Treatment
Intermittent Androgen Deprivation
Recommendation 4.1
➤ Intermittent therapy may be offered to men with high-risk biochemically
recurrent non-metastatic prostate cancer after RP and/or RT based
on evidence in meta-analyses of the non-inferiority of intermittent
androgen deprivation therapy (IADT) when compared to continuous
androgen deprivation therapy (CADT) with respect to overall survival.
This is further supported by evidence from four meta-analyses
testing superiority. Low-risk biochemical recurrence after radical
prostatectomy is defined as a PSA doubling time >1 year and pathologic
Gleason score <8. Low-risk biochemical recurrence after radiotherapy
is defined as an interval to biochemical recurrence >18 months and
clinical Gleason score <8. High-risk biochemical recurrence after
radical prostatectomy is defined as a PSA doubling time <1 year or a
pathologic Gleason score of 8–10. High-risk biochemical recurrence
after radiotherapy is defined as an interval to biochemical recurrence
<18 months or a clinical Gleason score of 8–10. Active surveillance may
be offered to men with low-risk biochemically recurrent non-metastatic
prostate cancer (Strong recommendation; EB-B-H).
Qualifying Statements for IADT
• Although men with noncastrate de novo metastatic prostate cancer were included
in the studies reviewed for this clinical question, alternative standard of care
therapies with proven survival benefits now exist, as outlined in Recommendation
1 to include ADT plus docetaxel, ADT plus abiraterone, ADT plus enzalutamide
or ADT plus apalutamide. Similar support for these existing standards of care
does not universally exist for men with LVD or those who develop M1 disease
after prior local therapy, and further research is needed. No specific additional
recommendation with respect to the use of IADT in the noncastrate metastatic
prostate cancer population was possible at this time because IADT has not been
studied in combination with additional cytotoxic or hormonal agents in this
population.
• Patients considering IADT should be made aware of the potential benefits of IADT
associated with the off-treatment intervals, such as reduced treatment side effects,
quality-of-life benefits and lower cost. As patients on IADT require close follow-up,
they must be motivated to adhere to frequent doctor visits for monitoring, even
during off-treatment periods.
