Risk of androgen deprivation therapy after active surveillance for prostate cancer: A real-world analysis

INTRODUCTION: Active surveillance (AS) allows men with favorable-risk prostate cancer (PC) to avoid or delay the toxicity of upfront treatment. However, whether these patients are at higher risk of subsequent treatment intensification with androgen deprivation therapy (ADT) is unknown. Herein, we examine real-world burden of ADT in men pursuing initial AS in the United States. METHODS: Retrospective cohort study of 38,573 men with localized PC managed with initial AS between 2009 and 2022 using the Merative MarketScan commercial and Medicare claims database. RESULTS: Median age was 60 (Inter quartile range [IQR] 56-65) and 64% had no/minimal comorbidity. The cumulative incidence of receiving any ADT after AS was 15.0% (95% Confidence Interval [95% CI:] 12.7%-17.7%). Patients diagnosed and managed in more contemporary years had a higher risk of subsequent ADT use. The cumulative incidence of definitive radiotherapy alone was 15.2% (95% CI: 13.8%-16.8%) and radiotherapy with concurrent ADT was 7.0% (95% CI: 5.7%-8.6%). Amongst those who received radiotherapy, the proportion receiving concurrent ADT within 5 and 10 years of diagnosis was 26% and 39%, respectively. CONCLUSIONS: Real-world US data show 1 in 6 men with PC ultimately underwent ADT after pursuing initial AS. Amongst men who ultimately received definitive radiotherapy, 1 in 3 received concurrent ADT. Improved patient selection-enhanced by modern imaging and biomarkers-may optimize outcomes while minimizing treatment intensification in men pursuing AS.