Androgen deprivation for prostate cancer: when and how, the good and the bad

Androgen deprivation therapy (ADT) is the mainstay systemic treatment of prostate cancer because of the androgen dependence of the disease. Although ADT has long been used to manage prostate cancer, its use continues to evolve as data from clinical trials mature and long-term effects are recognized. For patients with localized disease and high-risk features, short and long courses of ADT as neoadjuvant/adjuvant therapy have been shown to improve survival when used with radiation therapy, but this has not been demonstrated with radical prostatectomy. The role of ADT with salvage radiotherapy after radical prostatectomy continues to be defined. Lifelong ADT in patients with node-positive disease after surgery or with radiation is also associated with increased survival. Increasingly though, the adverse effects of ADT that go beyond those on libido and hot flashes are being acknowledged. The metabolic effects on lipids, glycemic control, and bone loss from ADT can lead to an increased risk of cardiovascular events and osteoporosis, which needs to be considered when deciding to initiate and treat patients with ADT. Large, randomized trials comparing intermittent to continuous ADT have now been reported. Although the hope for improved cancer outcomes with intermittent therapy has not come to realization, an interrupted approach to therapy may help mitigate some of the negative effects of ADT in selected patients by allowing for off-treatment intervals.