Immediate vs. Delayed ADT for Recurrent Prostate Cancer

Despite high cure rates with radical prostatectomy or radiation therapy for localized prostate cancer, approximately 30% of men experience a rising prostate-specific antigen (PSA) level, a condition known as biochemical recurrence (BCR) [1–3]. Elevations in PSA may indicate local or distant recurrence. Thus, once BCR occurs the patient is presumed to have recurrent prostate cancer. Among patients who develop BCR, approximately one-third will develop clinical recurrence within 8 years from BCR [4]. Depending on the type of initial local therapy, reasonable options for BCR patients include observation with close surveillance, salvage radical prostatectomy, salvage radiation therapy, androgen deprivation therapy (ADT), and enrollment in investigational clinical trials. Of these options, ADT has long been accepted and widely used as an effective treatment for patients with advanced, recurrent, and disseminated prostate cancer, but it is associated with disadvantages including side effects as well as substantial cost. Not all patients with recurrent prostate cancer have the same prognosis, and understanding clinical factors that affect developing metastatic disease is crucial. Clinicians must balance a patient’s competing benefit of survival gain and potential risk of an increased morbidity and impair quality of life. The trade-off between the relative benefits and harms of ADT in patients with recurrent prostate cancer is essential for consideration regarding in whom, how, and when it should be used. One of the most prominent questions in the treatment of patient with recurrent prostate cancer is that whether to initiate ADT immediately upon an increasing PSA level or to delay its use until the development of symptomatic or radiographic progression occurs. Despite the proven efficacy of ADT in recurrent prostate cancer, consensus as to the optimal time to initiate ADT remains in debate because results from clinical trials are mixed.