Long-term effects of androgen deprivation therapy in prostate cancer patients

Does androgen-deprivation therapy accelerate the development of frailty in older men with prostate cancer?: a conceptual review

The majority of men with prostate cancer are aged > or =65 years. Men, as they age, are more likely to suffer from impaired physical function. The standard treatment for recurrent prostate cancer is androgen-deprivation therapy (ADT). Well-established toxicities from ADT include lean weight loss or sarcopenia, muscle weakness, fatigue, and reduced activity levels. Frailty is a term from geriatrics that describes older individuals with limited physiologic reserve who are at significant risk for adverse outcomes, including falls, disability, hospitalization, and death. An increasingly accepted definition of frailty is a syndrome in which > or =3 of the following are present: unintentional (lean) weight loss > or =10 pounds in the past year, weakness (measured by grip strength), slow walking speed, self-reported exhaustion, and low physical activity. This clinical syndrome overlaps closely with the known toxicities of ADT. In addition, alterations in the inflammatory system, neuroendocrine system, and energy production are associated with this syndrome, as evidenced by biomarkers such as C-reactive protein, interleukin-6, and tumor necrosis factor-alpha. For this article, the authors reviewed the evidence for the effect of ADT on each of the 5 frailty components plus the identified biomarkers, and the evidence indicates that ADT may accelerate the development of frailty in vulnerable older men with prostate cancer. Given the association of frailty with important clinical outcomes such as hospitalization and death, this potential consequence of ADT should be considered carefully when initiating therapy in older patients with recurrent prostate cancer.

The association between sexual function, pain, and psychological adaptation of men diagnosed with chronic pelvic pain syndrome type III

INTRODUCTION

Prostatitis/chronic pelvic pain syndrome (CPPS) is known to have a negative impact on quality of life, especially on intimate relationships and sexual function. Information is, however, missing on the contribution of demographic and psychological variables to sexual variables. AIM. We compared the sexual function of men with CPPS to men without pain, and examined the relationship between the sexual, demographic, and psychological measures in men with CPPS.

MAIN OUTCOME MEASURES

Self-report questionnaires assessing demographic, pain, sexual function, and psychological adaptation.

METHODS

The sample consisted of 72 men diagnosed with CPPS and 98 men without any pain condition. Self-report questionnaires measuring demographic, pain, and sexual function were completed once at the eligibility visit by all subjects. CPPS subjects completed additional questionnaires related to pain and psychological adaptation.

RESULTS

CPPS subjects differed from controls by reporting significantly less frequent sexual desire or thoughts, less frequent sexual activities, less arousal/erectile function, less orgasm function, and higher frequencies of genital pain during/after intercourse. When we adjusted for age and marital status, the difference between groups remained for thoughts/desire, frequency of sexual activity, and arousal/erectile function. Analysis of factors related to sexual function in CPPS subjects included pain status and psychological adaptation. Results showed that frequency of sexual activity decreased with increasing depression, whereas arousal/erectile function decreased with increasing pain symptoms and stress appraisal. Orgasm function decreased with increasing depression and pleasure/satisfaction decreased with increasing pain symptoms, stress appraisal, and decreasing belief of a relationship between emotions and pain.

CONCLUSIONS

We found a differential sexual profile for men with CPPS when compared to men without pain. The results suggest that interventions addressing psychological factors affecting sexual responses should be further studied in prospective clinical trials as one possible way to improve sexual function and satisfaction in men with CPPS.

Androgen deprivation therapy for prostate cancer: effects on hand function

OBJECTIVES

Prostate cancer is the most frequently diagnosed malignancy. Luteinizing hormone-releasing hormone (LH-RH) agonists are used in most patients with locally advanced and metastatic prostate cancer, and decrease testosterone production. We aimed to find out the effects of androgen deprivation therapy with LH-RH agonist on the hand function, quality of life, and mood of the patients with prostate cancer.

SUBJECTS

A total of 20 patients with locally advanced prostate cancer and 20 age-matched healthy men were included in the study as LH-RH and control groups, respectively.

MAIN MEASURES

Age, body mass index, occupation and dominant hand, physical activity level, Beck depression inventory scores, 15D quality of life questionnaire scores, and Duruoz hand index scores were recorded. Handgrip strength was tested in the dominant hand using the Jamar hand dynamometer (Sammons Preston, Inc., Bollingbrook, IL). The Grooved Pegboard Test was used to test manual dexterity. Serum concentrations of total and free testosterone, estradiol levels were measured.

RESULTS

There were no differences between the groups in body mass index, physical activity level, and age (P > 0.05). Serum total and free testosterone, estradiol level, and the mean grip strength score were statistically lower in the LH-RH group. Manual dexterity was diminished in the LH-RH group (P < 0.001). The Duruoz hand index, and Beck depression inventory and 15D quality of life questionnaire scores were statistically lower in the LH-RH group (P < 0.005). We found a correlation between handgrip strength, dexterity, Beck depression inventory scores, 15D quality of life questionnaire scores, and total and free testosterone.

CONCLUSION

Men with low testosterone levels caused by androgen deprivation therapy have worse grip strength, dexterity, 15D quality of life questionnaire scores, and depressive symptoms than age-matched men who have not received androgen deprivation therapy.

Physical function in men with prostate cancer on androgen deprivation therapy

BACKGROUND AND PURPOSE

Androgen deprivation therapy (ADT) has become an increasingly standard intervention for both early and advanced stages of prostate cancer; however, decreased physical function and hypogonadism have been reported in men receiving ADT. The objectives of this study were: (1) to determine whether ADT (and hypogonadism) resulted in decreased strength and mobility and (2) to examine the effect of ADT on an associated test of cognitive and motor function by assessing visuomotor performance.

SUBJECTS AND METHODS

Physical function, walking speed, visuomotor performance, gonadal status, body composition, and Comorbidity Disease Index (CMDI) scores were assessed in a cohort of 100 participants that included: (1) men with prostate cancer who were not on ADT, (2) men with prostate cancer who were on short-term ADT (<6 months), (3) men with prostate cancer who were on long-term ADT (> or =6 months), and (4) control subjects who did not have prostate cancer.

RESULTS

Walking speed varied significantly across the 4 groups, even after adjusting for age, CMDI, and percentage of body fat. Age and CMDI were significantly associated with measurements of physical performance. Adjusted for covariates, men on long-term ADT walked 0.18 m/s slower than the control subjects. Physical function also varied significantly across the 4 groups. Androgen deprivation therapy did not have a significant effect on visuomotor performance.

DISCUSSION AND CONCLUSION

The results suggest that ADT has a significant effect on walking speed and physical performance in men with prostate cancer.

Cross-sex pattern of bone mineral density in early onset gender identity disorder

Hormonally controlled differences in bone mineral density (BMD) between males and females are well studied. The effects of cross-sex hormones on bone metabolism in patients with early onset gender identity disorder (EO-GID), however, are unclear. We examined BMD, total body fat (TBF) and total lean body mass (TLBM) in patients prior to initiation of sex hormone treatment and during treatment at months 3 and 12. The study included 33 EO-GID patients who were approved for sex reassignment and a control group of 122 healthy Norwegians (males, n=77; females, n=45). Male patients (n=12) received an oral dose of 50 mug ethinylestradiol daily for the first 3 months and 100 mug daily thereafter. Female patients (n=21) received 250 mg testosterone enantate intramuscularly every third week. BMD, TBF and TLBM were estimated using dual energy X-ray absorptiometry (DXA). In male patients, the DXA measurements except TBF were significantly lower compared to their same-sex control group at baseline and did not change during treatment. In female patients, the DXA measurements were slightly higher than in same-sex controls at baseline and also remained unchanged during treatment. In conclusion, this study reports that body composition and bone density of EO-GID patients show less pronounced sex differences compared to controls and that bone density was unaffected by cross-sex hormone treatment.

Exercise can prevent and even reverse adverse effects of androgen suppression treatment in men with prostate cancer

Side effects accompanying androgen deprivation therapy (ADT), including sarcopenia, loss of bone mass and reduction in muscle strength, can compromise physical function, particularly in older patients. Exercise, specifically resistance training, may be an effective and cost-efficient strategy to limit or even reverse some of these adverse effects during and following therapy. In this review, we discuss common morphological and physiological ADT-related side effects or 'Androgen Deprivation and Sarcopenia-Related Disorders' and the existing clinical trials incorporating physical exercise in prostate cancer patients receiving active therapy. Further, training concepts and guidelines are provided for prescribing resistance exercise programs for this population.

Glucose intolerance during hormonal therapy for prostate cancer

The aim of this study was to examine the influence of hormonal therapy (HT) on glucose metabolism in prostate cancer (PCa) patients. Fifty-two PCa patients receiving HT with gonadotropin-releasing hormone (GnRH) analogues and/or antiandrogen drugs were enrolled in this study. Both blood and urine samples were taken a few hours after breakfast before and after HT, and glucose levels in the blood and urine were measured. Elevations of blood glucose levels of 30-50, 50-100 and over 100 mg/dl after HT as compared with the levels before HT were observed in two, eight and five patients, respectively. Urine examination revealed deterioration of glucosuria in seven patients. The mean blood glucose level after HT was significantly higher than that measured before HT. The elevation of blood glucose level significantly correlated with concurrence of diabetes mellitus (DM) and higher body mass index (BMI) before HT. Deterioration of glucosuria significantly correlated with the concurrence of DM. HT for PCa patients, especially with concurrent DM or obesity, induces elevation of the blood glucose level and deterioration of glucosuria. Therefore, glucose intolerance should be considered during HT for PCa.

Resistance training and reduction of treatment side effects in prostate cancer patients

PURPOSE

To examine the effect of progressive resistance training on muscle function, functional performance, balance, body composition, and muscle thickness in men receiving androgen deprivation for prostate cancer.

METHODS

Ten men aged 59-82 yr on androgen deprivation for localized prostate cancer undertook progressive resistance training for 20 wk at 6- to 12-repetition maximum (RM) for 12 upper- and lower-body exercises in a university exercise rehabilitation clinic. Outcome measures included muscle strength and muscle endurance for the upper and lower body, functional performance (repeated chair rise, usual and fast 6-m walk, 6-m backwards walk, stair climb, and 400-m walk time), and balance by sensory organization test. Body composition was measured by dual-energy x-ray absorptiometry and muscle thickness at four anatomical sites by B-mode ultrasound. Blood samples were assessed for prostate specific antigen (PSA), testosterone, growth hormone (GH), cortisol, and hemoglobin.

RESULTS

Muscle strength (chest press, 40.5%; seated row, 41.9%; leg press, 96.3%; P < 0.001) and muscle endurance (chest press, 114.9%; leg press, 167.1%; P < 0.001) increased significantly after training. Significant improvement (P < 0.05) occurred in the 6-m usual walk (14.1%), 6-m backwards walk (22.3%), chair rise (26.8%), stair climbing (10.4%), 400-m walk (7.4%), and balance (7.8%). Muscle thickness increased (P < 0.05) by 15.7% at the quadriceps site. Whole-body lean mass was preserved with no change in fat mass. There were no significant changes in PSA, testosterone, GH, cortisol, or hemoglobin.

CONCLUSIONS

Progressive resistance exercise has beneficial effects on muscle strength, functional performance and balance in older men receiving androgen deprivation for prostate cancer and should be considered to preserve body composition and reduce treatment side effects.

Long-term quality of life among Dutch prostate cancer survivors: results of a population-based study

BACKGROUND

In this report, the authors describe the health-related quality of life (HRQL) of long-term prostate cancer survivors 5 to 10 years after diagnosis and compare it with the HRQL of an age-matched, normative sample of the general Dutch population.

METHODS

The population-based Eindhoven Cancer Registry was used to select all men who were diagnosed with prostate cancer from 1994 to 1998. Nine hundred sixty-four patients received questionnaires (the 36-item Short Form Health Survey [SF-36] and the Quality of Life-Cancer Survivors questionnaire), and 780 of 964 patients responded (81%).

RESULTS

Unselected, long-term prostate cancer survivors reported comparable HRQL scores but worse General Health Perceptions and better Mental Health scores than an age-matched, normative population. Patients who underwent radical prostatectomy had the highest physical HRQL, followed by patients who received 'watchful waiting,' and patients who received radiotherapy. Patients who received hormone treatment, in general, had the lowest physical HRQL.

CONCLUSIONS

The results of this study suggested that the long-term HRQL of prostate cancer survivors may vary significantly as a function of the type of primary treatment. Because baseline differences between treatment groups cannot be excluded as part of the explanation for these differences, the current findings need to be verified in longitudinal studies.

Long-term side effects of androgen deprivation therapy in men with non-metastatic prostate cancer: A systematic literature review

Increasing numbers of men with non-metastatic disease are receiving androgen deprivation therapy (ADT) for a variety of indications, some of which are supported by evidence from randomized trials. Balanced against possible survival benefits and better disease control are data that ADT adversely affects quality of life, particularly in the areas of sexual function, physical function, and energy. There is some evidence of worsening upper extremity physical strength but no clear evidence of decline in daily function with ADT. The impact of ADT on cognitive function is not clear at this time. ADT is associated with declines in bone mineral density within 6-12 months of commencing treatment, with increased fracture rates within 5 years of treatment. ADT use is also associated with a 10-15g/L decline in hemoglobin, although the clinical significance of this drop appears to be limited for most patients. It is reasonable for physicians who are about to start men on ADT to obtain a baseline bone mineral density, to counsel them about the impact on sexual function and possible treatments for sexual dysfunction, and to encourage regular exercise. Further insight into adverse effects of ADT and strategies to minimize these adverse effects await data from ongoing studies.

Secondary osteoporosis: a review of the recent evidence

OBJECTIVE

To review several causes of secondary osteoporosis as well as screening recommendations for underlying disorders.

METHODS

We conducted a review of the literature on many of the causes of osteoporosis that have been published during the past 15 years, focusing on those sources available from 2000 through the present. Indeed, more than two-thirds of the articles that we reviewed were printed during the past 6 years. These reports examined secondary osteoporosis in general, as well as many of the specific causes.

RESULTS

Secondary osteoporosis occurs in almost two-thirds of men, more than half of premenopausal and perimenopausal women, and about one-fifth of postmenopausal women. Its causes are vast, and they include hypogonadism, medications, hyperthyroidism, vitamin D deficiency, primary hyperparathyroidism, solid organ transplantation, gastrointestinal diseases, hematologic diseases, Cushing's syndrome, and idiopathic hypercalciuria. These causes have their own pathogenesis, epidemiologic features, and effect on the skeleton.

CONCLUSION

The causes of secondary osteoporosis are numerous, and an understanding of their characteristics with respect to bone density and potential fracture risk is essential in the management of osteoporosis. A heightened awareness of the possibility of their existence is necessary to provide optimal care.

Metabolic syndrome in men with prostate cancer undergoing long-term androgen-deprivation therapy

PURPOSE

Prostate cancer (PCa) is one of the most common cancers in men. Men with recurrent or metastatic PCa are treated with androgen-deprivation therapy (ADT), resulting in profound hypogonadism. Because male hypogonadism is a risk factor for metabolic syndrome and men with PCa have high cardiovascular mortality, we evaluated the prevalence of metabolic syndrome in men undergoing long-term ADT.

PATIENTS AND METHODS

This was a cross-sectional study. We evaluated 58 men, including 20 with PCa undergoing ADT for at least 12 months (ADT group), 18 age-matched men with nonmetastatic PCa who had received local treatment and were recently found to have an increasing prostate-specific antigen (non-ADT group), and 20 age-matched controls (control group). Men in the non-ADT and control groups were eugonadal. Metabolic syndrome was defined according to the Adult Treatment Panel III criteria.

RESULTS

Mean age was similar among the groups. Men on ADT had significantly higher body mass index and lower total and free testosterone levels. The prevalence of metabolic syndrome was higher in the ADT group compared with the non-ADT (P < .01) and control (P = .03) groups. Among the components of metabolic syndrome, men on ADT had a higher prevalence of abdominal obesity and hyperglycemia. Androgen-deprived men also had elevated triglycerides compared with controls (P = .02). The prevalence of hypertension and low high-density lipoprotein levels were similar.

CONCLUSION

These data suggest that metabolic syndrome was present in more than 50% of the men undergoing long-term ADT, predisposing them to higher cardiovascular risk. Abdominal obesity and hyperglycemia were responsible for this higher prevalence. We recommend prospective studies to further delineate this association.

Prevention and management of osteoporosis in men receiving androgen deprivation therapy: a survey of urologists and radiation oncologists

OBJECTIVES

To determine the current practice of clinicians in the diagnosis and management of osteoporosis among men taking androgen deprivation therapy (ADT), because ADT leads to decreased bone mineral density (BMD) and fractures.

METHODS

We sent out a survey to Canadian urologists and radiation oncologists. The survey included questions about BMD testing, treatment practices, referral patterns, and risk of osteoporosis.

RESULTS

The surveys were returned by 170 of 294 respondents (response rate 58%). Few respondents would obtain a baseline BMD in patients starting ADT. Forty percent would order a repeat BMD test after starting ADT if the baseline BMD were normal or unknown, but more than two thirds would if the baseline BMD showed osteoporosis. In men with a normal BMD starting ADT, respondents recommended weight-bearing exercises (58%), calcium (50%), vitamin D (47%), and bisphosphonate (6%) supplements. In men with osteoporosis at baseline, the use of nonprescription therapies increased slightly and bisphosphonate use increased to 44%. If osteoporosis were diagnosed, 11% would treat the patient themselves. The estimated risk of developing osteoporosis within 1 year of starting ADT with a normal baseline BMD ranged from 0% to 90% (median 20%).

CONCLUSIONS

To our knowledge, this is the first survey of its kind. The key findings included that few physicians would order a baseline BMD test, would prescribe bisphosphonates for prevention but almost one half would consider bisphosphonates to treat established osteoporosis, and wide variations exist in the practice patterns and risk perception surrounding ADT-related osteoporosis. Evidence-based guidelines are needed to help physicians deal effectively with osteoporosis prevention and management among men taking ADT.

Lipoprotein profile in men with prostate cancer undergoing androgen deprivation therapy

Sex steroids are known to modulate serum lipoproteins. Studies have suggested that serum testosterone levels are associated with a beneficial lipid profile. Androgen deprivation therapy (ADT) is employed in the treatment of recurrent and metastatic prostate cancer (PCa), resulting in profound hypogonadism. As male hypogonadism unfavorably influences lipid profile and men with PCa have high cardiovascular mortality, we evaluated the effects of long-term ADT on fasting lipids. This Cross-sectional study was conducted in a university-based research institution. We evaluated 44 men, 16 undergoing ADT for at least 12 months before the study (ADT group), 14 age-matched eugonadal men with non-metastatic PCa who were status post prostatectomy and/or radiotherapy and not on ADT (non-ADT group) and 14 age-matched eugonadal controls (Control group). None of the men had known history of diabetes or dyslipidemia. Mean age was similar in the three groups (P = 0.37). Serum total (P < 0.01) and free (P < 0.01) testosterone levels were lower in the ADT group compared to the other groups. Men on ADT had higher body mass index (BMI) compared to the other groups (P < 0.01). Men in the ADT group had significantly higher levels of total cholesterol compared to the other two groups (P = 0.03). After adjustment for BMI, men on ADT continued to have significantly higher fasting levels of total cholesterol (P = 0.02), LDL cholesterol (P = 0.04) and non-HDL cholesterol (P = 0.03) compared to the control group. No significant differences were seen in the levels of other lipoproteins between the three groups. These data show that men undergoing long-term ADT have higher total and LDL cholesterol than age-matched controls. Long-term prospective studies are needed to determine the time of onset of changes in these lipoproteins while on ADT and the influence of these changes on cardiovascular mortality.

Hyperglycemia and insulin resistance in men with prostate carcinoma who receive androgen-deprivation therapy

BACKGROUND

Prostate carcinoma (PCa) is one of the most common malignancies in men. Androgen-deprivation therapy (ADT) is used frequently in the treatment of recurrent and metastatic PCa, rendering these men hypogonadal. Because male hypogonadism is associated with an unfavorable metabolic profile, and men with PCa have high cardiovascular mortality, the authors evaluated the effects of long-term ADT on fasting glucose levels, insulin levels, and insulin resistance.

METHODS

To evaluate the long-term effects of ADT on fasting glucose and insulin resistance in men with PCa who received ADT and to determine whether these metabolic alterations are a result of hypogonadism, the authors conducted a cross-sectional study at a university-based research institution in the United States. In total, 53 men were evaluated, including 18 men with PCa who received ADT for at least 12 months prior to the onset of the study (the ADT group), 17 age-matched men with nonmetastatic PCa who had undergone prostatectomy and/or received radiotherapy and who were not receiving ADT (the non-ADT group), and 18 age-matched controls (the control group). None of the men had a known history of diabetes mellitus.

RESULTS

The mean age was similar in all 3 groups (P=0.33). Serum total testosterone levels (P<0.0001) and free testosterone levels (P<0.0001) were significantly lower in the ADT group compared with the other groups. Men in the ADT group had a higher BMI compared with the other groups (overall P=0.005). After adjustment for age and BMI, men in the ADT group had significantly higher fasting levels of the following parameters: 1) Glucose levels were 131.0+/-7.43 mg/dL in the ADT group compared with 103.0+/-7.42 mg/dL in the non-ADT group (P=0.01) and 99.0+/-7.58 mg/dL in the control group (P<0.01). 2) Insulin levels were 45.0+/-7.25 uU/mL in the ADT group compared with 24.0+/-7.24 uU/mL in the non-ADT group (P=0.05) and 19.0+/-7.39 uU/mL in the control group (P=0.02). 3) Leptin levels were 25.0+/-2.57 ng/mL in the ADT group compared with 12.0+/-2.56 ng/mL in the non-ADT group (P<0.01) and 6.0+/-2.62 ng/mL in the control group (P<0.01). 4) The homeostatic model assessment for insulin resistance (HOMAIR)=17.0+/-2.78 in the ADT group compared with HOMAIR=6.0+/-2.77 in the non-ADT group (P<0.01) and HOMAIR=5.0+/-2.83 in the control group (P=0.01). There was a significant negative correlation between total and free testosterone levels with fasting glucose, insulin, leptin, and HOMAIR.

CONCLUSIONS

The current data suggested that men with PCa who are receiving long-term ADT are at risk for developing insulin resistance and hyperglycemia, thus leading to their increased risk of cardiovascular disease. This adverse metabolic profile developed independent of age and BMI and appeared to be a direct result of androgen deprivation.

Outcome of salvage radiotherapy for biochemical failure after radical prostatectomy with or without hormonal therapy

BACKGROUND

This study analyzed the outcome of salvage radiotherapy for biochemical failure after radical prostatectomy (RP). By comparing the outcomes for patients who received RT alone and for those who received combined RT and hormonal therapy, we assessed the potential benefits of hormonal therapy.

PATIENTS AND METHODS

This cohort was comprised of 101 patients who received salvage RT between 1990 and 2001 for biochemical failure after RP. Fifty-nine of these patients also received hormone. Margin status (positive vs. negative), extracapsular extension (yes vs. no), seminal vesicle involvement (yes vs. no), pathologic stage, Gleason score, pre-RP PSA, post-RP PSA, pre-RT PSA, hormonal use, radiotherapy dose and technique, RP at M. D. Anderson Cancer Center, and time from RP to salvage RT were analyzed. Statistically significant variables were used to construct prognostic groups.

RESULTS

Independent prognostic factors for the RT-alone group were margin status and pre-RT PSA. RP at M. D. Anderson Cancer Center was marginally significant (p = 0.06) in multivariate analysis. Pre-RT PSA was the only significant prognostic factor for the combined-therapy group. We used a combination of margin status and pre-RT PSA to construct a prognostic model for response to the salvage treatment based on the RT group. We identified the favorable group as those patients with positive margin and pre-RT PSA < or = 0.5 ng/mL vs. the unfavorable group as otherwise. This stratification separates patients into clinically meaningful groups. The 5-year PSA control probabilities for the favorable vs. the unfavorable group were 83.7% vs. 61.7% with radiotherapy alone (p = 0.03). Androgen ablation seemed to be most beneficial in the unfavorable group.

CONCLUSION

After prostatectomy, favorable-group patients may fare well with salvage radiotherapy alone. These patients may be spared the toxicity of androgen ablation. The other patients may benefit most from a combined approach with hormonal treatment. We further suggest that salvage radiotherapy should be given early when the PSA is still low.

The effect of 6 months of androgen deprivation therapy on muscle and fat mass in older men with localized prostate cancer

OBJECTIVE

To evaluate body composition changes, specifically skeletal muscle mass, in men receiving androgen deprivation with luteinizing-hormone releasing hormone-agonist (LHRH-A) for prostate cancer (PCa) in comparison with healthy controls.

DESIGN

Retrospective analysis of body composition changes in men with prostate cancer receiving LHRH-A therapy from 2 clinical trials compared to men without prostate cancer serving as a placebo-control in another clinical trial.

SETTING

Clinical Research Center in Connecticut.

PARTICIPANTS

Thirty men (> 60 years) receiving 6 months of LHRH-A therapy for PCa were compared to a healthy group of 25 men without PCa.

MEASUREMENTS

Appendicular skeletal muscle/height2 (ASM/ht2), lean and fat mass were assessed by dual energy x-ray absorptiometry. Total testosterone levels were assessed by enzyme immunoassay.

RESULTS

At baseline, 12/30 (40%) of the treatment group and 7/25 (28%) of the control group (p = 0.11) met criteria for sarcopenia. There were no differences between control groups in ASM/ht2 or lean mass. The LHRH-A group had a higher percent body fat than the control group, 29.8 +/- 6.3 versus 26.3 +/- 4.6 (p = 0.02). ASM/ht2 and lean mass decreased in the LHRH-A group from 7.5 +/- 0.9 kg to 7.3 +/- 0.9 kg (-2.3% +/- 0.03; p < or = 0.001) and 53.5 +/- 5.4 kg to 52.3 +/- 5.3 kg (-2.1% +/- 0.03; p < or = 0.001), respectively. There was no muscle loss in the control group. At 6 months, the LHRH-A group had increased percent body fat from 29.8 +/- 6.4 to 32.2 +/- 5.8 (9.5% +/- 0.13; p < or = 0.001), whereas the control group had decreased in percent body fat from 26.6 +/- 4.6 to 25.3 +/- 5.0 (-3.8% +/- 0.08; p = 0.02).

CONCLUSIONS

Men undergoing LHRH-A treatment for PCa decreased appendicular skeletal muscle and lean tissue and increased body fat within 6 months of initiation of therapy. Lifestyle changes or medical interventions to minimize the effects of androgen deprivation therapy for PCa deserve investigation.

Preventing and treating the complications of hormone therapy

Hormonal manipulation in the form of androgen-deprivation therapy for prostate cancer was introduced by Huggins and Hodges in 1941 and resulted in a Nobel Prize in 1966. Hormonal therapy initially had been used in metastatic prostate cancer, but the indications have been expanded including failed local therapy, locally advanced prostate cancer, and neoadjuvant or adjuvant therapy in high-risk localized prostate cancer. In view of the magnitude of the problem of prostate cancer and relatively frequent use of hormonal manipulation, it is important for clinicians to be aware of common side effects, prevention, and treatment to improve quality of life and reduce morbidity and mortality in patients with prostate cancer. This review focuses on the common side effects of hormonal treatment such as osteoporosis, anemia, hot flashes, erectile dysfunction, muscle wasting, gynecomastia, decline in cognitive function, depression, increase in body fat and metabolic changes, and their prevention and treatment.

Associations between serum testosterone fall and cognitive function in prostate cancer patients

Data on the association between cognition and testosterone levels in elderly men are inconclusive. Androgen deprivation therapy is commonly used in the treatment of prostate cancer with the aim of achieving castration levels of serum testosterone. The study group comprised 26 elderly men (mean age 65 years) with newly diagnosed prostate cancer. Cognitive testing was done at baseline and at 6 and 12 months on androgen deprivation therapy. Cognitive performances were evaluated using verbal, visuomotor, and memory tests as well as tests of processing speed and attention. Castration levels of testosterone were achieved in all patients by 6 months. Significant associations between cognitive performances and testosterone decline were documented: visuomotor slowing, slowed reaction times in some attentional domains including working memory and impaired hit rate in a vigilance test, impaired delayed recall and recognition speed of letters, but improvement in object recall. The results suggest selective associations between testosterone decline and cognition. Documentation of cognitive performance with changes in serum testosterone levels has substantial implications for informed patient support in prostate cancer.

Cancer treatment-induced bone loss in patients with breast or prostate cancer

PURPOSE/OBJECTIVES

To review the prevalence, consequences, pathophysiology, diagnosis, and treatment of cancer treatment-induced bone loss (CTIBL) in patients with breast or prostate cancer.

DATA SOURCES

Published articles, abstracts, book chapters, electronic resources, and manufacturer information.

DATA SYNTHESIS

CTIBL is a long-term complication associated with cancer therapies that cause hypogonadism in patients with breast or prostate cancer. Early diagnosis and treatment of CTIBL is essential to prevent bone fractures. CTIBL treatment includes modification of lifestyles that increase the risk of developing bone loss and fractures and includes the use of bone loss therapies (e.g., bisphosphonates, selective estrogen receptor modifiers, calcitonin).

CONCLUSIONS

CTIBL is becoming more common as patients with breast or prostate cancer survive longer. Identifying and treating CTIBL early are important because once bone is lost, damaged bone becomes more difficult to repair; early diagnosis and treatment also may prevent fractures.

IMPLICATIONS FOR NURSING

Nurses must be knowledgeable about CTIBL to identify high-risk patients and educate patients and their families about CTIBL, bone loss therapies, and lifestyle modifications.

A mathematical investigation of the multiple pathways to recurrent prostate cancer: comparison with experimental data

Considerable research is aimed at determining the mechanisms by which hormone-refractory prostate cancer develops. In an effort to assist in the understanding of recurrent prostate cancer and the cellular processes that mediate this disease, a mathematical model is presented that describes both the pretreatment growth and the posttherapy relapse of human prostate cancer xenografts. Our goal is to evaluate the interplay between the multiple mechanisms that have been postulated as causes of androgen-independent relapse. Simulations of the model show that molecular events that render the androgen receptor irrelevant to disease progression, such as upregulation of BCL2, can result in relapse after androgen deprivation therapy. However, decreased apoptosis of androgen-independent cells alone overestimates the effects of hormone therapy when compared to experimental data. When decreased apoptosis is combined with continual androgen receptor activation, the posttherapy growth dynamics are in excellent correlation with experimental observations of the growth of LuCaP xenografts. Furthermore, the mathematical model predicts that upregulation of the androgen receptor, together with its increased activation, is alone sufficient to result in the androgen-independent growth of LNCaP xenografts. Recent experimental studies that suggest that the posttherapy increase in and continual activation of the androgen receptor are common and crucial features of recurrent prostate cancer provide validation of the model predictions. This approach provides a framework for using mathematical techniques to study novel therapeutic strategies aimed at controlling this disease.

Dose–response characteristics of low- and intermediate-risk prostate cancer treated with external beam radiotherapy

PURPOSE

In this era of dose escalation, the benefit of higher radiation doses for low-risk prostate cancer remains controversial. For intermediate-risk patients, the data suggest a benefit from higher doses. However, the quantitative characterization of the benefit for these patients is scarce. We investigated the radiation dose-response relation of tumor control probability in low-risk and intermediate-risk prostate cancer patients treated with radiotherapy alone. We also investigated the differences in the dose-response characteristics using the American Society for Therapeutic Radiology and Oncology (ASTRO) definition vs. an alternative biochemical failure definition.

METHODS AND MATERIALS

This study included 235 low-risk and 387 intermediate-risk prostate cancer patients treated with external beam radiotherapy without hormonal treatment between 1987 and 1998. The low-risk patients had 1992 American Joint Committee on Cancer Stage T2a or less disease as determined by digital rectal examination, prostate-specific antigen (PSA) levels of < or =10 ng/mL, and biopsy Gleason scores of < or =6. The intermediate-risk patients had one or more of the following: Stage T2b-c, PSA level of < or =20 ng/mL but >10 ng/mL, and/or Gleason score of 7, without any of the following high-risk features: Stage T3 or greater, PSA >20 ng/mL, or Gleason score > or =8. The logistic models were fitted to the data at varying points after treatment, and the dose-response parameters were estimated. We used two biochemical failure definitions. The ASTRO PSA failure was defined as three consecutive PSA rises, with the time to failure backdated to the mid-point between the nadir and the first rise. The second biochemical failure definition used was a PSA rise of > or =2 ng/mL above the current PSA nadir (CN + 2). The failure date was defined as the time at which the event occurred. Local, nodal, and distant relapses and the use of salvage hormonal therapy were also failures.

RESULTS

On the basis of the ASTRO definition, at 5 years after radiotherapy, the dose required for 50% tumor control (TCD(50)) for low-risk patients was 57.3 Gy (95% confidence interval [CI], 47.6-67.0). The gamma50 was 1.4 (95% CI, -0.1 to 2.9) around 57 Gy. A statistically significant dose-response relation was found using the ASTRO definition. However, no dose-response relation was noted using the CN + 2 definition for these low-risk patients. For the intermediate-risk patients, using the ASTRO definition, the TCD(50) was 67.5 Gy (95% CI, 65.5-69.5) Gy and the gamma50 was 2.2 (95% CI, 1.1-3.2) around TCD(50). Using the CN + 2 definition, the TCD(50) was 57.8 Gy (95% CI, 49.8-65.9) and the gamma50 was 1.4 (95% CI, 0.2-2.5). Recursive partitioning analysis identified two subgroups within the low-risk group, as well as the intermediate-risk group: PSA level <7.5 vs. > or =7.5 ng/mL. Most of the benefit from the higher doses for the low- and intermediate-risk group was derived from the patients with the higher PSA values. For the low-risk group, the dose-response curves essentially plateaued at 78 Gy.

CONCLUSION

A dose-response relation was found using the ASTRO definition for low-risk prostate cancer. However, we found only marginal or no dose-response relation when the CN + 2 definition was used. Most of the benefit from the higher doses derived from low-risk patients with higher PSA levels. In all cases, little projected gain appears to exist at doses >78 Gy for these patients. A dose-response relation was noted for the intermediate-risk patients using either the CN + 2 or ASTRO definition. Most of the benefit from the higher doses also derived from the intermediate-risk patients with higher PSA levels. Some room for improvement appears to exist with additional dose increases in this group.

Randomized Trial Comparing Iridium Implant Plus External-Beam Radiation Therapy With External-Beam Radiation Therapy Alone in Node-Negative Locally Advanced Cancer of the Prostate

Purpose

To determine if iridium implant (IM) and external-beam radiation therapy (EBRT) is better than standard EBRT in locally advanced prostate cancer.

Methods

Patients with T2 and T3 prostate cancer with no evidence of metastatic disease were randomly assigned to EBRT of 66 Gy in 33 fractions during 6.5 weeks or to IM of 35 Gy delivered to the prostate during 48 hours plus EBRT of 40 Gy in 20 fractions during 4 weeks. The primary outcome consisted of biochemical or clinical failure (BCF). BCF was defined by biochemical failure, clinical failure, or death as a result of prostate cancer. Secondary outcomes included 2-year postradiation biopsy positivity, toxicity, and survival.

Results

Between 1992 and 1997, 51 patients were randomly assigned to receive IM plus EBRT, and 53 patients were randomly assigned to receive EBRT alone. The median follow-up was 8.2 years. In the IM plus EBRT arm, 17 patients (29%) experienced BCF compared with 33 patients (61%) in the EBRT arm (hazard ratio, 0.42; P = .0024). Eighty-seven patients (84%) had a postradiation biopsy; 10 (24%) of 42 in the IM plus EBRT arm had biopsy positivity compared with 23 (51%) of 45 in the EBRT arm (odds ratio, 0.30; P = .015). Overall survival was 94% in the IM plus EBRT arm versus 92% in the EBRT arm.

Conclusion

The combination of IM plus EBRT was superior to EBRT alone for BCF and postradiation biopsy. This trial provides evidence that higher doses of radiation delivered in a shorter duration result in better local as well as biochemical control in locally advanced prostrate cancer.

Pathophysiology of Erectile Dysfunction

INTRODUCTION

Multiple regulatory systems are involved in normal erectile function. Disruption of psychological, neurological, hormonal, vascular, and cavernosal factors, individually, or in combination, can induced erectile dysfunction (ED). The contribution of neurogenic, vascular, and cavernosal factors was thoroughly reviewed by our committee, while psychological and hormonal factors contributing to ED were evaluated by other committees.

AIM

To provide state of the art knowledge on the physiology of ED.

METHODS

An international consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five different continents developed in a process over a 2-year period. Concerning the pathophysiology of ED committee, there were seven experts from five different countries.

MAIN OUTCOME MEASURE

Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

The epidemiology and classification of neurogenic ED was reviewed. The evidence for the association between vascular ED and atherosclerosis/hypercholesterolemia, hypertension and diabetes was evaluated. In addition, the pathophysiological mechanisms implicated in vascular ED were defined, including: arterial remodeling, increased vasoconstriction, impaired neurogenic vasodilatation, and impaired endothelium-dependent vasodilatation. The possible mechanisms underlying the association between chronic renal failure and ED were also evaluated as well as the evidence supporting the association of ED with various classes of medications.

CONCLUSIONS

A better understanding of how diseases interfere with the physiological mechanisms that regulate penile erection has been achieved over the last few years, which helps establish a strategy for the prevention and treatment of ED.

Assessing the impact of an alternative biochemical failure definition on radiation dose response for high-risk prostate cancer treated with external beam radiotherapy

PURPOSE

The American Society for Therapeutic Radiology and Oncology (ASTRO) biochemical failure definition has recently been compared with various alternative definitions. We assessed the effect of using an alternative failure definition on the dose-response characteristics of high-risk prostate cancer treated with radiotherapy alone.

METHODS AND MATERIALS

This study included 363 high-risk prostate cancer patients treated with external beam radiotherapy alone from 1987 to 1999. These patients have one or more of the following: 1992 American Joint Committee on Cancer (AJCC) digital rectal examination (DRE) stage > or = cT3, prostate-specific antigen (PSA) > 20 ng/mL, and/or biopsy Gleason score > or = 8. We previously reported the dose response based on the ASTRO definition for these patients. In this study, a biochemical failure is defined as a PSA rise > or = 2 ng/mL above the current nadir PSA (CN + 2). The failure date is defined as the time at which the event occurred (i.e., the call date).

RESULTS

Using CN + 2, the tumor control probability (TCP) continues to decrease with time as opposed to reaching a plateau as with the ASTRO definition. At 5 years, TCD50 (95% CI), the dose to achieve 50% tumor control, for high-risk prostate cancer, is 70.4 (68.0-72.9) Gy using CN + 2 [ASTRO: 75.5 (70.7-80.2) Gy]. The relative slope, gamma50 (95% CI) is 1.8 (0.8-2.8) [ASTRO: 1.7 (0.7-2.7)]. Recursive partitioning again identified two subgroups: PSA < vs. > or = 13 ng/mL (ASTRO: PSA < or = vs. > 20 ng/mL). The difference in TCD50 between the two subgroups is about 20 Gy at 5 years (ASTRO: about 15 Gy at 5 years).

CONCLUSION

This analysis using the CN + 2 failure definition continues to show a dose response for the high-risk group of patients. However, the dose-response characteristics differ from those estimated using the ASTRO definition. We observed that the position (TCD50) and steepness (gamma50) of the dose-response curve changed with time as long as the TCP continued to decrease. This suggests that the dose response characteristics derived from data with longer follow-up may be different from those derived with shorter follow-up using the CN + 2 or similar failure definitions which do not back-date the failure. These changes in dose-response characteristics as well as the time dependence of dose response should be noted when investigators design dose escalation trials for the high-risk prostate cancer patients.

Bicalutamide 150 mg maintains bone mineral density during monotherapy for localized or locally advanced prostate cancer

PURPOSE

We evaluated changes in bone mineral density (BMD), fat-free mass (FFM) and serum lipid levels during bicalutamide 150 mg monotherapy compared with medical castration for 2 years.

MATERIALS AND METHODS

A total of 103 men with localized or locally advanced prostate cancer (T1-T4, Nx, M0) for whom immediate androgen deprivation was indicated were enrolled in this prospective, multicenter, open-label, parallel group study. Patients were randomized to bicalutamide 150 mg once daily (51) or medical castration with a luteinizing hormone releasing hormone analogue (52) for 96 weeks. Primary end points were mean percent change from baseline in lumbar spine BMD, hip BMD and FFM at 96 weeks. Mean changes in lipid parameters with time were also evaluated.

RESULTS

BMD was maintained during bicalutamide 150 mg monotherapy (+2.42% for lumbar spine BMD and +1.13% for hip BMD at week 96), while castration was associated with a progressive loss in BMD (-5.40% and -4.39% at week 96, respectively, both p <0.0001 at week 96). There was no significant difference between bicalutamide 150 mg and castration in mean percent change from baseline in FFM (-1.56% and -3.86%, respectively, at week 96, p = 0.31), although there was a trend for greater progressive loss over time with castration. Mean changes in lipid parameters were small and similar in the 2 groups.

CONCLUSIONS

Bicalutamide 150 mg monotherapy may offer an important advantage compared to castration in terms of bone loss and body composition for patients who require long-term androgen deprivation for localized or locally advanced prostate cancer.

Androgens and bone

Loss of estrogens or androgens increases the rate of bone remodeling by removing restraining effects on osteoblastogenesis and osteoclastogenesis, and also causes a focal imbalance between resorption and formation by prolonging the lifespan of osteoclasts and shortening the lifespan of osteoblasts. Conversely, androgens, as well as estrogens, maintain cancellous bone mass and integrity, regardless of age or sex. Although androgens, via the androgen receptor (AR), and estrogens, via the estrogen receptors (ERs), can exert these effects, their relative contribution remains uncertain. Recent studies suggest that androgen action on cancellous bone depends on (local) aromatization of androgens into estrogens. However, at least in rodents, androgen action on cancellous bone can be directly mediated via AR activation, even in the absence of ERs. Androgens also increase cortical bone size via stimulation of both longitudinal and radial growth. First, androgens, like estrogens, have a biphasic effect on endochondral bone formation: at the start of puberty, sex steroids stimulate endochondral bone formation, whereas they induce epiphyseal closure at the end of puberty. Androgen action on the growth plate is, however, clearly mediated via aromatization in estrogens and interaction with ERalpha. Androgens increase radial growth, whereas estrogens decrease periosteal bone formation. This effect of androgens may be important because bone strength in males seems to be determined by relatively higher periosteal bone formation and, therefore, greater bone dimensions, relative to muscle mass at older age. Experiments in mice again suggest that both the AR and ERalpha pathways are involved in androgen action on radial bone growth. ERbeta may mediate growth-limiting effects of estrogens in the female but does not seem to be involved in the regulation of bone size in males. In conclusion, androgens may protect men against osteoporosis via maintenance of cancellous bone mass and expansion of cortical bone. Such androgen action on bone is mediated by the AR and ERalpha.

Effect of adjuvant androgen deprivation on thyroid function tests in prostate cancer patients

Androgen deprivation (AD) used in the treatment of prostate cancer is known to alter concentrations of sex hormones and their binding globulins. Less is known as to its effect on thyroid hormones. In this prospective study the effects of AD on thyroid function were clarified. Levels of serum thyroid stimulating hormone (TSH), free thyroxine (FT4) and thyroid binding globulin concentrations were measured in prostate cancer patients treated with either radical radiotherapy and androgen deprivation for 12 months (AD) or radical radiotherapy alone (RT). Measurements were made at baseline, and at 3, 6 and 12 months. At baseline and at 3 months the results of thyroid function tests did not differ significantly between groups. A significant decline in serum testosterone in the AD group was accompanied by a significant decline in FT4 at 6 and 12 months, while no significant changes in thyroid function were observed in the RT group. The decline in FT4 among AD patients did not evoke a normal TSH response. Prolonged use of AD hampers the interpretation of thyroid test results. This finding has substantial implications for the follow-up of patients in hormonally treated prostate cancer.

Current controversies in testosterone testing: aging and obesity

The interpretation of the total serum testosterone concentration is problematic because it is related directly to the serum SHBG concentration.Frequently, an estimate of the serum free testosterone concentration is obtained to better assess the clinical status of the patient. We reviewed five methods for the determination of free testosterone or a surrogate test/index and the problems with these methods. The calculated free testosterone or BAT (highly positively correlated) are recommended as the preferred tests to assess biologically-active testosterone, although interlaboratory values may differ because standards are not available. The controversies in evaluating gonadal function are illustrated by the andropause (elevated SHBG) and obese men (decreased SHBG).

Exploring the effects of luteinizing hormone-releasing hormone agonist therapy on bone health: implications in the management of prostate cancer

Osteoporosis is a complication that may be associated with long-term androgen deprivation therapy (ADT) in men with prostate cancer. Androgen deprivation increases bone resorption, thereby leading to a more rapid decrease of bone mineral density (BMD) at multiple skeletal sites as compared with age-matched healthy men. ADT has been associated with an increased risk of skeletal fracture in several retrospective analyses. The role of androgens in maintaining bone health appears to be mediated indirectly through their conversion to estrogens, although testosterone may be an important factor in bone formation. Physicians need to be aware of the potential for osteoporosis and should inform patients of appropriate lifestyle and diet modifications, such as calcium and vitamin D supplementation, and exercise at the initiation of ADT. Evaluating BMD may become the accepted norm. Several studies suggest that bisphosphonates may be beneficial in preventing and treating osteoporosis in patients with prostate cancer. The overall benefit of ADT in men with prostate cancer will continue to improve as potential side effects, such as osteoporosis, are recognized and addressed successfully.

Prostate cancer: radical prostatectomy

Today, more men than ever before are being followed after radical prostatectomy. Prognosis and follow-up should be based on the pathologic specimen. Measurable prostate-specific antigen (PSA) after surgery defines failure, with time to detectable PSA and rate of PSA rise being useful prognostic factors. The natural history of untreated biochemical failure is protracted, a fact to be considered in discussions of adjuvant treatment. Early in disease recurrence, imaging studies to locate residual disease rarely are useful clinically. Both adjuvant and salvage radiation to the prostate bed have benefits and risks, but neither is superior in overall prostate cancer survival. The timing of hormone therapy remains largely empiric. The promise of effective cytotoxic chemotherapy still is greater than its actual benefits, although novel cytostatic agents are being developed. The future management of this disease will improve with better molecular definition of risk and therapeutic response.

Adjuvant hormone therapy after radiation or surgery for localized or locally advanced prostate cancer

Prostate cancer is being diagnosed at an earlier age and earlier disease stage than previously and increasing numbers of relatively young men are receiving potentially curative radical prostatectomy or radiotherapy for early prostate cancer. Although many of these men have an excellent outcome, a significant proportion subsequently experience disease recurrence or cancer-related death. Men with unfavorable tumor characteristics at the time of radical prostatectomy or radiotherapy are particularly at high risk of experiencing disease recurrence. One strategy to improve outcome for these men is adjuvant hormone therapy (hormone therapy administered immediately after therapy of primary curative intent). Surgical castration (bilateral orchiectomy), medical castration using the luteinizing hormone-releasing hormone (LHRH) agonist goserelin, and antiandrogen monotherapy have been investigated as adjuvant hormone therapy to radical prostatectomy and radiotherapy, and each therapy has demonstrated clinical benefits because of a significant improvement in disease-free survival. Furthermore, data are available to indicate that adjuvant hormone therapy achieved by goserelin or bilateral orchiectomy improves overall survival, particularly in men at high risk of progression. Because the effects of LHRH agonists are reversible, they provide a more acceptable method of adjuvant therapy compared to bilateral orchiectomy, particularly in the adjuvant setting, and are preferred by patients. However, the adverse effects on quality of life, in particular on sexual interest and function and bone mineral density, may limit the use of LHRH agonists in some patients. However, these parameters are maintained with nonsteroidal antiandrogens. The first data from the Early Prostate Cancer program indicate that adjuvant bicalutamide 150 mg is associated with a significant improvement in progression-free survival after radical prostatectomy or radiotherapy. Gynecomastia and breast pain are the most common side effects associated with bicalutamide therapy. Medical or surgical castration in combination with an antiandrogen (combined androgen blockade) is another option for use as an adjuvant hormone therapy. However, no study has reported on the use of combined androgen blockade in this setting. Adjuvant hormone therapy provides clinicians with another treatment option for patients with early prostate cancer and unfavorable tumor characteristics.

Andropause: Symptom Management for Prostate Cancer Patients Treated With Hormonal Ablation

Andropause, or the age-related decline in serum testosterone, has become a popular topic in the medical literature over the past several years. Andropause includes a constellation of symptoms related to lack of androgens, including diminished libido, decreased generalized feeling of well-being, osteoporosis, and a host of other symptoms. The andropause syndrome is very prominent in men undergoing hormonal ablation therapy for prostate cancer. Most significant in this population are the side effects of hot flashes, anemia, gynecomastia, depression, cognitive decline, sarcopenia, a decreased overall quality of life, sexual dysfunction, and osteoporosis with subsequent bone fractures. The concept of andropause in prostate cancer patients is poorly represented in the literature. In this article, we review the current literature on the symptoms, signs, and possible therapies available to men who cannot take replacement testosterone.

Evaluation of the Houston biochemical relapse definition in men treated with prolonged neoadjuvant and adjuvant androgen ablation and assessment of follow-up lead-time bias

PURPOSE

To validate the Houston prostate-specific antigen relapse definition in a mature cohort of men treated with external beam radiotherapy (EBRT) and adjuvant androgen ablation (AA) and men treated with EBRT monotherapy, and to compare these results with the American Society for Therapeutic Radiology and Oncology (ASTRO) and Vancouver prostate-specific antigen relapse (biochemical no evidence of disease) definitions.

METHODS AND MATERIALS

A prospective database of 1490 men treated with EBRT, with or without AA, was examined. The impact on hazard proportions, as well as the predictive ability, of the Houston, ASTRO, and Vancouver definitions was tested.

RESULTS

For all patients, the Houston definition was more accurate (79.5%) than the ASTRO (76.7%) or Vancouver (77.2%) definitions in predicting subsequent clinical relapse. The Houston definition was superior to the ASTRO definition in those treated both with and without AA and equivalent to the Vancouver definition in those receiving AA. The Houston definition demonstrated proportional hazards when categorized for the use of AA, unlike the ASTRO and Vancouver definitions. The effect of inadequate follow-up on the projected relapse rates was negligible with the Houston definition.

CONCLUSION

The Houston relapse definition is favored after EBRT monotherapy or combined EBRT and AA. Use of the Cox proportional hazard multivariate analysis is appropriate with the Houston definition, but not with the ASTRO or Vancouver definitions if AA and non-AA patients are combined.

Dose-response for biochemical control among high-risk prostate cancer patients after external beam radiotherapy

INTRODUCTION

The literature on dose-response characteristics of high-risk prostate cancer has been scarce in this era, when these patients are treated with hormone therapy along with radiotherapy. In this study, we estimated the dose-response of prostate-specific antigen (PSA) control probability in high-risk prostate cancer patients treated with radiotherapy alone.

METHODS AND MATERIALS

The data set contains information on 363 high-risk prostate cancer patients who were treated with external beam radiotherapy without hormonal treatment between February 1987 and September 1998. These patients have one or more of the following adverse prognostic features: digital rectal examination stage > or =cT3, PSA >20 ng/mL, and biopsy Gleason score > or =8. These patients had biopsy-proven adenocarcinoma of prostate and were staged according to the 1992 AJCC staging system that was based on digital rectal examination. The logistic model was fitted to the data at various time points after treatment, and the dose-response parameters were estimated.

RESULTS

The dose required to have 50% tumor control, TCD50 (95% confidence interval), for high-risk patients is 75.5 (range: 70.7-80.2) Gy. The gamma 50 (95% confidence interval) is 1.7 (range: 0.7-2.7) around 75.5 Gy. Recursive partitioning analysis based on the null Martingale residuals identifies two subgroups within the high-risk group. The TCD50 estimates of the two subgroups (PSA < or = vs. >20 ng/mL) differ by 15 Gy at 5 years. There is a dose response in both subgroups.

CONCLUSION

We recognize that this study has the usual limitations of a retrospective study that includes treatment policy change that spanned a long time frame. However, our data strongly suggest a benefit of dose escalation for all the patients in the entire high-risk group. There is a steep dose response in PSA control probability around a modern dose of 78 Gy. A 5-Gy dose increase beyond 78 Gy may improve PSA control by about 10%.

Finasteride and flutamide therapy in patients with advanced prostate cancer: response to subsequent castration and long-term follow-up

OBJECTIVES

To report the efficacy of castration after progression on finasteride and flutamide. Standard androgen deprivation strategies for prostate cancer typically lead to castrate levels of testosterone. One alternative is the use of finasteride and flutamide.

METHODS

A Phase II trial evaluated the combination of finasteride (5 mg/day) and flutamide (250 mg three times daily) in patients with rising prostate-specific antigen levels after local treatment for prostate cancer or with newly discovered metastatic disease. Patients were followed up for subsequent events, including castration-free, androgen-independent prostate cancer (AIPC)-free, and overall survival.

RESULTS

With a median follow-up of 88 months, 5 patients (25%) continued on finasteride and flutamide, and 12 had stopped this combination and subsequently underwent medical or surgical castration. No patients experienced a flutamide withdrawal effect. All patients experienced more than a 50% decline in prostate-specific antigen after castration (mean 89%). The median protocol treatment failure-free survival was 29.9 months, the median castration-free survival was 37 months, and the median AIPC-free survival was 48.6 months. At 5 years, the overall survival rate was 65% (95% confidence interval 47% to 90%); 29% were alive and have not required castration, and 35% were alive and free of AIPC.

CONCLUSIONS

Finasteride and flutamide have a durable effect in suppressing prostate-specific antigen progression in some men with advanced prostate cancer. Furthermore, castration induces secondary responses that may be of shorter duration than if started initially, although the overall period of hormonally responsive prostate cancer is more than 4 years.

Quality of life after treatment for prostate cancer

Quality of life is a major concern of patients when they are choosing treatment for prostate cancer. Health-related quality of life is a patient-centered variable from the field of health services research that can be measured in a valid and reliable manner. Using standardized questionnaires specifically developed to capture health-related quality of life data in men with prostate cancer, the effect of treatments on patients' quality of life can be studied. Patients with localized disease who are undergoing radical prostatectomy tend to have more sexual and urinary dysfunction than men undergoing external beam radiation therapy, although both groups have more impairment in these areas than age-matched controls. Men undergoing external beam radiation therapy have worse bowel function and more urinary distress from irritative voiding symptoms than men undergoing radical prostatectomy or age-matched controls. Recent studies of men undergoing interstitial brachytherapy indicate that these patients have less urinary leakage than those who undergo radical prostatectomy, but experience considerably more irritating voiding symptoms, which often profoundly affect their quality of life. Better information regarding the potential impact of prostate cancer treatment on quality of life will improve medical decision-making.

Low bone density and high percentage of body fat among men who were treated with androgen deprivation therapy for prostate carcinoma

BACKGROUND

Men with prostate carcinoma who are treated with androgen deprivation therapy (ADT) are reported to be at an increased risk of bone loss and weight changes due to the sudden disruption of hormonal levels. In the current case-control study, the authors examined the prevalence and magnitude of low bone density and obesity among men with prostate carcinoma who were treated with ADT.

METHODS

Sixty-two men with prostate carcinoma who had been receiving ADT for 1-5 years were included as cases. Healthy men (n = 47) with a prostate specific antigen level < 4.0 ng/mL were recruited as controls. Body composition and bone mineral density (BMD) were measured using dual-energy X-ray absorptiometry. The average age was 74.3 years for the cases and 72.8 years for the controls.

RESULTS

The results of the current study demonstrate that prostate carcinoma cases had significantly higher body weight (86.5 kg vs. 80.6 kg), a higher percentage of body fat (30% vs. 26%), and a lower total body BMD (1.12 mg/cm(2) vs. 1.17mg/ cm(2)) compared with controls (P < 0.05). Cases were more likely to be obese (27.4% vs 43%) and have low BMD at trochanter (32.3% vs. 10.6%), intertrochanter (48.4% vs. 29.8%), and total hip measurements (50.0% vs. 25.3%).

CONCLUSIONS

The results of the current study indicate that men with prostate carcinoma who are treated with ADT have a significantly increased risk of low bone density and obesity.