To the Editor: Dr Nanda and colleagues1 reported that hormonal therapy (HT) for prostate cancer was not associated with increased mortality in men with a single coronary artery disease (CAD) risk factor. However, their analysis may have underestimated the risk to patients with diabetes.
Diabetes, unlike hypertension and hypercholesterolemia, is classified as a CAD risk equivalent, meaning that patients with diabetes have a risk comparable with nondiabetic patients with established CAD.2 Moreover, androgen suppression is associated with insulin resistance,3 possibly increasing the risk of both cardiac and noncardiac complications of diabetes. Because of this, patients with diabetes should be analyzed as a separate group, lest evidence of harm be diluted or obscured by benefit to lower-risk patients. In addition, diabetes and hypertension frequently coexist,4 so the risk calculated for patients with normotensive diabetes should not be considered representative of patients with diabetes in general.