Androgen deprivation therapy in men with prostate cancer: how should the side effects be monitored and treated?

Adverse effects of androgen deprivation therapy (ADT) are a consequence of the induced sex steroid deficiency. ADT increases fat mass leading to insulin resistance and diabetes, and accelerates bone loss causing increased fracture risk. Given the high prevalence of cardiovascular disease and reduced bone density in ADT-naïve men with prostate cancer, the benefits of ADT have to be carefully weighed against its side effects, especially as a diagnosis of prostate cancer does not alter the life expectancy for most men. Men commencing ADT should be counselled about and be carefully monitored for these and other ADT-induced complications, which include fatigue, sexual dysfunction, hot flushes and anaemia. ADT-associated side effects should be prevented and treated in order that ADT-induced toxicity does not outweigh its benefits. Future clinical trials are needed: first, to better define the effects of ADT on survival in men with localized prostate cancer or with biochemical prostate-specific antigen recurrence; second, to delineate ADT-associated harm, especially with respect to cardiovascular events and fractures; and third, to test the efficacy of interventions designed to minimize ADT-related adverse outcomes. Such information will be essential to better quantify the risk-benefit ratio of ADT in the individual man with prostate cancer.