Survival Trend in Individuals With De Novo Metastatic Prostate Cancer After the Introduction of Doublet Therapy

Incidental Brain Metastases From Prostate Cancer Diagnosed With PSMA PET/CT and MRI: A Case Series and Literature Review

BACKGROUND

Brain metastases (BMETS) from prostate cancer are rare. Hence, brain imaging in neurologically asymptomatic patients with advanced prostate cancer (aPC) is not routinely performed. Prostate-specific membrane antigen (PSMA) PET/CT uses a radiotracer that binds to prostate cancer epithelial cells and is FDA-approved for initial staging for high-risk prostate cancer, detecting prostate cancer recurrence, and determining eligibility for radionuclide therapy.

METHODS

We report six patients with asymptomatic BMETS from aPC found on staging PSMA PET/CT or MRI. Along with cranial MRI, PSMA PET/CT may be useful for detecting asymptomatic intracranial metastasis in select patients with prostate cancer.

RESULTS

Brain metastases were diagnosed in four patients by staging PSMA PET/CT scan-three after systemic disease progression and one during routine surveillance. In two other patients, BMETS were detected using MRI despite negative PSMA PET/CT for brain lesions. All were neurologically asymptomatic. Three patients had undetectable serum prostate-specific antigen (PSA) concentrations; one had neuroendocrine differentiation on histology.

CONCLUSION

In patients with poorly differentiated or neuroendocrine aPC, BMETS may occur without neurologic symptoms and stable PSA. PSMA PET/CT may complement brain MRI for identifying BMETS in these patients.

Targeting Aggressive Prostate Carcinoma Cells with Mesothelin-CAR-T Cells

Background: Advancing chimeric antigen receptor (CAR) T cell therapy for solid tumors remains a major challenge in cancer immunotherapy. Prostate cancer (PCa), particularly in its aggressive forms, may be a suitable target for CAR-T therapy given the range of associated tumor antigens. However, due to the high plasticity and heterogeneity of aggressive PCa and the complexity of the tumor environment, there is a need to broaden the repertoire of targetable antigens and deepen our understanding of CAR-T behavior in stressed microenvironmental conditions. Growing evidence supports mesothelin as a promising cancer-associated marker and a compelling target for CAR-T cell approaches in solid tumors. Objectives and Methods: Here, we employed gene expression datasets to investigate mesothelin expression in both primary and metastatic PCa tumors. Additionally, we evaluated mesothelin expression across various preclinical PCa models and assessed the therapeutic efficacy of second-generation mesothelin-targeted CAR-T (meso-CAR-T) cells under both normoxic and hypoxic conditions, with hypoxia as a representative tumor-associated stress condition. Results: Our results revealed a significant enrichment of mesothelin in 3-10% of metastatic prostate tumors, contrasting with its minimal expression in primary tumors. In line with these findings, we observed increased mesothelin expression in an aggressive variant of the 22Rv1 cell line, which displayed an epithelial-mesenchymal plasticity (EMP) phenotype. Meso-CAR-T cells demonstrated potent cytotoxicity and remarkable selectivity toward these carcinoma cells under both severe hypoxia (1% O2) or normoxia (21% O2), highlighting their ability to withstand metabolic stress within the tumor microenvironment. Conclusions: Our study underscores the potential of meso-CAR-T cells as a promising strategy for targeting specific subtypes of metastatic prostate cancer.

The Effects of Surgical Androgen Deprivation Therapy for Advanced Prostate Cancer on Peripapillary Retinal Nerve Fiber Layer Thickness

Background: Prostate cancer is the most common malignancy in men, and androgen deprivation therapy (ADT) serves as the primary approach for managing advanced cases. Certain research has suggested the impact of androgens on the physiological homeostasis of the optic nerve. Our aim was to investigate the impact of surgical ADT on peripapillary retinal nerve fiber layer (RNFL) thickness in patients with advanced prostate cancer. Methods: The study comprised 30 patients who had undergone bilateral orchiectomy for advanced prostate cancer, with a total of 60 eyes included in the analysis. Each participant received a standard ophthalmological examination. Peripapillary RNFL thickness measurements were performed preoperatively and 12 months postoperatively using optical coherence tomography. Results: The mean age of the patients was 73.77 ± 8.8 years. At the 12th month following surgery, we observed that the mean average thickness of the right and left RNFL, as well as the thickness of the left nasal, left inferior, and right and left temporal quadrants, was significantly thinner compared to presurgical values (P< .05). However, when comparing pre- and postsurgical measurements, the RNFL thickness in the right and left superior quadrants, as well as the right nasal and right inferior quadrants, showed no statistically significant difference. Conclusion: In this study, a significant difference was observed between the preoperative and 12-months postoperative peripapillary RNFL thickness values in patients who underwent surgical ADT for advanced prostate cancer. Additional research using larger sample sizes is required to clinically examine the impact of ADT on optic nerve homeostasis.

Selective treatment de-escalation in advanced prostate cancer: have we come full circle?

Compelling evidence has solidified the notion of early treatment intensification in managing patients with metastatic hormone-sensitive prostate cancer (mHSPC). Landmark trials have provided Level 1 evidence for the survival benefits achieved by combining multiple agents. The efficacy of combined therapy relies not only on how treatment is intensified but also on how it is de-escalated. This underscores the importance of tailored treatment approaches, potentially involving a reduction in therapy for specific patients, to strike a balance between the benefits of hormonal treatment and its associated adverse effects. While de-escalation of therapy in mHSPC remains challenging due to limited evidence, it is recommended for elderly or frail patients, those with poor performance status, or experiencing significant toxicity. However, for patients with excellent prostate-specific antigen responses or favourable biomarkers, decisions should be personalised, weighing the potential benefits of continued treatment against the risk of long-term side effects, using risk stratification tools where appropriate.

5-hydroxymethylcytosine sequencing of plasma cell-free DNA identifies epigenomic features in prostate cancer patients receiving androgen deprivation therapies

BACKGROUND

We evaluated whether 5hmC signatures in cell-free DNA (cfDNA) are associated with treatment failure to androgen-deprivation therapies (ADT) among men with hormone-naive prostate cancer.

METHODS

We collected a total of 139 serial plasma samples from 55 prostate cancer patients receiving ADT at 3 time points including baseline (before initiating ADT, n = 55); 3 months (after initiating ADT, n = 55); and disease progression (n = 15) within 24 months or 24 months if no progression was detected (n = 14). We used selective chemical labeling sequencing to quantify 5hmC abundance across the genome and Kaplan-Meier analysis to assess survival association.

RESULTS

Here we show a significant 5hmC difference in 1642 of 23433 genes between patients with and without progression (false discovery rate [FDR] < 0.1) in baseline plasma samples. Patients with progression demonstrate significant 5hmC enrichments in multiple hallmark gene sets, with androgen responses as the top enriched gene-set (FDR = 1.19E-13). We further show a significant association between high activity scores in these gene sets and poor progression-free survival (P < 0.05), even after adjusting for circulating tumor DNA fraction and prostate-specific antigen values. Additionally, our longitudinal analysis shows that the high activity score is significantly reduced after 3 months of initiating ADT (P = 0.0004) but returns to higher levels when the disease progresses (P = 0.0317).

CONCLUSIONS

5hmC-based activity scores from gene-sets involved in AR responses show great potential in assessing treatment resistance, monitoring disease progression, and identifying patients who would benefit from upfront treatment intensification. However, further studies are needed to validate these findings.

Cardiovascular Risk in Prostate Cancer

Cardiovascular disease is common in patients with prostate cancer and is an important cause of death. Cardiovascular risk factors are frequent in this population and are often not addressed to thresholds recommended by cardiovascular practice guidelines. Androgen deprivation therapy (ADT) reduces muscle strength and increases adiposity, thereby increasing the risk of diabetes and hypertension, although its relationship with adverse cardiovascular events requires confirmation. Androgen receptor signaling inhibitors and CYP17A1 inhibitors may confer incremental risks of hypertension and cardiovascular events to ADT. Lower cardiovascular risk with gonadotropin-releasing hormone antagonists as compared with agonists requires prespecified randomized clinical trial confirmation.

Considerable decline in prostate cancer mortality in Nordic countries after 2000

BACKGROUND AND PURPOSE

In the late 1990s, the Nordic countries, with Norway at the top, were among the countries with the highest prostate cancer mortality in the world. We present updated mortality rates from the Nordic countries and discuss possible interpretations of changes in trends.

MATERIAL AND METHODS

Age-standardized rates for prostate-specific mortality in 1985-2022, estimated lifetime risk of death (0-84 years) and annual changes in mortality were obtained from the NORDCAN database. Joinpoint regression was used to evaluate trend changes for the period 1985-2022. For comparison, rates from other European countries from 2022 were retrieved from the GLOBOCAN database.

RESULTS

Between 1995-99 and 2018-22, mortality in men aged 40-84 years decreased from 38% in Denmark to 59% in Norway. By 2022 Norway had the second lowest mortality among the Nordic countries overall, and the lowest under 85 years. The life-time risk of dying from prostate cancer declined from 5.6-7.1% in 1995-99 to 3.1-4.2% in the last 5-year period. During the last years mortality has decreased most rapidly in Sweden (4.5% annually from 2016) and Norway (4.3% annually from 2014). The Nordic countries are no longer among the countries with the highest mortality in Europe.

INTERPRETATION

Mortality from prostate cancer has decreased significantly in the Nordic countries over the last decades. Possible explanatory factors are likely to include improvements in prostate cancer management strategies and treatment.

Treatment-related Hypertension as a Prognostic Factor for De Novo Metastatic Hormone-sensitive Prostate Cancer: A Retrospective Real-world Evidence Study

Background and objective

Hypertension (HTN) has been linked to an elevated risk of prostate cancer (PC) development and poorer prognosis in localized cases, and is a common side effect of hormonal PC treatments. However, its relationship with the prognosis of metastatic PC is still unclear. We assessed the prognostic role of treatment-related HTN in patients with de novo metastatic hormone-sensitive PC (mHSPC) undergoing androgen deprivation therapy (ADT) alone or in combination with docetaxel or androgen receptor pathway inhibitors (ARPIs).

Methods

Our retrospective analysis included 100 patients with de novo mHSPC treated with ADT, ADT + docetaxel, or ADT + ARPI between 2014 and 2021. Data on clinical variables, antihypertensive drugs, and blood pressure were collected from treatment initiation to 7 mo from ADT start. HTN development within 7 mo from hormonal treatment initiation was graded according to the Common Toxicity Criteria for Adverse Events version 5.0, and Cox analyses were performed for time to castration resistance (TTCR) and overall survival (OS).

Key findings and limitations

In the overall population, grade (G) 2-3 HTN development within 7 mo from hormonal treatment initiation was associated with improved TTCR and OS at both univariate (TTCR: 19.8 vs 7.9 mo, hazard ratio [HR]: 0.35, 95% confidence interval [CI]: 0.20-0.63, p < 0.001; OS: 42 vs 18.4 mo, HR: 0.48, 95% CI: 0.26-0.87, p = 0.017) and multivariate (TTCR: HR: 0.41, 95% CI: 0.18-0.91, p = 0.029; OS: HR: 0.42, 95% CI: 0.18-0.97, p = 0.042) analyses. A subgroup analysis of the ADT + ARPI-treated population revealed 7-mo treatment-related G2-3 HTN to be an independent positive prognostic factor in terms of both TTCR and OS multivariate survival analyses (HR: 0.30, 95% CI: 0.09-0.95, p = 0.040, and HR: 0.12, 95% CI: 0.02-0.57, p = 0.008, respectively).

Conclusions and clinical implications

The early development or worsening of HTN under hormonal treatment may be associated with longer TTCR and OS in de novo mHSPC patients. Larger studies are needed to validate these findings and explore the potential underlying mechanisms.

Patient summary

In this report, we examined the outcomes of patients with metastatic hormone-sensitive prostate cancer and their correlation with hypertension toxicities. We found that patients who developed clinically significant blood pressure toxicity early in oncological treatment experienced longer survival.

Trends in novel antiandrogen receptor signal inhibitor use and medical costs in prostate cancer

OBJECTIVE

We aimed to examine trends in novel antiandrogen receptor signal inhibitor (ARSI) usage and medical costs by collecting real-world big data included in The National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data, covering most of the clinical practices throughout Japan.

METHODS

Usage data for outpatient prescriptions from 2016 to 2021 were extracted from the NDB Open Data. Among the 459,610 million tablets/capsules prescribed, prostate cancer-specific agents (bicalutamide, estramustine phosphate, flutamide, abiraterone, enzalutamide, apalutamide, and darolutamide) were selected to investigate the trends of usage and medical costs.

RESULTS

In total, 764.8 billion medications were recorded. Among these, standard dose-adjusted prescriptions for bicalutamide, abiraterone, enzalutamide, apalutamide, darolutamide, and other vintages (estramustine phosphate, flutamide) was 276, 14.2, 18.1, 2.19, 0.34, and 20.3 million, respectively. The usage of ARSI increased significantly from 6.1% in 2016 to 16% in 2021. The medical costs for prostate cancer-specific agents increased significantly (1.8-fold) from 2016 to 2021. Despite the limited usage of ARSIs, a majority of the medical costs had been spent on ARSIs. Medical costs associated with ARSIs increased significantly from 59% to 89% (p < 0.001).

CONCLUSION

ARSI usage and medical costs associated with prostate cancer increased significantly from 2016 to 2021. Despite the limited use of ARSIs, a considerable proportion of the medical costs for prostate cancer-specific agents had been spent on ARSIs.

Epidemiology of men with synchronous metastatic prostate cancer diagnosis - A nationwide 26-year temporal analysis

BACKGROUND

Evolving imaging modalities, increased awareness, and prostate-specific antigen testing in men with synchronous metastatic prostate cancer (mHSPC) are expected to have prolonged survival. Here we analyze trends in survival among men diagnosed with synchronous metastatic prostate cancer in Denmark.

METHODS

Here, we included all men diagnosed with mHSPC (N = 12,017) in Denmark between January 1st, 1995, and December 31st, 2021. Men were followed until December 31st, 2022. Median time to death was calculated by the Kaplan Meier method and the 3-year risk of prostate cancer death per calendar year was estimated by the Aalen-Johansen estimator from time of diagnosis.

FINDINGS

Median follow-up was 9 years (IQR: 4-15), from 2015 59 % of the men with mHSPC had treatment beyond androgen depletion therapy. Median survival increased from 1.7 years (IQR: 1·3-2·0) to 3.8 years (IQR: 3·3-4·2) in men diagnosed in 1995 and 2018, respectively (p < 0·001), after which median survival was not reached. The prostate cancer-specific mortality three years after diagnosis decreased from 66 % (95 %CI: 60-72) in 1995 to 28 % (95 %CI: 25-32) in 2019 (p < 0·001). From the period 1995-1999 to 2015-2021 median overall survival increased from 1·7 years (IQR: 0·8-3·7) to 4·5 years (IQR: 2·4-not reached; p < 0·001) in men age < 65 years and from 1·5 years (IQR: 0·7-2·9) to 3·1 years (IQR: 1·6-5·7; p < 0.001) in men older than 74 years at diagnosis.

INTERPRETATION

The improved survival suggests that, among other contributing factors, implementing novel therapies has likely been efficacious outside the clinical trial setting. Still, most men diagnosed with synchronous metastatic prostate cancer will die of prostate cancer. As such the need for life-prolonging and age-tailored treatment trials remains evident.

Cardiovascular Risk in Prostate Cancer: JACC: CardioOncology State-of-the-Art Review

Cardiovascular disease is common in patients with prostate cancer and is a significant cause of death. Cardiovascular risk factors are frequent in this population and are often not addressed to thresholds recommended by cardiovascular practice guidelines. Androgen deprivation therapy reduces muscle strength and increases adiposity, increasing the risk for diabetes and hypertension, although its relationship with adverse cardiovascular events requires confirmation. Androgen receptor pathway inhibitors, including androgen receptor antagonists and cytochrome P450 17A1 inhibitors confer incremental risks for hypertension and cardiovascular events to androgen deprivation therapy. Lower cardiovascular risk with gonadotropin-releasing hormone antagonists compared with agonists requires confirmation in well-designed randomized trials.

The Cost-Effectiveness of Germline BReast CAncer Gene Testing in Metastatic Prostate Cancer Followed by Cascade Testing of First-Degree Relatives of Mutation Carriers

OBJECTIVES

Patients with metastatic prostate cancer (mPCa) with BReast CAncer gene (BRCA) mutations benefit from targeted treatments (eg, olaparib). In addition, family members of affected patients have increased risk of hereditary cancers and benefit from early detection and prevention. International guidelines recommend genetic testing in mPCa; however, the value for money of testing patients with mPCa and cascade testing of blood-related family members has not been assessed. In this context, we evaluated the cost-effectiveness of germline BRCA testing in patients with mPCa followed by cascade testing of first-degree relatives (FDRs) of mutation carriers.

METHODS

We conducted a cost-utility analysis of germline BRCA testing using 2 scenarios: (1) testing patients with mPCa only and (2) testing patients with mPCa and FDRs of those who test positive. A semi-Markov multi-health-state transition model was constructed using a lifetime time horizon. The analyses were performed from an Australian payer perspective. Decision uncertainty was characterized using probabilistic analyses.

RESULTS

Compared with no testing, BRCA testing in mPCa was associated with an incremental cost of AU$3731 and a gain of 0.014 quality-adjusted life-years (QALYs), resulting in an incremental cost-effectiveness ratio of AU$265 942/QALY. Extending testing to FDRs of variant-positive patients resulted in an incremental cost-effectiveness ratio of AU$16 392/QALY. Probability of cost-effectiveness at a willingness-to-pay of AU$75 000/QALY was 0% in the standalone mPCa analysis and 100% in the cascade testing analysis.

CONCLUSION

BRCA testing when performed as a standalone strategy in patients with mPCa may not be cost-effective but demonstrates significant value for money after the inclusion of cascade testing of FDRs of mutation carriers.

Androgen receptor pathway inhibitors and taxanes in metastatic prostate cancer: an outcome-adaptive randomized platform trial

ProBio is the first outcome-adaptive platform trial in prostate cancer utilizing a Bayesian framework to evaluate efficacy within predefined biomarker signatures across systemic treatments. Prospective circulating tumor DNA and germline DNA analysis was performed in patients with metastatic castration-resistant prostate cancer before randomization to androgen receptor pathway inhibitors (ARPIs), taxanes or a physician's choice control arm. The primary endpoint was the time to no longer clinically benefitting (NLCB). Secondary endpoints included overall survival and (serious) adverse events. Upon reaching the time to NLCB, patients could be re-randomized. The primary endpoint was met after 218 randomizations. ARPIs demonstrated ~50% longer time to NLCB compared to taxanes (median, 11.1 versus 6.9 months) and the physician's choice arm (median, 11.1 versus 7.4 months) in the biomarker-unselected or 'all' patient population. ARPIs demonstrated longer overall survival (median, 38.7 versus 21.7 and 21.8 months for taxanes and physician's choice, respectively). Biomarker signature findings suggest that the largest increase in time to NLCB was observed in AR (single-nucleotide variant/genomic structural rearrangement)-negative and TP53 wild-type patients and TMPRSS2-ERG fusion-positive patients, whereas no difference between ARPIs and taxanes was observed in TP53-altered patients. In summary, ARPIs outperform taxanes and physician's choice treatment in patients with metastatic castration-resistant prostate cancer with detectable circulating tumor DNA. ClinicalTrials.gov registration: NCT03903835 .

5-hydroxymethylcytosine sequencing in plasma cell-free DNA identifies unique epigenomic features in prostate cancer patients resistant to androgen deprivation therapies

Background

Currently, no biomarkers are available to identify resistance to androgen-deprivation therapies (ADT) in men with hormone-naive prostate cancer. Since 5-hydroxymethylcytosines (5hmC) in gene body are associated with gene activation, in this study, we evaluated whether 5hmC signatures in cell-free DNA (cfDNA) predicts early resistance to ADT.

Results

We collected a total of 139 serial plasma samples from 55 prostate cancer patients receiving ADT at three time points including baseline (prior to initiating ADT, N=55), 3-month (after initiating ADT, N=55), and disease progression (N=15) within 24 months or 24-month if no progression was detected (N=14). To quantify 5hmC abundance across the genome, we used selective chemical labeling sequencing and mapped sequence reads to individual genes. Differential methylation analysis in baseline samples identified significant 5hmC difference in 1,642 of 23,433 genes between patients with and without progression (false discovery rate, FDR<0.1). Patients with disease progression showed significant 5hmC enrichments in multiple hallmark gene sets with androgen responses as top enriched gene set (FDR=1.19E-13). Interestingly, this enrichment was driven by a subgroup of patients featuring a significant 5hmC hypermethylation in the gene sets involving AR , FOXA1 and GRHL2 . To quantify overall activities of these gene sets, we developed a gene set activity scoring algorithm and observed significant association of high activity scores with poor progression-free survival (P<0.05). Longitudinal analysis showed that the high activity scores were significantly reduced after 3-months of initiating ADT (P<0.0001) but returned to higher levels when the disease was progressed (P<0.05).

Conclusions

This study demonstrates that 5hmC-based activity scores from gene sets involved in AR , FOXA1 and GRHL2 may be used as biomarkers to determine early treatment resistance, monitor disease progression, and potentially identify patients who would benefit from upfront treatment intensification.

Outcome of patients with solid malignancies considered for intensive care unit admission: a single-center prospective cohort study

PURPOSE

To identify the predictors and outcomes of ICU triage decisions in patients with solid malignancies (SM) and to investigate the usefulness of the National Early Warning Score (NEWS) and quick Sequential Organ Failure Assessment (qSOFA) score at triage.

METHODS

All patients with SM for whom ICU admission was requested between July 2019 and December 2021 in a French university-affiliated hospital were included prospectively.

RESULTS

Of the 6262 patients considered for ICU admission, 410 (6.5%) had SM (age, 66 [58-73] years; metastases, 60.1%; and performance status 0-2, 81%). Of these 410 patients, 176 (42.9%) were admitted to the ICU, including 141 (80.1%) subsequently discharged alive. Breast cancer, hemoptysis, and pneumothorax were associated with ICU admission; whereas older age, performance status 3-4, metastatic disease, and request at night were associated with denial of ICU admission. The NEWS, and the qSOFA score in patients with suspected infection, determined at triage performed poorly for predicting hospital mortality (area under the receiver operating characteristics curve, 0.52 and 0.62, respectively). Performance status 3-4 was independently associated with higher 6-month mortality and first-line anticancer treatment with lower 6-month mortality. Hospital mortality was 33.3% in patients admitted to the ICU after refusal of the first request.

CONCLUSION

Patients with SM were frequently denied ICU admission despite excellent in-ICU survival. Poor performance status was associated with ICU admission denial and higher 6-month mortality, but none of the other reasons for denying ICU admission predicted 6-month mortality. Physiological scores had limited usefulness in this setting.

Cardio-oncology in advanced prostate cancer

Treatment intensification with androgen deprivation therapy (ADT) and androgen receptor pathway inhibitors (ARPi) have led to improved survival in advanced prostate cancer. However, ADT is linked to significant cardiovascular toxicity, and ARPi also negatively impacts cardiovascular health. Together with a higher prevalence of baseline cardiovascular risk factors reported among prostate cancer survivors at diagnosis, there is a pressing need to prioritise and optimise cardiovascular health in this population. Firstly, While no dedicated cardiovascular toxicity risk calculators are available, other tools such as SCORE2 can be used for baseline cardiovascular risk assessment. Next, selected patients on combination therapy may benefit from de-escalation of ADT to minimise its toxicities while maintaining cancer control. These patients can be characterised by an exceptional PSA response to hormonal treatment, favourable disease characteristics and competing comorbidities that warrant a less aggressive treatment regime. In addition, emerging molecular and genomic biomarkers hold the potential to identify patients who are suited for a de-escalated treatment approach either with ADT or with ARPi. One such biomarker is AR-V7 splice variant that predicts resistance to ARPi. Lastly, optimization of modifiable cardiovascular risk factors for patients through a coherent framework (ABCDE) and exercise therapy is equally important. This article aims to comprehensively review the cardiovascular impact of hormonal manipulation in metastatic hormone-sensitive prostate cancer, propose overarching strategies to mitigate cardiovascular toxicity associated with hormonal treatment, and, most importantly, raise awareness about the detrimental cardiovascular effects inherent in our current management strategies involving hormonal agents.

Survival in Patients With De Novo Metastatic Prostate Cancer

This cross-sectional study investigates trends in overall survival among patients with newly diagnosed metastatic prostate cancer in 2 national registries in the United States.