Treatment Options for Androgen Deprivation Therapy
In a program supported by Verity Pharmaceuticals, E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, discusses reinforcing consistent testosterone suppression in ADT and the role of triptorelin with Scott B. Sellinger, MD, President of Advanced Urology Institute and a Partner at Southeastern Urological Center in Tallahassee, Florida, and Paul R. Sieber, MD, FACS, President of Keystone Urology Specialists in Lancaster, Pennsylvania. They discuss the history of different forms of androgen deprivation therapy (ADT), go into detail about the potency and effectiveness of the luteinizing hormone-releasing hormone (LHRH) analog triptorelin, and argue for the importance of regularly testing T and ensuring compliance to dosing schedules to avoid T flare.
Dr. Crawford begins by asking Drs. Sellinger and Sieber what the goal of ADT is, and whether there are any other goals of ADT, to which they respond, respectively: to lower testosterone (T), and to monitor the patient beyond just their prostate specific antigen (PSA) level. Dr. Crawford then briefly summarizes the history of ADT and describes the different current options for hormone therapy, including estrogens, surgical castration (i.e., orchiectomy), luteinizing hormone-releasing hormone (LHRH) agonists, LHRH antagonists, antiandrogens, combined androgen blockade, and 17,20 lyase inhibitors. He notes that orchiectomy, once called the “gold standard” is not done very often anymore, that estrogens are associated with cardiovascular risks, and that antiandrogens are associated with gynecomastia.
Dr. Crawford proceeds to go into detail about the established survival benefits of adding in an antiandrogen to an LHRH compound, but notes the problem of testosterone escapes. Dr. Sellinger then explains that there is mounting evidence supporting a new castration level of <20 ng/dL, and explains that late dosing is a problem since inconsistent T levels lead to escapes. Speaking as a practitioner, Dr. Sieber underscores that late dosing is extremely common. Dr. Sellinger also argues that it is necessary to test more regularly for T. He then discusses the mechanism of action of triptorelin, a particularly potent LHRH analog, and compares it to degarelix and relugolix. Dr. Sieber goes further into the history of triptorelin which he notes was registered the same year as leuprolide and has been more widely used in Europe than in the US. Dr. Sieber highlights research that indicates triptorelin is more effective at maintaining low levels of T than leuprolide.
The program concludes with key take-home messages, and Drs. Crawford, Sellinger, and Sieber emphasize that not all forms of ADT are equally effective, and that monitoring patients to ensure they are complying with treatment and keeping T levels low is necessary.
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ABOUT THE AUTHOR
Researcher-physician E. David Crawford, MD, Jack A. Vickers Director of Prostate Research and Professor of Urology at the University of California, San Diego, has devoted his career in medicine to educating the public about men's health issues and finding effective techniques and procedures to address prostate cancer, the most common malignancy affecting men in the United States.
Scott B. Sellinger, MD, FACS, is president of Advanced Urology Institute in Tallahassee, Florida. He has been a partner at Southeastern Urological Center, now a division of Advanced Urology Institute, since 1991. Dr. Sellinger earned his medical degree from the University of Florida in Gainesville, prior to which he received his BS degree in chemistry from Syracuse University in New York. He completed his urology residency at the University of Florida and has lived in Tallahassee for over 32 years.
Dr. Sellinger was president of the Capital Medical Society in 2003 and served as president of the Florida Urological Society in 2005. In 2018, Dr. Sellinger served as president of the Southeastern Section of the American Urological Association (SESAUA). In 2019, he served as president of the American Association of Clinical Urologists (AACU). In addition to his urology specific work, Dr. Sellinger has developed a special interest in risk management and prevention of medical errors and has lectured extensively on this subject. He is also interested in large group practice development and management. For several years, Dr. Sellinger has served on the board of Advanced Urology Institute (AUI) representing his care center in Tallahassee. In January 2021, he became the second president of AUI, now one of the largest independent urology practices in the United States. Dr. Sellinger currently chairs the Advanced Prostate Cancer (APC) committee and oversees seven APC clinics within AUI. Since 2015, he has also served on the Large Urology Group Practice Association (LUGPA) Board of Directors, where he currently serves as President-Elect. At LUGPA, he is proud to represent over 2300 urologists by working to preserve and advance the independent practice of urology.
