life impact. New imaging may help or further add to the controversy, since BCR patients may have metastases on newer imaging. Until definitive data are available, men with BCR should be counselled regarding the lack of data to support ADT benefit in nonmetastatic BCR.