Men starting androgen deprivation: systematic statin and blood pressure care lowered cholesterol, not events

Design

International, multicentre randomised trial, median 5.8 years

Population

2487 men with prostate cancer starting androgen deprivation therapy

Primary outcome

Hierarchical composite of cardiovascular events and risk-factor control (win ratio)

Effect

Win ratio 1.60 (95% CI 1.42 to 1.81); hard events HR 1.08 (0.79 to 1.49)

This international randomised trial enrolled 2487 men, mean age 68, with prostate cancer who had recently started or were about to start androgen deprivation therapy. Half received usual care; half were also referred to an internist or cardiologist who aimed for systolic pressure of 130 mmHg or lower and prescribed a statin regardless of cholesterol, alongside smoking and lifestyle advice. Follow-up was a median 5.8 years.

The hierarchical outcome, ranking cardiovascular death, heart attack, stroke, heart failure and then risk-factor control, favoured referral (win ratio 1.60, 95% CI 1.42 to 1.81). Almost all of that came from cholesterol, which was about 12 mg/dL lower, because more men were on statins. Blood pressure at close-out barely differed (131 against 133 mmHg), and the time to a hard cardiovascular event did not differ (hazard ratio 1.08, 0.79 to 1.49).

Androgen deprivation worsens weight, lipids and insulin resistance, and these men often die of cardiovascular disease rather than cancer. The trial shows a structured approach changes the numbers; it could not show it changes events. The sensible reading is that cardiovascular risk deserves the same review in these men as in anyone else of similar age, without assuming a specialist referral is the step that matters.

• Check blood pressure, lipids, HbA1c and smoking status when androgen deprivation starts.
• Assess statin eligibility in men on androgen deprivation using standard risk assessment.
• Recheck weight and glucose during treatment; androgen deprivation worsens both.
• Coordinate with the oncologist so cardiovascular care is not left to fall between teams.

Why it matters

A positive headline built on cholesterol numbers is not the same as fewer heart attacks.

Don't overread it

The benefit was on a surrogate; hard cardiovascular events did not differ.

The statistics, in plain English

A win ratio compares every intervention patient with every control patient, first on the most serious outcome and then down the list; 1.60 means the intervention 'won' 60% more comparisons than it lost. Here the wins came from cholesterol, the least serious item. The hazard ratio for hard events (1.08) has an interval running from a 21% reduction to a 49% increase, so the trial cannot tell whether events changed.

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