title: Patterns of Declining Use and the Adverse Effect of Primary Androgen Deprivation on All-cause Mortality in Elderly Men with Prostate Cancer.
abstract: BACKGROUND
  Primary androgen deprivation therapy (pADT) is commonly used to treat elderly men diagnosed with localized prostate cancer (CaP), despite the lack of evidence supporting its use.
  
  
  OBJECTIVE
  To examine the effect of pADT on mortality and to assess contemporary trends of pADT use in elderly men with CaP.
  
  
  METHODS
  Men older than 65 yr residing in Surveillance, Epidemiology, and End Results (SEER) registry areas diagnosed with localized or locally advanced CaP between 1992 and 2009 and not receiving definitive therapy.
  
  
  METHODS
  Propensity score (PS)-weighted Cox proportional hazards models were used to estimate the effect of pADT use on overall survival among patients receiving pADT. The interaction between comorbidity-adjusted life expectancy (LE) and pADT use was assessed within the Cox and PS-weighted models. Contemporary (2004-2009) trends for pADT use were analyzed by linear regression.
  
  
  CONCLUSIONS
  The primary cohort included 46 376 men, of whom 17 873 received pADT (39%). Patients with >10 yr LE had lower pADT utilization rates than patients with short LE. Between 2004 and 2009, the use of pADT in men with localized CaP decreased by 14% (from 36% to 22%). Relative to observation, pADT was associated with a survival disadvantage, with a hazard ratio for all-cause mortality of 1.37 (95% confidence interval 1.20-1.56). Limitations included biases not accounted for by the PS-weighted model, changes in CaP staging over the study period, the absence of prostate-specific antigen (PSA) data prior to 2004, and the limits of retrospective analysis to demonstrate causality.
  
  
  CONCLUSIONS
  The use of pADT in elderly men with localized CaP has decreased over time. For men forgoing primary definitive therapy, the use of pADT is not associated with a survival benefit compared to observation, and denies men an opportunity for cure with definitive therapy. The deleterious effect of pADT is most pronounced in men with prolonged LE.
  
  
  RESULTS
  In this report, we assessed the effect of primary androgen deprivation (pADT) on prostate cancer mortality and determined current trends in the use of pADT. We showed that use of pADT in men aged >65 yr with localized prostate cancer has decreased over time. We also found that pADT is detrimental to men with localized prostate cancer, and particularly men with longer life expectancy. Therefore, we conclude that ADT should not be used as a primary treatment for men with prostate cancer that has not spread beyond the prostate.
authors.affiliation: VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA.
authors.forename: Jesse D
authors.initials: JD
authors.lastname: Sammon
authors.affiliation: VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA.
authors.forename: Firas
authors.initials: F
authors.lastname: Abdollah
authors.affiliation: Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital / Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
authors.forename: Gally
authors.initials: G
authors.lastname: Reznor
authors.affiliation: VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Pucheril
authors.affiliation: Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Toni K
authors.initials: TK
authors.lastname: Choueiri
authors.affiliation: Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
authors.forename: Jim C
authors.initials: JC
authors.lastname: Hu
authors.affiliation: Department of Urology, Yale University, New Haven, CT, USA.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Kim
authors.affiliation: Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital / Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
authors.forename: Marianne
authors.initials: M
authors.lastname: Schmid
authors.affiliation: VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA.
authors.forename: Akshay
authors.initials: A
authors.lastname: Sood
authors.affiliation: Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada.
authors.forename: Maxine
authors.initials: M
authors.lastname: Sun
authors.affiliation: Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital / Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
authors.forename: Adam S
authors.initials: AS
authors.lastname: Kibel
authors.affiliation: Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Nguyen
authors.affiliation: VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA.
authors.forename: Mani
authors.initials: M
authors.lastname: Menon
authors.affiliation: Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital / Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA. Electronic address: qtrinh@partners.org.
authors.forename: Quoc-Dien
authors.initials: QD
authors.lastname: Trinh
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000726:Androgen Antagonists / Q000627:therapeutic use*; D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D009919:Orchiectomy; D016016:Proportional Hazards Models; D011471:Prostatic Neoplasms / Q000401:mortality / Q000628:therapy*; D012042:Registries; D012189:Retrospective Studies; D018426:SEER Program
chemical_list: D000726:Androgen Antagonists; D018931:Antineoplastic Agents, Hormonal
keywords: Androgen deprivation; Medicare; Prostate cancer; SEER