ONCOmmunity

Effects of Androgen Deprivation Therapy on Prostate Cancer Outcomes According to Competing Event Risk: Secondary Analysis of a Phase 3 Randomised Trial.

By: Loren K Mell, Stephanie L Pugh, Christopher U Jones, Tyler J Nelson, Kaveh Zakeri, Brent S Rose, Kenneth L Zeitzer, Elizabeth M Gore, Jean-Paul Bahary, Luis Souhami, Jeff M Michalski, Alan C Hartford, Mark V Mishra, Mack Roach, Matthew B Parliament, Kwang N Choi, Thomas M Pisansky, Siraj M Husain, Shawn C Malone, Eric M Horwitz, Felix Feng

University of California San Diego, Moores Cancer Center, San Diego, CA, USA. Electronic address: lmell@ucsd.edu.
2022-7-19; doi: 10.1016/j.eururo.2023.01.020

Abstract

Background

Previous studies indicate that the benefit of short-term androgen deprivation therapy (ADT) with radiotherapy (RT) for prostate cancer depends on competing risks.

Objective

To determine whether a quantitative method to stratify patients by risk for competing events (omega score) could identify subgroups that selectively benefit from ADT.

Design,

An ancillary analysis of NRG/RTOG 9408 phase 3 trial (NCT00002597) involving 1945 prostate cancer patients was conducted.

Intervention

Short-term ADT.

Outcome

We applied generalised competing event regression models incorporating age, performance status, comorbidity, T category, Gleason score (GS), and prostate-specific antigen (PSA), to stratify patients according to relative hazards for primary cancer-related events (distant metastasis or prostate cancer death) versus competing noncancer mortality. We tested interactions between ADT and subgroups defined by standard risk criteria versus relative risk (RR) using the omega score.

Results

T2b, higher GS, and higher PSA were associated with an increased RR for cancer-related versus competing mortality events (a higher omega score); increased age and comorbidity were associated with a decreased omega score. Of 996 patients with low-risk/favourable intermediate-risk (FIR) disease, 286 (28.7%) had a high omega score (≥0.314). Of 768 patients with unfavourable intermediate-risk disease, 175 (22.8%) had a low omega score. The overall discordance in risk classification was 26.1%. Both standard criteria and omega score identified significant interactions for the effect of ADT on cancer-related events and late mortality in low- versus high-risk subgroups. Within the low-risk/FIR subgroup, a higher omega score identified patients in whom ADT significantly reduced cancer events and improved event-free survival. Limitations are the need for external/prospective validation and lower RT doses than contemporary standards.

Conclusions

Stratification based on competing event risk is useful for identifying prostate cancer patients who selectively benefit from ADT.

Patient

We analysed the effectiveness of androgen deprivation therapy (ADT) for localised prostate cancer among patients, defined by the relative risk (RR) for cancer versus noncancer events. Among patients with traditional low-risk/favourable intermediate-risk disease, those with a higher RR benefitted from short-term ADT.