Presenter(s)
J. Janopaul-Naylor1, D. Patil2, N. Sebastian3, K. Salari4, B. Hershatter5, C. Gaffney6, M. G. Sanda7, S. S. Joshi7, P. R. Patel5, A. Jani8, and S. A. Patel8; 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 2Emory University, Atlanta, GA, 3Emory Proton Therapy Center, Atlanta, OH, 4Emory University, Atlanta, GA, United States, 5Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, 6Memorial Sloan Kettering Cancer Center, New York, NY, 7Department of Urology, Emory University School of Medicine, Atlanta, GA, 8Department of Radiation Oncology, Emory University, Atlanta, GA
Purpose/Objective(s): Men with favorable risk prostate cancer have high cure rates with prostatectomy (RP) or definitive prostate radiotherapy (RT) alone. Conservative management with active surveillance (AS) offers an alternative to definitive treatment without compromise in long-term survival. However, whether more intense future treatment, namely androgen deprivation therapy (ADT), may be required for patients pursuing AS is unknown. We aimed to quantify the lifetime risk of ADT use for men with localized prostate cancer pursuing AS.
Materials/Methods: We performed a retrospective, population-based study using real world claims data from Merative MarketScan ® Commercial and Medicare Databases between 2009 and 2023. We included 38,573 patients with non-metastatic prostate cancer undergoing AS for at least 1 year and measured cumulative incidence of any ADT, as well as incidence of definitive prostate RT with or without concurrent ADT.
Results: Amongst this cohort, the median age was 60 (IQR 56-65) and 64% had no/minimal comorbidity. The lifetime cumulative incidence of receiving any ADT was 15.0% (95% CI: 12.7% - 17.7%) with a median time to ADT of 26.8 months (IQR 16.8 – 45.8 months). The cumulative incidence of RT alone was 15.2% (95% CI: 13.8% - 16.8%) and of RT plus concurrent ADT was 7.0% (95% CI: 5.7% - 8.6%). Among patients who received RT, the proportion who received concurrent ADT within 5, 10, and 15 years of initial diagnosis were 26%, 39%, and 46%, respectively. On multivariable regression analysis, older age (HR 2.68, 95% CI: 2.27 – 3.16, p<0.001) and greater comorbidity index (HR 1.23, 95% CI: 1.02 – 1.48, p=0.020) were more likely to receive any ADT. Excluding men >75 years old and/or with multiple medical comorbidities, the lifetime cumulative incidence of any ADT was 13.4% (95% CI: 10.9% - 16.5%), of RT alone was 14.1% (95% CI: 12.7% - 15.7%), and of RT plus concurrent ADT was 6.6% (95% CI: 5.1% - 8.5%).
Conclusion: In this US population database of men with localized prostate cancer pursuing initial AS, 1 in 6 ultimately received ADT at some point in their lifetime. Amongst men who ultimately pursue curative RT, 1 in 3 will receive concurrent ADT, with risk increasing linearly over time on AS. These patients achieve high rates of cure with definitive treatment upfront without the short- and long-term sequelae of ADT. Optimal patient selection for AS with use of MR targeted biopsy, genomic and histopathologic biomarkers, and accurate life-expectancy calculators will facilitate optimal oncologic outcomes while reducing risk of treatment escalation.