Endocrine Therapy for Prostate Cancer in Patients with Cardiovascular Disease

Primary Treatment Options

The American College of Cardiology recommends continuous androgen deprivation therapy (ADT) as the cornerstone of treatment for metastatic prostate cancer, with bilateral orchiectomy or LHRH agonists (goserelin, leuprolide) being equally effective for achieving castration 1, 2
For fit patients, ADT plus docetaxel chemotherapy significantly improves survival and is recommended as first-line treatment, according to the National Comprehensive Cancer Network 2, 4
Second-generation antiandrogens (apalutamide, enzalutamide, or abiraterone) plus ADT are Category 1 recommendations that improve both progression-free and overall survival, as stated by the American Urological Association 4

External beam radiotherapy plus neoadjuvant LHRH agonist for 3-6 months followed by adjuvant hormonal therapy for 2-3 years is the standard approach for locally advanced or high-risk disease, according to the European Association of Urology 5, 6
This combination improves prostate cancer-specific survival (HR 0.56; 95% CI 0.32-0.98) compared to radiotherapy alone, as reported by the European Association of Urology 6

The American Heart Association notes that GnRH agonists carry increased risk of myocardial infarction, sudden cardiac death, and stroke, which must be carefully weighed against treatment benefits in patients with pre-existing cardiovascular disease 1
Screen for metabolic syndrome complications including cardiovascular risk factors in men on long-term ADT, as recommended by the American Diabetes Association 3

Combined Androgen Blockade (CAB) provides minimal survival benefit (1-5% absolute reduction at 5 years) with number needed to treat of 20-100 patients, according to the American Society of Clinical Oncology 1
Nonsteroidal antiandrogen monotherapy shows equivalent survival to castration with potentially more attractive side-effect profile regarding sexual function, as stated by the European Association of Urology 1, 6

Abiraterone or enzalutamide are recommended for asymptomatic/mildly symptomatic chemotherapy-naïve metastatic CRPC, according to the National Comprehensive Cancer Network 2
Docetaxel 75 mg/m² every 3 weeks is recommended for symptomatic metastatic CRPC, as stated by the American Society of Clinical Oncology 2, 5

Zoledronic acid 4 mg IV every 3-4 weeks or denosumab 120 mg SC every 4 weeks prevents skeletal-related events in CRPC patients with bone metastases, according to the American Society of Clinical Oncology 3, 7
Single 8 Gy fraction of external beam radiotherapy provides equivalent pain relief to fractionated regimens (10 × 3 Gy) for symptomatic bone metastases, as reported by the European Association of Urology 3, 9, 10