Are you concerned about dementia as a side effect of ADT?

May 10, 2019

"There’s mounting evidence that the risk for dementia increases with prolonged use. While impacting only a minority of patients, I think the risk is real," says one urologist.

"I’m always concerned about treatment side effects. Androgen suppression, of course, is an essential component of prolonging life for many patients with prostate cancer. But it can certainly impact their quality of life.

There’s mounting evidence that the risk for dementia increases with prolonged use. While impacting only a minority of patients, I think the risk is real.

But it’s all about benefits outweighing risks. Knowing how to navigate between quality and duration of life remains one of my biggest challenges. I share that information about any treatment with patients. ADT can prolong life many years; without it men would likely succumb to their disease.

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It’s hard to tell if I’m seeing dementia occur in men on ADT because of the patient’s age. Often, patients needing ADT are older, and older patients are at greater risk at baseline for dementia. Now studies are showing that patients on androgen deprivation are at greater risk of developing dementia when they’re older, as well.

So, am I concerned? Yes. Would it be enough for me to stop using it? Usually not.

I do leave the decision to the patient, but as I mentioned, most often the benefit-which is life prolongation-outweighs the risks.

I have a couple of patients who have been on ADT well into their 80s and 90s. When I met them, there was, perhaps, some baseline dementia. ADT might accelerate it, but I can’t tell.”

Matthew McCormack, MD / Reno, NV

Next: "I think the benefit of androgen deprivation outweighs the risk of side effects.""I’m not too concerned about it. I think the benefit of androgen deprivation outweighs the risk of side effects.

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I’ve used androgen deprivation for years and there’s more than one indication for using ADT-one is for metastatic prostate cancer and the other one is adjuvant therapy for either cryosurgery or radiation. For cryosurgery or radiation, the treatment is of very short-term duration. For metastatic prostate cancer, however, you’re talking long-term therapy, and it’s either that or they die from the metastatic disease.

But even with long-term treatment, I haven’t really noticed any dementia developing, to be honest. I’ve read about it, but I have not observed that in my practice.

Patients who need androgen deprivation tend to be older people. Metastatic cancer often occurs in older individuals and older individuals can suffer from dementia.

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I have seen other side effects from androgen deprivation-hot flashes, fatigue, and loss of muscle strength-but those aren’t as concerning when you’re considering the longevity ADT can add to the patient’s life, and the use of it definitely prolongs the patient’s life.”

Andrew Wolszczak, MD / Marathon, FL

Next:"We are concerned. There is new data coming out demonstrating a potential increase in dementia in men on ADT."

"We are concerned. There is new data coming out demonstrating a potential increase in dementia in men on ADT.

The problem is we don’t have many options in men with advanced prostate cancer. ADT just means depriving the patient of testosterone and has been a main treatment option for years. The old-fashioned method was to do an orchiectomy, which was a deforming and permanent procedure. That’s how the whole LHRH-agonist drugs came about. There were alternative treatments like estrogens, but they were associated with heart attack and stroke, so are no longer in use. As we use ADT, we’re having these discussions with patients.

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But the increased risk of dementia isn’t restricted to ADT. There’s another class of urologic drugs that’s used very commonly-anticholinergic medications for overactive bladder and urge incontinence. Studies have demonstrated long-term use of anticholinergic medications is associated with an increased risk of cognitive decline and dementia. Most concerning is the fact that some of these effects are not reversible when the medication is stopped. As these medications have been in use for years, they are often generic and inexpensive, and generally covered by health insurance.

Then there’s mirabegron, a beta-3 agonist, which does not seem to be associated with dementia. Unfortunately, as it is newer and more expensive, it can be very difficult to get covered by insurance.

As newer information about potential long-term cognitive side effects is discovered, I try to include this information in my discussion with patients.”

Diane Hartman, MD / Golden, CO