The authors note that their finding of no benefit from androgen deprivation therapy (ADT) in low-risk patients is consistent with those of other studies in this area. They previously found a borderline survival benefit for high-risk patients, but this was not confirmed in the current study.
Limitations of this observational study include differences in baseline disease characteristics between those who did and did not receive ADT; changes in disease and treatment trends (due to the long follow-up of almost 20 years); missing prostate-specific antigen data; the inclusion only of men aged ≥66 years; and lack of information on oral antiandrogen use. It is also possible that the study did not have sufficient power to detect a difference in survival, if there is one. The authors of a related Comment article note that such limitations must be balanced against the recognition that there are not likely to be any additional randomized trials in this area.
The authors conclude that there is a limited role for ADT as primary therapy for men with localised prostate cancer, and that these results should be considered alongside the associated adverse events and costs before consideration is made to starting treatment in this patient group.
The NICE clinical guideline on prostate cancer (2014) states that active surveillance should be offered as an option to men with low-risk localised prostate cancer for whom radical prostatectomy or radiotherapy is suitable. For those with intermediate- and high-risk localised prostate cancer, a combination of radical radiotherapy and ADT should be offered; active surveillance should be considered for those who do not wish to have immediate radical prostatectomy or radiotherapy.
The decision to proceed from an active surveillance regimen to radical treatment should be made in the light of the individual man's personal preferences, comorbidities and life expectancy. Radical treatment should be offered to men with localised prostate cancer who have chosen an active surveillance regimen and who have evidence of disease progression.