Management of patients with advanced prostate cancer-metastatic and/or castration-resistant prostate cancer: Report of the Advanced Prostate Cancer Consensus Conference (APCCC) 2022

Silent metastasis in metastatic castrate-resistant prostate cancer: a collection of two case reports

Treatment monitoring in metastatic castrate-resistant prostate cancer has become a hot topic in the androgen receptor pathway inhibitors (ARPIs) era. Patients without increase in their PSA level at the time of imaging progression are not a rare phenomenon. What is the best monitoring strategy in asymptomatic cases represents a salient question. Here we presented 2 case reports involving men with metastatic castration-resistant prostate cancer who experienced disease progression without the anticipated increase in PSA levels. Our 2 cases show that imaging beyond standard PSA determination should be incorporate to monitor disease progression in patients with metastatic castrate-resistant prostate cancer even in the context of an undetectable PSA.

Pembrolizumab Plus Docetaxel Versus Docetaxel for Previously Treated Metastatic Castration-Resistant Prostate Cancer: The Randomized, Double-Blind, Phase III KEYNOTE-921 Trial

PURPOSE

The standard of care for metastatic castration-resistant prostate cancer (mCRPC) after second-generation androgen receptor pathway inhibitor (ARPI) therapy is still docetaxel. The randomized, double-blind, phase III KEYNOTE-921 trial (Clinicaltrials.gov identifier: NCT03834506) evaluated the efficacy and safety of pembrolizumab or placebo plus docetaxel for previously treated mCRPC.

METHODS

Adults with mCRPC who progressed after androgen-deprivation therapy and one ARPI were randomly assigned 1:1 to pembrolizumab or placebo plus docetaxel with concomitant prednisone. Dual primary end points were radiographic progression-free survival (rPFS) by blinded independent central review per Prostate Cancer Working Group 3-modified RECIST 1.1 and overall survival (OS). Safety was a secondary end point.

RESULTS

Between May 30, 2019, and June 17, 2021, 515 participants were randomly assigned to pembrolizumab plus docetaxel and 515 to placebo plus docetaxel. Median time from random assignment to data cutoff date (June 20, 2022) at final analysis (FA) was 22.7 months (range, 12.1-36.7). At first interim analysis (data cutoff date: September 27, 2021), median rPFS was 8.6 months (95% CI, 8.3 to 10.2) with pembrolizumab plus docetaxel versus 8.3 months (95% CI, 8.2 to 8.5) with placebo plus docetaxel (hazard ratio [HR], 0.85 [95% CI, 0.71 to 1.01]; P = .03). At FA, median OS was 19.6 months (95% CI, 18.2 to 20.9) versus 19.0 months (95% CI, 17.9 to 20.9), respectively (HR, 0.92 [95% CI, 0.78 to 1.09]; P = .17). Grade ≥3 treatment-related adverse events occurred in 43.2% of participants who received pembrolizumab plus docetaxel and 36.6% of participants who received placebo plus docetaxel. Two and seven participants, respectively, died due to a treatment-related adverse event. Pneumonitis was the most common immune-mediated adverse event (7.0% v 3.1%).

CONCLUSION

The addition of pembrolizumab to docetaxel did not significantly improve efficacy outcomes for participants with previously treated mCRPC. The current standard of care remains unchanged.

Days spent with healthcare contact by patients with metastatic castrate resistant prostate cancer in the last year of life

BACKGROUND

Days spent with healthcare contact during cancer treatment, or "time toxicity," may be particularly relevant to patients with end-stage malignancies, including metastatic castrate resistant prostate cancer (mCRPC), considering further cancer-directed therapies near the end-of-life.

PATIENTS AND METHODS

We retrospectively assessed healthcare contact days (ie, days with healthcare contact outside the home) in the last 12 months of 96 patients with mCRPC at an academic cancer center. We compared contact days in the 90-day period between 12 and 9 months prior to death ("first quarter") and the 90-day period prior to death ("last quarter") using the Wilcoxon signed rank test, with additional univariate analyses focused on clinicodemographic variables, particularly systemic treatments.

RESULTS

There were higher median [IQR] total contact days in the last vs first quarter (6 [2,17] vs 4 [3,6], P < .01), driven by emergency room visits and hospitalizations. Compared to patients off treatment in the first quarter (4 [3,4]), chemotherapy (5 [4,6], P = .02) and radiotherapeutics (5 [4,9], P = .03) were associated with greater contact days, but not androgen signaling inhibitors (3 [2,5], P = .20). However, there were no differences in contact days by treatment in the last quarter. Patients enrolled in hospice experienced similar contact days between the last and first quarters (4 [2,15] vs 4 [3,7], P = .22).

CONCLUSION

Patients with mCRPC experienced increased healthcare contact in the last three months of life resulting from higher inpatient level of care, despite most enrolling in hospice. Future studies can further set expectations on time toxicity in end-stage mCRPC.

Are evidence-based guidelines translating into clinical practice? A national population-based study of the use of treatment intensification in metastatic hormone-sensitive prostate cancer (mHSPC) in England

BACKGROUND AND OBJECTIVE

International guidelines recommend treatment intensification combining docetaxel or androgen receptor pathway inhibitors with androgen deprivation therapy for metastatic hormone-sensitive prostate cancer (mHSPC). However, evidence suggests underuse in many high-income countries. This study evaluates the use of treatment intensification in the English National Health Service (NHS) and explores patient and hospital-level factors associated with variation.

METHODS

All men diagnosed with mHSPC in England between January 2018 and December 2022 were identified through the national cancer registry. Treatment intensification within six months of diagnosis was assessed using hospital and systemic anti-cancer therapy data. Multilevel regression models explored associations between treatment intensification and sociodemographic factors including age, comorbidities, frailty, ethnicity, socioeconomic status, rurality, and year of diagnosis. Variation among the 47 specialist multidisciplinary teams (sMDTs), responsible for coordinating prostate cancer care in England, was also evaluated.

KEY FINDINGS AND LIMITATIONS

Among 29,713 mHSPC patients, treatment intensification use was 39.0 %. Treatment intensification use decreased with age, comorbidities, frailty, socioeconomic deprivation, and among black patients (p always < 0.05). 59.8 % (n = 9184) of men aged 75 or younger had a record of treatment intensification, compared to only 16.8 % (n = 2404) of men older than 75. The use of treatment intensification across sMDTs ranged from 20.3 % to 53.7 %, with greater variation in older patients, particularly those older than 75.

CONCLUSIONS AND CLINICAL IMPLICATIONS

There is potential underuse of treatment intensification for mHSPC patients, particularly among older, black, and socioeconomically deprived patients. Significant variation in practice exists between specialist prostate cancer teams (sMDTs) nationally, especially in older populations, indicating that many patients may not receive optimal care.

Biochemical recurrence after radical prostatectomy and postoperative radiotherapy: current evidence and controversial issues

PURPOSE OF REVIEW

This review explores challenges in managing biochemical recurrence (BCR) after radical prostatectomy and postoperative radiotherapy for prostate cancer (PCa) highlighting gaps in risk stratification, imaging, and emerging therapies, as well as advances in molecular imaging and personalized treatment.

RECENT FINDINGS

Approximately half of PCa patients experience a second BCR after postoperative radiotherapy. Time to recurrence, PSA kinetics, adverse pathological features (ISUP 4-5, pT3-4, and positive surgical margins), alongside genetic profile, are key factors for risk stratification. Combination of androgen deprivation therapy (ADT) and novel androgen receptor pathway inhibitors (ARPIs) represents an established treatment choice. However, recent findings emphasize the growing role of prostate-specific membrane antigen (PSMA) PET in detecting recurrent disease and guide tailored strategies. Based on early phase II trials and retrospective studies, metastasis-directed therapy (MDT) has demonstrated promising efficacy in oligorecurrent PCa, although further validation is warranted.

SUMMARY

BCR after radical prostatectomy and postoperative radiotherapy represents a challenge in PCa management. Risk stratification is key for guiding the addition of ARPIs to standard ADT. PSMA PET may further refine tailored strategies such as MDT, whose promising efficacy needs further exploration. Ongoing trials will clarify treatment sequencing and patient selection in the evolving paradigm of BCR management.

Management of de Novo Metastatic Hormone-Sensitive Prostate Cancer (mHSPC) and the Role of Radiation Therapy: A Consensus by the Italian Association of Radiotherapy and Clinical Oncology (AIRO)

PURPOSE

Prostate cancer treatments paradigms are in continuous evolution, especially in the metastatic setting. In this context, the Genito-Urinary Group of Italian Association of Radiotherapy and Clinical Oncology aimed to create a consensus on radiation therapy indication in de novo metastatic hormone-sensitive prostate cancer both on primary tumor and metastatic sites.

METHODS

A panel of experts, involved in clinical management of prostate cancer, through the estimate-talk-estimate method, developed a list of items and correspondent statements on the identified topic.

RESULTS

Seven conclusive items were identified with 12 statements about the chosen topic, radiation therapy in metastatic hormone-sensitive prostate cancer on primary tumor and metastatic sites.

CONCLUSIONS

This consensus might help clinicians in prostate cancer managing in daily clinical practice.

Real-world effectiveness of novel hormonal agents and docetaxel in patients with prostate cancer: A head-to-head comparison

Next-generation hormonal-targeted therapies for advanced prostate cancer are widely used. We aimed to evaluate the effectiveness and health resource utilization (HRU) of novel hormonal agents (NHAs) compared to chemotherapy in a real-world context. After propensity score matching, survival analysis revealed no significant difference in overall survival between the individuals treated with NHAs and those treated with docetaxel (hazard ratio [HR]: 1.00, 95% confidence interval [CI]: 0.89-1.11) in the cohort of 1,056 patients. Similar results were observed for prostate-specific antigen (PSA) progression-free survival (HR: 1.02, 95% CI: 0.91-1.14) and PSA response rate (72% [95% CI: 68-76%] for NHAs vs. 76% [95% CI: 72-80%] for docetaxel, p > 0.05). Additionally, patients treated with NHAs had a significantly lower annual HRU during follow up. These findings indicate comparable effectiveness between NHAs and chemotherapy, with a more favorable HRU profile for NHA-treated patients, suggesting potential cost-effectiveness of NHAs.

Prognostic Value of PARP1 and PARP2 Copy Number Alterations in Prostate Cancer

PARP1/2 have overlapping yet nonredundant biological functions in DNA repair and androgen receptor-transcriptional regulation. Studies on PARP alterations in human tumors have yielded conflicting results. In prostate cancer (PCa), PARP1/2 protein overexpression has been related to androgen deprivation therapy resistance, biochemical recurrence, and progression to metastases. PARP inhibitors have been approved for treating metastatic castration-resistant PCa with homologous recombination repair gene mutations. However, the significance of PARP1/2 genomic alterations is not fully studied. We aimed to analyze PARP1/2 alterations in PCa, assess their value as prognostic markers, and explore their relevance for potential therapeutic stratification. PARP1/2 copy number status was evaluated in 121 PCa primary tumors using real-time PCR. In 29 of them, a regional pelvic lymph node involvement was also analyzed. BRCA1/2 somatic mutations were analyzed in 24 PCa cases. Relationship with clinicopathological features, progression to metastases, and prostate-specific antigen recurrence was assessed. PARP1 loss and PARP2 gain were detected in 34.7% and 32.2% of primary tumors, respectively, with a high frequency of co-occurrence (P < .001). Both alterations were statistically associated with locally advanced disease at the time of diagnosis (P = .036; P = .006), metastatic dissemination (P = .014; P = .003), and other aggressive clinicopathological characteristics (such as the presence of Gleason pattern 5, high-grade, and high-stage). Cases with exclusive PARP2 gain had the shortest time to prostate-specific antigen recurrence, whereas double wt patients displayed the best outcome (P = .007). In 29 paired primary tumors and regional pelvic lymph node involvement, PARP1 loss showed strong concordance (P = .001), whereas PARP2 gain did not (P = .411). In conclusion, loss of PARP1 and gain of PARP2 show strong co-occurrence and are associated with clinicopathological characteristics of aggressiveness. PARP2 alterations appear to have a particularly significant impact on disease prognosis. Furthermore, these data suggest that the analysis of PARP1/2 copy number status could be useful in predicting PCa outcomes. Its role in therapy warrants further evaluation.

Radiographic Progression Without Corresponding Prostate-specific Antigen Progression in Patients with Metastatic Castration-sensitive Prostate Cancer Receiving Apalutamide: Secondary Analysis of the TITAN Trial

BACKGROUND AND OBJECTIVE

In prostate cancer treated with androgen deprivation therapy (ADT), the initial sign of treatment resistance is often prostate-specific antigen (PSA) progression, followed by radiographic progression. However, the association between these two forms of progression remains unclear, especially in patients with metastatic castration-sensitive prostate cancer (mCSPC) treated with androgen receptor pathway inhibitors. We sought to evaluate the association between radiographic progression, PSA progression, and outcomes of apalutamide therapy in mCSPC.

METHODS

We analyzed individual participant-level data for patients randomized within the TITAN trial who experienced radiographic progression during follow-up (N = 326). This study investigated radiographic progression without simultaneous or preceding PSA progression, as defined by the Prostate Cancer Working Group 2 (discordant progression), and explored the association of such progression with radiographic progression-free survival.

KEY FINDINGS AND LIMITATIONS

Among the patients who developed radiographic progression, 115 (35.3%) had been treated with apalutamide plus ADT (the apalutamide group) and 211 (64.7%) with placebo plus ADT (the placebo group). Discordant progression occurred in 52.2% of patients (60 of 115) in the apalutamide group and 27.5% (58 of 211) in the placebo group (p < 0.001). A multivariable logistic regression analysis showed that discordant progression was associated with apalutamide treatment. We found evidence of an association between discordant progression and shorter radiographic progression-free survival.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This study found that nearly half of the patients with mCSPC treated with apalutamide who experienced radiographic progression developed it without corresponding PSA progression, suggesting that heavy reliance on PSA monitoring may be inadequate for assessing disease activity in this context.

PATIENT SUMMARY

In patients who have metastatic castration-sensitive prostate cancer (mCSPC) and are being treated with apalutamide, radiographic images may show cancer progression even if prostate-specific antigen tests indicate no change. This highlights the importance of regular imaging when using apalutamide to manage mCSPC.

Feasibility and efficacy of therapeutic drug monitoring of abiraterone in metastatic castration resistant prostate cancer patients

BACKGROUND

Previous studies demonstrated better outcomes for mCRPC (metastatic castration resistant prostate cancer) patients with higher abiraterone exposure (minimal plasma concentration (Cmin) > 8.4 ng/mL), but around 40% of patients experience exposure below this target. Pharmacokinetic (PK)-guided interventions following Therapeutic Drug Monitoring (TDM) could optimise exposure and outcomes. We aimed to evaluate the feasibility and effect on treatment outcomes of abiraterone TDM.

METHODS

Patients with low exposure levels (Low-group, Cmin < 8.4 ng/mL) got a PK-guided intervention. We compared exposure, adverse event (AE) incidence, time on treatment (ToT) and Prostate-Specific Antigen response rate (PSArr) between the Low-group and Adequate-group.

RESULTS

We included 167 mCRPC patients, with 56 in the Adequate-group and 111 in the Low-group. Interventions were successful 86% of the time. Exposure between groups became corresponding (Low-group: 7.95 to 20.5 ng/mL, Adequate-group: 20.8 ng/mL, p = 0.72) with comparable AE incidence (17% vs. 23%, p = 0.4). Median ToT and PSArr were similar (351 vs. 379 days, p = 0.35; 61.3% vs. 67.9%, p = 0.51).

CONCLUSIONS

PK-guided interventions improved above target exposure from 33.5% to 81.4% of patients without additional AEs. While historically, low exposure patients had significantly shorter survival, PK-guided interventions eliminated this disparity. As interventions are effective, low-cost and safe, TDM for abiraterone should be considered to enhance treatment outcomes.

The Importance of Multiparametric Magnetic Resonance Imaging, Positron Emission Tomography/Computed Tomography, and Biopsy for Identifying and Delineating the Extent of Intraprostatic Radiorecurrent Prostate Cancer: A Secondary Analysis of the F-SHARP Clinical Trial

PURPOSE

Up to 50% of clinical recurrences after curative-intent prostate cancer radiation are intraprostatic radiorecurrences (IPRRs). Salvage local therapy (SLT) is increasingly offered, particularly as focal SLT, to reduce toxicity due to prior radiation. Limited data exist on the relative value of magnetic resonance imaging (MRI), positron emission tomography/computed tomography (PET/CT), and biopsy on SLT target delineation. We compared MRI, PET/CT, and biopsy in patients with IPRRs and the impact each modality has on identifying IPRRs and defining the extent of prostatic involvement.

METHODS AND MATERIALS

We performed a secondary analysis of 62 patients enrolled in a phase 1/2 clinical trial of salvage high-dose-rate brachytherapy. The IPRR was delineated using each imaging modality and by defining the involved regions of the prostate on biopsy. The exact binomial distribution was used to estimate the sensitivity of MRI and PET/CT to detect the IPRR. Exact conditional logistic regression was used to compare the tumor identified by MRI and PET/CT with the areas of biopsy involvement (gold standard) and estimate the proportion of patients with prostatic involvement outside of the image-defined targets.

RESULTS

The sensitivity for detecting the IPRR was 91.8% for MRI and 85.5% for PET/CT. Most patients had biopsy-proven cancer outside of the MRI-defined (70.5%) and PET/CT-defined (73.8%) target. Delineating the brachytherapy target using imaging only would have missed the full extent of recurrence in 63.9%.

CONCLUSIONS

Although MRI and PET/CT are valuable, a thorough biopsy is a mandatory tool to avoid missing areas of imaging-occult prostatic involvement when delivering focal SLT.

Impact of interdisciplinary tumor boards (ITB) and personalized treatment on survival outcomes in metastatic castration-resistant prostate cancer

PURPOSE

Interdisciplinary tumor boards (ITB) are essential in optimizing treatment recommendations for metastatic castration-resistant prostate cancer (mCRPC) by incorporating oncology guidelines, clinical trials, and patient-specific factors to ensure individualized care. This study examines clinical parameters that influence ITB recommendations, evaluates their adherence to guidelines, and assesses their impact on patient survival.

METHODS

In a retrospective analysis, data from 187 mCRPC patients discussed at an ITB in a tertiary care center in 2018 were evaluated. Patient- and disease-specific factors were correlated with adherence to National Comprehensive Cancer Network® (NCCN®) guidelines and overall survival (OS). The impact of clinical parameters on survival outcomes was assessed through univariate and multivariate analyses.

RESULTS

The median patient age was 72.8 years, with a median prostate-specific antigen (PSA) level of 65.0 ng/ml. Guideline-compliant recommendations were given in 42.9% of cases, while 57.1% received individualized recommendations. Clinical trial eligibility was noted in 24.8% of patients. Individualized ITB recommendations were associated with significantly longer OS (38.3 vs. 21.2 months, p = 0.03). Shorter OS correlated with renal impairment (p = 0.007), symptomatic metastases (p < 0.0001), and visceral metastases (p < 0.0001). Limitations include the retrospective design, lack of follow-up on therapy adherence, and absence of progression-free survival (PFS) data.

CONCLUSION

ITB discussions improve survival in mCRPC patients, mainly due to personalized approaches and better access to clinical trials. Visceral and symptomatic metastases as well as renal impairment are risk factors for reduced OS, emphasizing the need for careful management of these high-risk patients. The results support the expanded use of ITB to improve mCRPC treatment outcomes.

Multi-gene risk score for prediction of clinical outcomes in treatment-naïve metastatic castrate-resistant prostate cancer

BACKGROUND

To determine the performance of a multi-gene copy number variation (MG-CNV) risk score in metastatic tissue and plasma biospecimens from treatment-naïve metastatic castration-resistant prostate cancer (mCRPC) patients for prediction of clinical outcomes.

METHODS

The mCRPC tissue and plasma cell-free DNA (cfDNA) biospecimen sequencing results obtained from publicly accessed cohorts in dbGaP, cBioPortal, and an institutional mCRPC cohort were used to develop a MG-CNV risk score derived from gains in AR, MYC, COL22A1, PIK3CA, PIK3CB, NOTCH1 and losses in TMPRSS2, NCOR1, ZBTB16, TP53, NKX3-1 in independent cohorts for determining overall survival (OS), progression-free survival (PFS) to first-line androgen receptor pathway inhibitors (ARPIs). The range of the risk scores for each cohort was dichotomized into "high-risk" and "low-risk" groups and association with OS/PFS determined. Univariate and multivariable Cox proportional hazards regressions were applied for survival analyses (P < .05 for statistical significance).

RESULTS

Of 1137 metastatic tissue-plasma biospecimens across all cohorts, 699/1137 were treatment-naive mCRPC (235/699 metastatic tissue; 464/699 plasma-cfDNA), and 311/1137 were matched tissue-cfDNA pairs. In multivariable analysis, the MG-CNV risk score derived from metastatic tissue or in cfDNA was statistically significantly associated with OS with high score associated with short survival (hazard ratio = 2.65, confidence interval = 1.99 to 3.51; P = 1.35-11) and shorter PFS to ARPIs (median PFS of 7.8 months) compared with 14 months in patients with low-risk score.

CONCLUSIONS

A molecular risk score in treatment-naïve mCRPC state obtained either in metastatic tissue or cfDNA predicts clinical survival outcomes and offers a tumor biology-based tool to design biomarker-based enrichment clinical trials.

Treatment of metastatic castration-resistant prostate cancer: review of current evidence and synthesis of expert opinions on radioligand therapy

Background

Despite the boom in the development of cancer management in the last decade, most patients with metastatic prostate cancer (PCa) eventually progress to metastatic castration-resistant PCa (mCRPC) and often require multiple lines of treatment. The treatment landscape of mCRPC has evolved rapidly in recent years, introducing various types of systemic therapies, including taxane-based chemotherapy, androgen receptor pathway inhibitors, bone-targeted radionuclides (e.g., radium-223), immune checkpoint inhibitors, poly(adenosine diphosphate [ADP]-ribose) polymerase (PARP) inhibitors, and radioligand therapies (RLTs) [e.g., a prostate-specific membrane antigen (PSMA) ligand labelled with 177Lu].

Methods

To help clinicians navigate the increasingly complex treatment landscape of mCRPC, this article reviews the evidence on different therapeutic regimens from pivotal trials. In addition, it reports on the results of a questionnaire developed and distributed by the Hong Kong Society of Uro-Oncology (HKSUO), with the aim of collecting the perspectives of specialists experienced in the treatment of advanced PCa in Hong Kong with regard to the clinical application of RLT, primarily [177Lu]Lu-PSMA-617/analogue therapy.

Results

A total of 43 questionnaire respondents (including clinical oncologists, urologists, nuclear medicine specialists, and medical oncologists) voted on 27 consensus questions divided into eight sections. Consensus or strong consensus (correspondingly ≥75% or ≥90% acceptance for an answer option) was reached for 10 questions. Subsequently, a panel of 13 local and overseas experts coordinated by the HKSUO discussed the voting results and provided further insights into certain questions.

Conclusion

The literature review, the voting results of the questionnaire, and the expert opinions are expected to facilitate better understanding of recent therapeutic advancements and the role of novel RLTs in the treatment of mCRPC among clinicians.

Impact of stereotactic body radiotherapy after progression in castrate resistant prostate cancer patients undergoing first line abiraterone treatment. A subgroup analysis from ARTO trial (NCT03449719)

BACKGROUND

ARTO trial was a phase II randomized trial suggesting the benefit of a concomitant treatment strategy including Abiraterone acetate plus predisone (AAP) and stereotactic body radiotherapy (SBRT) in oligometastatic castrate resistant prostate cancer (omCRPC). The object of the current analysis is to explore whether the benefit provided by SBRT to AAP is maintained at later stages of disease after oligoprogression METHODS: Patients enrolled in ARTO trial in whom a first progression event was reported were divided in two groups according to the treatment approach received, regardless of the initial randomization. After first progression event, Patients in Group A received SBRT on oligoprogressive disease, while patients in group B received second line systemic treatment. Palliative RT was not considered for the purpose of this analysis. Progression-Free survival (PFS) 1 and 2 were defined as time between AAP start and first progression event and time between first and second progression event, death or last follow up, (whichever came first), respectively. Cox regression analysis was performed to compare PFS1 + PFS2 in patients in group A vs Group B. Kaplan-Meier analysis was performed to compare overall survival between the two groups RESULTS: Median PFS1 + PFS2 was 45.9 months vs. not reached in group A (n = 43) vs Group B (n = 20), respectively (HR 0.63, 95% CI 0.17-2.33, p value 0.489), no significant difference was detected. Median OS was not reached in neither of the two arms of treatment, with a non-significant trend in favour of the experimental arm (HR 0.50, 95% CI 0.14-1.78, p = 0.284) CONCLUSIONS: Results from the present analysis show that SBRT after progression may be a viable and feasible option for omCRPC after progression if compared to second line systemic therapy.

Management of Patients with Advanced Prostate Cancer. Report from the 2024 Advanced Prostate Cancer Consensus Conference (APCCC)

BACKGROUND AND OBJECTIVE

Innovations have improved outcomes in advanced prostate cancer (PC). Nonetheless, we continue to lack high-level evidence on a variety of topics that greatly impact daily practice. The 2024 Advanced Prostate Cancer Consensus Conference (APCCC) surveyed experts on key questions in clinical management in order to supplement evidence-based guidelines. Here we present voting results for questions from APCCC 2024.

METHODS

Before the conference, a panel of 120 international PC experts used a modified Delphi process to develop 183 multiple-choice consensus questions on eight different topics. Before the conference, these questions were administered via a web-based survey to the voting panel members ("panellists").

KEY FINDINGS AND LIMITATIONS

Consensus was a priori defined as ≥75% agreement, with strong consensus defined as ≥90% agreement. The voting results show varying degrees of consensus, as discussed in this article and detailed in the Supplementary material. These findings do not include a formal literature review or meta-analysis.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The voting results can help physicians and patients navigate controversial areas of clinical management for which high-level evidence is scant or conflicting. The findings can also help funders and policymakers in prioritising areas for future research. Diagnostic and treatment decisions should always be individualised on the basis of patient and cancer characteristics, and should incorporate current and emerging clinical evidence, guidelines, and logistic and economic factors. Enrolment in clinical trials is always strongly encouraged. Importantly, APCCC 2024 once again identified important gaps (areas of nonconsensus) that merit evaluation in specifically designed trials.

Clinical, Diagnostic and Therapeutic Framework of mHSPC and nmCRPC: A Multidisciplinary Consensus Project of the Italian Society for Uro-Oncology (SIUrO)

The recent evidences provided in metastatic hormone sensitive prostate cancer (nmHSPC) and in nonmetastatic castration resistant (nmCRPC) introduced the possibility to adopt Androgen Receptor Signaling inhibitor (ARSi) alone (both settings) or with chemotherapy (in mHSPC). In daily clinical practice there are some opening questions regarding the inclusion of next generation imaging, mainly PSMA-PET, how integrate local treatment as radiotherapy, how to select patients or drugs in a multiple-choice scenario, and how to manage patients with comorbidities and polypharmacy. These issues led the Italian Society for Uro-Oncology (SIUrO) to develop a consensus project involving all of the most important Italian scientific societies engaged in the multidisciplinary and multiprofessional management of the disease. This paper describes the items and statements approved, with the aim to support clinicians in managing metastatic hormone sensitive and nonmetastatic castration resistant prostate cancer patients.

Intensification Approaches and Treatment Sequencing in Metastatic Castration-resistant Prostate Cancer: A Systematic Review

BACKGROUND AND OBJECTIVE

Recently, research on treatment intensification has gathered momentum, and three novel therapy combinations were approved for metastatic castration-resistant prostate cancer (mCRPC). This systematic review summarizes the current and emerging evidence around intensified strategies for mCRPC and provides guidance for an ideal therapeutic sequencing.

METHODS

Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines were followed to perform this review. PubMed, EMBASE, Web of Science, Cochrane Library, ClinicalTrials.gov, and major international societies' online proceedings were searched comprehensively until May 15, 2024, for terms related to treatment intensification and sequencing for mCRPC.

KEY FINDINGS AND LIMITATIONS

Overall, 28 clinical trials and 24 ongoing studies of intensification treatments were included in this review. Algorithms of optimal sequencing of approved treatments for mCRPC were outlined according to the use of androgen receptor pathway inhibitors (ARPIs) with or without docetaxel for earlier disease states. In first line, poly(ADP-ribose) polymerase inhibitor + ARPI combinations improve radiographical progression-free survival (rPFS), particularly for those with BRCA1/2 alterations. The AKT inhibitor combination of ipatasertib + abiraterone extends rPFS in those with PTEN loss or PIK3CA/AKT1/PTEN alterations. In those with two or more risk factors for early progression on enzalutamide, radionuclide 177-Lu-PSMA-617 + enzalutamide prolongs progression-free survival. Ongoing research of intensified approaches for mCRPC, and available and potential predictive and prognostic biomarkers are discussed.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Recent approvals and ongoing investigations of single agents and intensification approaches will keep transforming the mCRPC treatment landscape. Improvement of patient profiling applying recognized genomic, molecular, and clinical predictive and prognostic indicators is fundamental to optimize sequential use of available therapies.

The expanding role of next-generation imaging in prostate cancer management: a cross-sectional survey exploring the clinical practice of uro-oncologists in North-Eastern Italy; on behalf of GUONE (Gruppo Uro-Oncologico del Nord-Est)

Background

Next-generation imaging (NGI) technologies such as multiparametric magnetic resonance imaging (mpMRI) and total-body NGI (tbNGI) methodologies including choline, fluciclovine or PSMA positron emission tomography/computed tomography (PET/CT), whole-body MRI (wbMRI), and PET/MRI are becoming increasingly available, but their use in different prostate cancer (PCa) settings is under debate. The Gruppo Uro-Oncologico del Nord-Est (GUONE) designed a survey to explore the current clinical practice of NGI utilization in a specific macro-region in North-Eastern Italy.

Methods

A cross-sectional survey was conducted by administering an anonymous online multiple-choice questionnaire to uro-oncologists practicing in North-Eastern Italy, using the Google Forms® platform. The use of NGI was investigated in the following settings: primary staging of PCa; management of biochemical (BCR) and local recurrence (LR); re-staging in metastatic hormone-sensitive PCa (mHSPC), metastatic castration-resistant PCa (mCRPC), non-metastatic CRPC (nmCRPC), and oligometastatic PCa (OMPC).

Results

In all, 100 uro-oncologists accessed and completed the survey. In primary N/M staging, the use of tbNGI increases in accordance with NCCN risk groups. Re-staging with choline and PSMA PET/CT is the prevalent choice in the case of BCR after radical prostatectomy. Moreover, when the PSA value rises, there is a parallel increased use of tbNGI. When an LR is suspected, PSMA PET/CT plus mpMRI is the most selected option. Re-staging with tbNGI (PSMA PET/CT) is preferred in mHSPC, mCRPC, and nmCRPC patients in case of progression of disease. Overall, there is a limited use of wbMRI and PET/MRI in all the settings investigated.

Conclusion

Our survey describes the expanding role of NGI modalities in the management of PCa patients, from primary staging and re-staging to management of advanced PCa and assessment of treatment response. Several controversial issues have emerged, which need to be addressed in prospective studies to develop a standardized and cost-effective NGI utilization.

The Emerging Predictive and Prognostic Role of Aggressive-Variant-Associated Tumor Suppressor Genes Across Prostate Cancer Stages

Aggressive variant prostate cancer (AVPC) is characterized by a molecular signature involving combined defects in TP53, RB1, and/or PTEN (AVPC-TSGs), identifiable through immunohistochemistry or genomic analysis. The reported prevalence of AVPC-TSG alterations varies widely, reflecting differences in assay sensitivity, treatment pressure, and disease stage evolution. Although robust clinical evidence is still emerging, the study of AVPC-TSG alterations in prostate cancer (PCa) is promising. Alterations in TP53, RB1, and PTEN, as well as the combined loss of AVPC-TSGs, may have significant implications for prognosis and treatment. These biomarkers might help predict responses to various therapies, including hormonal treatments, cytotoxic agents, radiotherapy, and targeted therapies. Understanding the impact of these molecular alterations in patients with PCa is crucial for personalized management. In this review, we provide a comprehensive overview of the emerging prognostic and predictive roles of AVPC-TSG alterations across PCa stages. Moreover, we discuss the implications of different methods used for detecting AVPC-TSG alterations and summarize factors influencing their prevalence. As our comprehension of the genomic landscape of PCa disease deepens, incorporating genomic profiling into clinical decision making will become increasingly important for improving patient outcomes.

Stereotactic body radiotherapy as metastasis-directed therapy in oligometastatic prostate cancer: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The use of stereotactic body radiotherapy (SBRT) to definitively treat oligometastases in prostate cancer has drawn large clinical and research interests within radiation oncology. However, the evidence is considered in its early stages and there is currently no systematic review of randomized controlled trials (RCTs) in this field. We aimed to evaluate the efficacy and safety of SBRT as metastasis-directed therapy (MDT) in oligometastatic prostate cancer (OMPC) compared to no MDT reported in RCTs.

METHODS

MEDLINE, Embase, CINAHL Complete, and Cochrane Library were searched on October 28, 2023. Eligible studies were RCTs comparing SBRT as MDT with no MDT in extracranial OMPC, without restrictions on follow-up time, publication status, language, or year. Participant subsets fulfilling the eligibility criteria were included. Critical outcomes were overall survival and grade ≥ 3 toxicity, and additional important outcomes were progression-free survival (PFS), local control, grade 5 toxicity, health-related quality of life, and systemic therapy-free survival. Meta-analyses were planned. Risk of bias was assessed using the Cochrane risk-of-bias tool version 2, and the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

In total, 1825 unique study reports were identified and seven phase II RCTs with 559 eligible participants were included. Four trials included multiple types of primary cancer. Outcome definitions were heterogeneous except for overall survival and toxicity. For overall survival, only one study reported events in both arms. Meta-analysis of the grade ≥ 3 toxicity results from two trials showed no difference (pooled risk ratio 0.78, 95% confidence interval 0.37-1.65, p = 0.52). Four trials reported significantly longer PFS, with a pooled hazard ratio of 0.31 (95% confidence interval 0.21-0.45, p < 0.00001). Risk of bias was of some concerns or high. Quality of evidence was low or moderate.

CONCLUSIONS

Phase II trials have shown promising improvements in PFS for several OMPC states without excess toxicity. Overall survival comparisons are immature. In future confirmatory phase III trials, adequately large sample sizes, blinding of outcome assessors, and/or increased adherence to assigned intervention could improve the quality of evidence. PROSPERO registration number: CRD42021230131.

Evolocumab in metastatic castration-resistant prostate cancer: study protocol for a single-arm, phase II trial, and initial experience with use of a validated lipid biomarker to direct therapy

Background

Despite advances in the treatment of metastatic castration-resistant prostate cancer (mCRPC), primary and secondary resistance to current therapies remains. Elevated circulating sphingolipids are associated with poor outcomes in patients with mCRPC, including therapeutic resistance and shorter overall survival. PCPro is a clinically accessible, regulatory compliant plasma lipid biomarker of poor prognosis in mCRPC, which incorporates prognostic sphingolipids. We hypothesize that reversal of the PCPro signature in men with mCRPC by sphingolipid-lowering agents will improve their clinical outcomes. However, the first step is to determine whether this poor prognostic lipid signature can be modulated. A potential sphingolipid-lowering agent is the PCSK9-inhibitor evolocumab, which is used in the management of hypercholesterolemia.

Objectives

Our primary objective is to assess whether treatment with evolocumab during standard anticancer therapy can safely modify the PCPro signature in men with mCRPC.

Design

This is a multicenter, open label phase II trial.

Methods

Men with mCRPC commencing docetaxel, cabazitaxel, abiraterone, enzalutamide, olaparib, or lutetium-177 PSMA for disease progression will be screened for the presence of PCPro. Those who are PCPro positive will receive a 12-week course of evolocumab concurrent with their standard therapy. Dosage is as per cardiovascular guidelines (420 mg subcutaneously every 4 weeks). PCPro will be repeated after 12 weeks. The primary endpoint is reversal of PCPro. The secondary endpoint is the safety of combination therapy with exploratory endpoints characterizing changes in comprehensive lipid profiles pre- and post-treatment.

Discussion

This study will evaluate whether evolocumab can safely modify the PCPro signature in men with mCRPC, providing essential data to the development of precision metabolic therapy in the management of prostate cancer.

Trial registration

This study is approved by the Human Research Ethics Committee (X22-0072 and 2022/ETH00427). It is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622001003763).

Controversies in prostate cancer management: Consensus recommendations from experts in northern Spain

In recent years, various aspects of prostate cancer (PC) management have undergone significant changes, including the implementation of therapeutic strategies such as the use of new hormonal agents like abiraterone, apalutamide, enzalutamide or darolutamide and the incorporation of next generation imaging techniques (NGI). However, the evidence regarding the role of NGI and the therapeutic decision-making based on their findings is not solid. Following the methodology of the Advanced Prostate Cancer Consensus Conference (APCCC), a multidisciplinary expert consensus was developed to address controversial questions concerning the use of NGI and clinical management in four priority scenarios: localized PC, PC after radical prostatectomy, PC after radiotherapy with curative intent, and metastatic hormone-sensitive PC. This consensus represents the opinions of medical oncology, radiation oncology and urology physicians and provides useful recommendations for clinical practice.

Association of Declining Prostate-specific Antigen Levels with Clinical Outcomes in Patients with Metastatic Castration-resistant Prostate Cancer Receiving [177Lu]Lu-PSMA-617 in the Phase 3 VISION Trial

BACKGROUND AND OBJECTIVE

The prognostic value of declining prostate-specific antigen (PSA) levels is under investigation in patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer (mCRPC) receiving PSMA-targeted radioligand therapy with [177Lu]Lu-PSMA-617 (177Lu-PSMA-617). This post hoc analysis of the phase 3 VISION trial aimed to evaluate associations between PSA decline and clinical and patient-reported outcomes in patients receiving 177Lu-PSMA-617.

METHODS

Of 831 enrolled patients with PSMA-positive progressive mCRPC treated previously with one or more androgen receptor pathway inhibitors and one to two taxanes, 551 were randomised to 177Lu-PSMA-617 plus protocol-permitted standard of care (SoC). Radiographic progression-free survival, overall survival, radiographic objective response rate, and patient-reported health-related quality of life (HRQoL) and pain were analysed in subgroups of patients categorised by the magnitude of unconfirmed PSA decline from baseline.

KEY FINDINGS AND LIMITATIONS

Patients randomised to 177Lu-PSMA-617 with the best PSA declines of ≥0-<50% (96/551 [17%]), ≥50-<90% (152/551 [28%]), and ≥90% (83/551 [15%]) up to and including week 12 had 61%, 72%, and 88% reduced risks of radiographic disease progression or death, and 51%, 70%, and 87% reduced risks of death, respectively, versus those with increased PSA levels (160/551 [29%]), based on hazard ratios in a multivariate Cox proportional hazard model. In patients with greater PSA declines, radiographic responses were more frequent and median time to worsening in HRQoL and pain scores were longer.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The magnitude of PSA decline was associated with improvement in clinical and patient-reported outcomes in patients with mCRPC receiving 177Lu-PSMA-617 plus SoC in VISION. PSA decline therefore appears to have a prognostic value during 177Lu-PSMA-617 treatment in this population.

Talazoparib plus enzalutamide in metastatic castration-resistant prostate cancer: Safety analyses from the randomized, placebo-controlled, phase III TALAPRO-2 study

BACKGROUND

This detailed analysis further characterizes the safety profile of talazoparib plus enzalutamide in the ongoing randomized, phase III TALAPRO-2 study in patients with metastatic castration-resistant prostate cancer (mCRPC). In both the all-comers and homologous recombination repair (HRR)-deficient populations, talazoparib plus enzalutamide significantly improved radiographic progression-free survival compared with placebo plus enzalutamide.

METHODS

The talazoparib plus enzalutamide safety populations in TALAPRO-2 included 398 patients from cohort 1 (all-comers, unselected for HRR gene alterations) and 198 patients from the combined HRR-deficient population (patients from the all-comers population with HRR gene alterations plus subsequently enrolled patients with HRR gene alterations; cohort 2). Patients received talazoparib 0.5 mg (0.35 mg, moderate renal impairment) and enzalutamide 160 mg once daily. Safety analyses evaluated common treatment-emergent adverse events (TEAE), their type, severity, timing, seriousness, and relationship to study treatment.

RESULTS

In the all-comers (n = 398) and HRR-deficient populations (n = 198), all-cause grade 3/4 (G3/4) TEAEs with talazoparib plus enzalutamide were reported in 71.9 % and 66.2 % of patients, respectively. Most common G3/4 hematologic TEAEs were anemia (46.7 % and 40.9 %, respectively), neutropenia (18.3 % and 18.7 %), and thrombocytopenia (7.3 % and 7.1 %). Median time to event was 3.3 and 3.3 months for G3/4 anemia, 2.3 and 2.3 months for G3/4 neutropenia, and 2.3 and 1.5 months for G3/4 thrombocytopenia. Maximum hemoglobin reduction occurred after 13 and 15 weeks of treatment. 18.8 % and 10.1 % of patients discontinued talazoparib. TEAEs were managed with dose interruption (62.1 % and 57.6 %), reduction (52.8 % and 52.0 %), hematologic supportive care (13.1 % and 10.6 %), and packed red blood cell transfusions (39.2 % and 35.9 %).

CONCLUSION

Talazoparib plus enzalutamide had a generally manageable safety profile in patients with mCRPC within the all-comers and the HRR-deficient populations.

CLINICALTRIALS

GOV IDENTIFIER

NCT03395197.

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.

Prognostic and Predictive Role of SPOP Mutations in Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

Mutations in the speckle-type POZ (SPOP) gene are frequently identified in prostate cancer (PC); yet, prognostic implications for affected patients remain unclear. Limited consensus exists regarding tailored treatments for SPOP-mutant (SPOPmut) PC.

OBJECTIVE

To elucidate the prognostic and predictive significance of SPOP mutations across distinct PC stages and treatments.

EVIDENCE ACQUISITION

A systematic literature search of PubMed, Embase, and Scopus was conducted up to January 29, 2024. The meta-analysis included studies comparing survival outcomes between SPOPmut and SPOP wild-type (SPOPwt) PC.

EVIDENCE SYNTHESIS

From 669 records, 26 studies (including five abstracts) were analyzed. A meta-analysis of metastasis-free survival in localized (hazard ratio [HR]: 0.72, 95% confidence interval [CI]: 0.59-0.88; p < 0.01) and overall survival (OS) in metastatic PC (HR: 0.64, 95% CI: 0.53-0.76; p < 0.01) showed a favorable prognosis for patients with SPOPmut PC. In metastatic settings, SPOP mutations correlated with improved progression-free survival (PFS) and OS in patients undergoing androgen deprivation therapy ± androgen receptor signaling inhibitor (HR: 0.51, 95% CI: 0.35-0.76, p < 0.01, and HR: 0.60, 95% CI:0.46-0.79, p < 0.01, respectively). In metastatic castration-resistant PC, only abiraterone provided improved PFS and OS to patients with SPOP mutations compared with patients with SPOPwt, but data were limited. SPOP mutations did not correlate with improved PFS (p = 0.80) or OS (p = 0.27) for docetaxel.

CONCLUSIONS

Patients with SPOPmut PC seem to exhibit superior oncological outcomes compared with patients with SPOPwt. Tailored risk stratification and treatment approaches should be explored in such patients.

PATIENT SUMMARY

Speckle-type POZ (SPOP) mutations could be a favorable prognostic factor in patients with prostate cancer (PC) and may also predict better progression-free and overall survival than treatment with hormonal agents. Therefore, less intensified treatments omitting chemotherapy for patients with SPOP-mutant PC should be explored in clinical trials.

Prevalence and clinicopathological characteristics of de novo metastatic cancer at a major radiotherapy centre in West Africa: a cross-sectional study

Background

Cancer is a major public health challenge in West Africa, with a significant proportion of cancer-related deaths attributed to distant metastasis. De novo metastatic cancer (DnMC), where metastasis is detected at diagnosis, presents considerable therapeutic challenges, particularly in limited-resource settings where novel treatments are often unavailable and/or unaffordable.

Aim

To determine the prevalence, incidence and clinicopathological characteristics of patients diagnosed with DnMC at a major radiotherapy center in West Africa.

Methods

This was a single-institution-based quantitative cross-sectional study. Data on the prevalence and incidence of DnMC were retrieved from a hospital-based cancer registry whereas patients' demographic and clinicopathologic data were extracted from patients' medical records and analysed with STATA software (version 16). Descriptive statistics were used to summarise patient- and tumour-related characteristics.

Results

The prevalence and incidence of DnMC were 15.2% and 5.3%, respectively, with a 36% overall incidence rate of metastatic cancer. The mean age was 50.9 years (SD 15.2), ranging from 15 to 90 years, with a male-to-female ratio of 1:1.6. Also, 28.8% had a history of alcohol intake whereas 13.7% were (tobacco) smokers. Additionally, 10.3% of the patients had a positive family history of cancer. Pain (28.2%) was the most common presenting symptom, followed by bleeding (16.5%). In all, 34.9% had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 whereas 33.3% were ECOG 1. The gastrointestinal tract (25.8%) and breasts (17.6%) were the most frequent primary cancer sites, whereas 4.4% had metastatic cancers of unknown primary origin. The most frequent sites of distant metastasis were the lungs (34.6%), liver (28.9%) and bone (13.8%). Adenocarcinoma was the most prevalent histological type (35.2%).

Conclusion

There was a relatively high rate of DnMC compared with high-income countries, emphasising the need for early detection and expanded access to comprehensive cancer care in limited-resource settings.

Baseline Nodal Status on 68Ga-PSMA-11 Positron Emission Tomography/Computed Tomography in Men with Intermediate- to High-risk Prostate Cancer Is Prognostic for Treatment Failure: Follow-up of the proPSMA Trial

BACKGROUND AND OBJECTIVE

There is uncertainty regarding the clinical significance of 68Ga-PSMA-11 positron emission tomography (PET) computed tomography (CT) findings in men with prostate cancer. In this prespecified objective of the proPSMA study, we report the prognostic value of PET-defined nodal involvement.

METHODS

Men with intermediate- to high-risk prostate cancer (grade group 3-5, prostate-specific antigen [PSA] ≥20 ng/ml, or clinical stage ≥T3) underwent 68Ga-PSMA-11 PET-CT or CT and bone scanning as first- or second-line imaging. Patients without distant metastatic disease (miM0) in either arm were stratified by prostate-specific membrane antigen (PSMA) PET-CT negative (miN0) or positive (miN1) regional nodal status and followed for up to 54 mo. Treatment failure was defined as biochemical failure, commencement of salvage therapy, or development of distant metastatic disease. Freedom from treatment failure (FFTF) was plotted on Kaplan-Meier curves for patients with miN0 and miN1 cancer based on PET-CT and CT/bone scan classification. Cox proportional hazards were used to derive a hazard ratio (HR) for FFTF.

KEY FINDINGS AND LIMITATIONS

A total of 302 patients were randomised at ten sites. Of them, 294 underwent a PSMA PET-CT. In all, 251 patients with miM0 disease were included in this analysis. Patients were treated with curative-intent surgery or radiotherapy ± androgen deprivation. FFTF was greater in the PSMA PET-CT miN0M0 group than in the miN1M0 group (HR 2.1 [95% confidence interval {CI} 1.2-3.7], p = 0.01). CT/bone scan-defined N0M0 versus N1M0 was not prognostic for FFTF (HR 0.6, 95% CI 0.1-2.4, p = 0.45). In a multivariate analysis, PSMA PET-CT miN1M0 versus miN0M0 remained prognostic after adjusting for PSA, Gleason grade group, and age (HR 2.0, 95% CI 1.10-3.64, p = 0.007).

CONCLUSIONS AND CLINICAL IMPLICATIONS

PSMA PET-CT regional nodal staging at baseline is prognostic for medium-term oncological outcomes, identifying patients at a higher risk of treatment failure.

PATIENT SUMMARY

Men with prostate cancer who have cancer in their nearby lymph nodes observed on a prostate-specific membrane antigen positron emission tomography scan have poorer outcomes than men who have no nearby lymph node involvement.

A modified Delphi consensus regarding the clinical utility of triplet therapy in patients with metastatic hormone-sensitive prostate cancer patients in the UK

OBJECTIVES

This study aimed to determine the clinical utility of the androgen deprivation therapy (ADT)+docetaxel (DOCE)+androgen receptor-targeted agent (ARTA) triplet therapy in patients with metastatic hormone-sensitive prostate cancer (mHSPC) in the UK.

DESIGN

A modified Delphi method. A steering group of eight UK healthcare professionals experienced in prostate cancer care discussed treatment challenges, developing 39 consensus statements across four topics. Agreement with the statements was tested with a broader panel of professionals within this therapeutic area in the UK through an anonymous survey, using a four-point Likert scale. This was distributed by the steering group members and an independent third party. Following the survey, the steering group convened to discuss the results and formulate recommendations.

SETTING

The steering group convened online for discussions. The survey was distributed via email by the clinicians and the independent third party.

PARTICIPANTS

Healthcare professionals involved in the provision of prostate cancer care, working in relevant professional roles (oncology, urology or geriatric consultant, oncology nurse specialist, and hospital pharmacist) within the UK. No patients or members of the public were involved within the study.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

Consensus was defined as high (≥75% agreement) and very high (≥90% agreement).

RESULTS

Responses were received from 120 healthcare professionals, including oncologists (n=73), urologists (n=16), geriatricians (n=15), nurse specialists (n=11) and hospital pharmacists (n=5). Consensus was reached for 37 out of 39 (95%) statements, and 27/39 (69%) statements achieved very high agreement ≥90%. Consensus was not reached for 2/39 (5%) statements.

CONCLUSIONS

Based on the consensus observed, the steering group developed a set of recommendations for the clinical utility of ADT+DOCE+ARTA in treating patients with mHSPC in the UK. Following these recommendations enables clinicians to identify appropriate patients with mHSPC for triplet treatment, thereby improving patients' outcomes.

GDF15 propeptide promotes bone metastasis of castration-resistant prostate cancer by augmenting the bone microenvironment

BACKGROUND

Bone metastasis (BM) is a common and fatal condition in patients with castration-resistant prostate cancer (CRPC). However, there are no useful blood biomarkers for CRPC with BM, and the mechanism underlying BM is unclear. In this study, we investigated precise blood biomarkers for evaluating BM that can improve the prognosis of patients with CRPC.

METHODS

We comprehensively examined culture supernatants from four prostate cancer (PCa) cell lines using Orbitrap mass spectrometry to identify specific proteins secreted abundantly by PCa cells. The effects of this protein to PCa cells, osteoblasts, osteoclasts were examined, and BM mouse model. In addition, we measured the plasma concentration of this protein in CRPC patients for whom bone scan index (BSI) by bone scintigraphy was performed.

RESULTS

A total of 2,787 proteins were identified by secretome analysis. We focused on GDF15 propeptide (GDPP), which is secreted by osteoblasts, osteoclasts, and PCa cells. GDPP promoted the proliferation, invasion, and migration of PC3 and DU145 CRPC cells, and GDPP aggravated BM in a mouse model. Importantly, GDPP accelerated bone formation and absorption in the bone microenvironment by enhancing the proliferation of osteoblasts and osteoclasts by upregulating individual transcription factors such as RUNX2, OSX, ATF4, NFATc1, and DC-STAMP. In clinical settings, including a total of 416 patients, GDPP was more diagnostic of BM than prostate-specific antigen (PSA) (AUC = 0.92 and 0.78) and the seven other blood biomarkers (alkaline phosphatase, lactate dehydrogenase, bone alkaline phosphatase, tartrate-resistant acid phosphatase 5b, osteocalcin, procollagen I N-terminal propeptide and mature GDF15) in patients with CRPC. The changes in BSI over time with systemic treatment were correlated with that of GDPP (r = 0.63) but not with that of PSA (r = -0.16).

CONCLUSIONS

GDPP augments the tumor microenvironment of BM and is a novel blood biomarker of BM in CRPC, which could lead to early treatment interventions in patients with CRPC.

Combined Fixed-duration Systemic Treatment and Metastasis-directed Radiotherapy for Oligometastatic Hormone-sensitive Prostate Cancer

BACKGROUND AND OBJECTIVE

It is unclear whether "total therapy" (androgen deprivation therapy [ADT] with or without an androgen receptor pathway inhibitor [ARPI], metastasis-directed therapy, and local therapy to the prostate if de novo) may lead to long-term durable remission in oligometastatic hormone-sensitive prostate cancer (omHSPC). This study aims to evaluate the outcomes after the completion of total therapy in patients with omHSPC.

METHODS

A retrospective single-institution cohort of consecutive patients with omHSPC identified on conventional or molecular imaging treated with total therapy was assembled. All patients had prostate-specific antigen ≤0.1 ng/ml at the completion of systemic therapy. Kaplan-Meier and Cox regression models were used to evaluate the key outcomes of interest: clinical progression-free survival (cPFS), eugonadal progression-free survival (PFS), and time to restart of ADT (TTrADT).

KEY FINDINGS AND LIMITATIONS

Eighty-nine patients were included, of whom 23 were with de novo omHSPC; the median number of metastases was 1, and detection of disease by molecular imaging was performed in 43 patients (48%). Forty-nine patients (55%) received ADT + ARPI doublet and 40 (45%) received ADT alone. At a median follow-up of 37 mo, there were 46 cPFS events; 3-yr cPFS rate was 45% (95% confidence interval 33-56) and the median eugonadal PFS was 12 mo. The median TTrADT was 47 mo, and 60% had not restarted ADT at 3 yr. Duration of systemic therapy ≥12 mo was the only significant predictor of better outcomes.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Of the patients receiving total therapy for omHSPC, 45% remained progression free at 3 yr after completing therapy, hinting at the potential for long-term remission and possible cure with this strategy in a subset of patients with omHSPC. Prospective trials evaluating this approach are needed.

PATIENT SUMMARY

In this report, we looked at outcomes in men who had received a fixed duration of hormonal therapy along with radiotherapy to metastatic sites (and prostate radiotherapy or surgery in those with newly diagnosed disease) for oligometastatic prostate cancer. We found that nearly half of the patients had no evidence of cancer recurrence at 3 yr after completing therapy, and 60% had not resumed any therapy at this time point.

Surgical Castration as an Alternative to Improve Systemic Treatment for Advanced Prostate Cancer: A Window of Opportunity for Developing Countries

PURPOSE

The Brazilian Public Health System (BPHS) serves approximately 71,730 patients with prostate cancer (PC) every year for which androgen deprivation therapy (ADT) is the primary treatment for patients with advanced hormone-sensitive prostate cancer (aHSPC). Androgen receptor pathway inhibitors (ARPIs) are not accessible through the BPHS. Using the BPHS as a model, this study assesses the long-term economic effect of surgical versus medical castration in aHSPC treatment to strategize cost reduction and the incorporation of ARPI in developing countries.

PATIENTS AND METHODS

Data of patients with aHSPC (ie, TxN1M0 ineligible for local treatment or TxNxM1) from the BPHS database were analyzed from January 1, 2011, to December 31, 2021, using the TECHTRIALS artificial intelligence platform. The main outcomes were quantitative and descriptive analyses as well as a cost analysis of surgical versus chemical castration.

RESULTS

Of the 274,519 patients with aHSPC who received active treatment during the 11-year study period, 90% (n = 246,683) underwent chemical castration and 10% (n = 27,836) underwent bilateral subcapsular orchiectomy (BSO). The median duration of chemical castration was 28 months. The BPHS spent an estimated total of $665,552,091.40 US dollars (USD) on chemical castration and $5,939,348.47 USD on BSO, respectively. The cost per patient was $2,698 USD and $213.37 USD for chemical castration and BSO, respectively. Hypothetically, if all patients with aHSPC had undergone BSO, the total direct cost for the BPHS would have been $42,774,832.20 USD, saving $622,777,259.20 USD over 11 years, making it possible to offer low-dose abiraterone to 65% of aHSPC patients.

CONCLUSION

On the basis of this extensive financial analysis from the world's largest public health system database, BSO appears to be a valuable alternative to chemical castration for treating aHSPC. In resource-limited environments, the cost savings from using BSO may allow access to drugs that will improve survival such as ARPIs.

Combination therapies with Wnt signaling inhibition: A better choice for prostate cancer treatment

The intractability and high mortality rate of castration-resistant prostate cancer (CRPC) remain the most challenging problems in the field of prostate cancer (PCa). Emerging evidence has shown that the dysregulation of Wnt signaling pathways, which are highly conserved cascades that regulate embryonic development and maintain tissue homeostasis, is involved in various stages of PCa occurrence and progression. In this review, we systemically discuss the mechanisms by which the androgen receptor (AR) signaling pathway and Wnt signaling pathways participate in the occurrence of PCa and its progression to CRPC. Specifically, we elaborate on how Wnt signaling pathways induce the malignant transformation of prostate cells, promote the malignant progression of PCa and establish an immunosuppressive prostate tumor microenvironment through interaction with the AR pathway or in an AR-independent manner. We also discuss how Wnt signaling pathways enhances the stemness characteristics of prostate cancer stem cells (PCSCs) to induce the occurrence and metastasis of CPPC. Additionally, we discuss the latest progress in the use of different types of drugs that inhibit the Wnt signaling pathways in the treatment of PCa. We believe that the combination of Wnt signaling-based drugs with endocrine and other therapies is necessary and may enhance the clinical efficacy in the treatment of all types of PCa.

Intrapatient Intermetastatic Heterogeneity Determined by Triple-Tracer PET Imaging in mCRPC Patients and Correlation to Survival: The 3TMPO Cohort Study

Intrapatient intermetastatic heterogeneity (IIH) has been demonstrated in metastatic castration-resistant prostate cancer (mCRPC) patients and is of the utmost importance for radiopharmaceutical therapy (RPT) eligibility. This study was designed to determine the prevalence of IIH and RPT eligibility in mCRPC patients through a triple-tracer PET imaging strategy. Methods: This was a multisite prospective observational study in which mCRPC patients underwent both 18F-FDG and 68Ga-prostate-specific membrane antigen (PSMA)-617 PET/CT scans. A third scan with 68Ga-DOTATATE, a potential biomarker of neuroendocrine differentiation, was performed if an 18F-FDG-positive/68Ga-PSMA-negative lesion was found. Per-tracer lesion positivity was defined as having an uptake at least 50% above that of the liver. IIH prevalence was defined as the percentage of participants having at least 2 lesions with discordant features on multitracer PET. Results: IIH was observed in 81 patients (82.7%), and at least 1 18F-FDG-positive/68Ga-PSMA-negative lesion was found in 45 patients (45.9%). Of the 37 participants who also underwent 68Ga-DOTATATE PET/CT, 6 (16.2%) had at least 1 68Ga-DOTATATE-positive lesion. In total, 12 different combinations of lesion imaging phenotypes were observed. On the basis of our prespecified criteria, 52 (53.1%) participants were determined to be eligible for PSMA RPT, but none for DOTATATE RPT. Patients with IIH had a significantly shorter median overall survival than patients without IIH (9.5 mo vs. not reached; log-rank P = 0.03; hazard ratio, 2.7; 95% CI, 1.1-6.8). Conclusion: Most mCRPC patients showed IIH, which was associated with shorter overall survival. On the basis of a triple-tracer PET approach, multiple phenotypic combinations were found. Correlation of these imaging phenotypes with genomics and treatment response will be relevant for precision medicine.

Optimizing triple therapy in patients with metastatic hormone-sensitive prostate cancer

Triple therapy with docetaxel, androgen deprivation therapy (ADT) and androgen receptor pathway inhibitors (ARPIs) has demonstrated survival benefits in patients with metastatic hormone-sensitive prostate cancer (mHSPC), especially in those with high-risk disease. However, once the use of ADT and docetaxel is established, guidelines do not clearly specify which ARPI is most appropriate. In this work, a literature review to identify phase III clinical trials, systematic reviews, meta-analyses, and clinical practice guidelines on triple therapy in mHSPC was carried out. Evidence and recommendations were qualitatively reviewed to provide guidelines on the most suitable ARPI based on patient risk, disease volume, and nature of metastases (synchronous or metachronous). This review aims to update the previously published consensus on the optimal pharmacological treatment for mHSPC and to expose the opinions of hospital pharmacy, urology and medical and radiation oncology experts.

Correlation analyses of radiographic progression-free survival with clinical and health-related quality of life outcomes in metastatic castration-resistant prostate cancer: Analysis of the phase 3 VISION trial

BACKGROUND

[177Lu]Lu-PSMA-617 (177Lu-PSMA-617) plus protocol-permitted standard of care (SOC) prolonged overall survival (OS) and radiographic progression-free survival (rPFS) versus SOC in patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer (mCRPC) in the phase 3 VISION study, in addition to beneficial effects on symptomatic skeletal events (SSEs) and health-related quality of life (HRQOL).

METHODS

Post hoc analyses used the full analysis set from the VISION study (N = 831) overall and by randomized treatment arm (177Lu-PSMA-617 plus SOC, n = 551; SOC, n = 280). Correlations were determined between OS and rPFS and between rPFS or OS and time to SSE or to worsening HRQOL (Functional Assessment of Cancer Therapy-Prostate [FACT-P] and 5-level EQ-5D [EQ-5D-5L]). Correlation analyses used an iterative multiple imputation copula-based approach (correlation coefficients [rho] of <0.3 were defined as weak, ≥0.3 and <0.5 as mild, ≥0.5 and <0.7 as moderate, and ≥0.7 as strong).

RESULTS

In the overall population, rPFS correlated strongly with OS (rho, ≥0.7). Correlations between rPFS or OS and time to SSE without death were weak or mild. Time to worsening in the FACT-P total score and emotional and physical well-being domains correlated mildly or moderately with rPFS and moderately with OS. Correlation coefficients for time-to-worsening EQ-5D-5L scores were mild to moderate for both rPFS and OS. Correlation coefficients were similar between treatment arms.

CONCLUSIONS

In this analysis of the VISION study, rPFS correlated strongly with OS but not with time to SSE or worsening HRQOL. These findings require further investigation.

Estetrol Inhibits the Prostate Cancer Tumor Stimulators FSH and IGF-1

Background: The co-treatment of androgen deprivation therapy (ADT) for advanced prostate cancer (PCa) with the fetal estrogen estetrol (E4) may further inhibit endocrine PCa tumor stimulators. We previously reported the suppression of follicle-stimulating hormone (FSH), total and free testosterone, and prostate-specific antigen by ADT+E4. Here, we provide more detailed data on FSH suppression by E4 and present new findings on the effect of ADT+E4 on insulin-like growth factor-1 (IGF-1). Methods: A Phase II, double-blind, randomized, placebo-controlled study (the PCombi study) was conducted in advanced PCa patients treated with ADT. The study assessed the effect of E4 co-treatment with LHRH agonist ADT on tumor stimulators, including FSH and IGF-1. Patients starting ADT were randomized 2:1 to receive either 40 mg E4 (n = 41) or placebo (n = 21) for 24 weeks. Non-parametric analyses were performed on the per-protocol population (PP) and individual changes were visualized. Results: The PP included 57 patients (37 ADT+E4; 20 ADT+placebo). ADT+E4 almost completely suppressed FSH in all patients (98% versus 37%; p < 0.0001). IGF-1 levels decreased by 41% with ADT+E4 versus an increase of 10% with ADT+placebo (p < 0.0001). Conclusions: The almost complete suppression of the tumor stimulator FSH using ADT plus E4 observed in all individual patients in this study, along with the augmented suppression of IGF-1 versus an increase by ADT only, may be clinically relevant and suggest the enhanced anti-cancer treatment efficacy of E4 in addition to the previously reported additional suppression of total and free T and PSA.

Treatment response assessment in mCRPC: is PSMA-PET/CT going to take the lead?

The assessment of response to therapy in prostate cancer (PCa) patients is an ongoing, open issue. Prostate-specific antigen has limitations, especially in advanced metastatic PCa, which often displays intratumor variability in terms of response to therapy. Conventional imaging (i.e. computerized tomography and bone scan) is of limited use for its low sensitivity and specificity. Positron-emission tomography (PET) with prostate-specific membrane antigen (PSMA) demonstrated higher sensitivity and specificity, and novel PSMA-based criteria have been recently proposed for treatment response, with promising results in different scenarios, from chemotherapy to radioligand therapy. PSMA-based criteria have been found to outperform the current RECIST 1.1 and Prostate Cancer Working Group 3 frameworks in describing the behavior of PCa, precisely assessing tumor phenotypes through molecular-imaging-derived parameters. This review critically explores the current evidence about the role of PSMA PET/computed tomography in the assessment of treatment response.

DeepFusionCDR: Employing Multi-Omics Integration and Molecule-Specific Transformers for Enhanced Prediction of Cancer Drug Responses

Deep learning approaches have demonstrated remarkable potential in predicting cancer drug responses (CDRs), using cell line and drug features. However, existing methods predominantly rely on single-omics data of cell lines, potentially overlooking the complex biological mechanisms governing cell line responses. This paper introduces DeepFusionCDR, a novel approach employing unsupervised contrastive learning to amalgamate multi-omics features, including mutation, transcriptome, methylome, and copy number variation data, from cell lines. Furthermore, we incorporate molecular SMILES-specific transformers to derive drug features from their chemical structures. The unified multi-omics and drug signatures are combined, and a multi-layer perceptron (MLP) is applied to predict IC50 values for cell line-drug pairs. Moreover, this MLP can discern whether a cell line is resistant or sensitive to a particular drug. We assessed DeepFusionCDR's performance on the GDSC dataset and juxtaposed it against cutting-edge methods, demonstrating its superior performance in regression and classification tasks. We also conducted ablation studies and case analyses to exhibit the effectiveness and versatility of our proposed approach. Our results underscore the potential of DeepFusionCDR to enhance CDR predictions by harnessing the power of multi-omics fusion and molecular-specific transformers. The prediction of DeepFusionCDR on TCGA patient data and case study highlight the practical application scenarios of DeepFusionCDR in real-world environments.

Activity of Lutetium-177 Prostate-specific Membrane Antigen and Determinants of Outcomes in Patients with Metastatic Castration-resistant Prostate Cancer Previously Treated with Cabazitaxel: The PACAP Study

BACKGROUND

Both cabazitaxel and lutetium-177 prostate-specific membrane antigen (Lu-PSMA) improve survival in metastatic castration-resistant prostate cancer (mCRPC) after an androgen receptor pathway inhibitor and docetaxel, but there are limited data regarding Lu-PSMA activity after cabazitaxel.

OBJECTIVE

To assess the activity of Lu-PSMA and determinants of outcomes after cabazitaxel in mCRPC.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis was conducted of consecutive mCRPC patients from eight European centers treated with Lu-PSMA after cabazitaxel.

INTERVENTION

Lu-PSMA every 6-8 wk at a dose of 6-7.6 GBq.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was radiographic progression-free survival (rPFS). The secondary endpoints included time to prostate-specific antigen (PSA) progression (TTPSA), overall survival (OS), PSA decline, objective response rate (ORR), clinical benefit, and safety.

RESULTS AND LIMITATIONS

Of 126 patients, 68% had International Society of Urological Pathology (ISUP) grade 4-5 disease, 21% had visceral metastases, and 7% had lymph node disease only. DNA damage repair (DDR) alterations were detected in 11/50 (22%) patients with available testing. Patients received a median number of 3 Lu-PSMA cycles (interquartile range 2-4). With a median follow-up of 12.0 mo, the median rPFS was 4.4 mo (95% confidence interval [CI] 3.2-5.4), TTPSA 3.5 mo (95% CI 3.0-4.6), and OS 8.9 mo (95% CI 6.5-12.7). The ORR was 35%, and 55 patients (44%) experienced a PSA decline of ≥50%. The time to castration resistance of <12 mo was associated with shorter rPFS (p = 0.01). A similar trend was observed for ISUP grade 4-5 (p = 0.08), and baseline positron-emission tomography parameters including PSMA mean standardized uptake value (SUV) and maximum SUV (respectively, p = 0.06 and 0.05). The duration of previous cabazitaxel or DDR status did not impact outcomes. Patients experiencing a PSA decline of ≥ 50% on therapy demonstrated longer rPFS, TTPSA, and OS (all p < 0.0001). Limitations include retrospective data collection and investigator-based rPFS assessment.

CONCLUSIONS

Lu-PSMA demonstrated a substantial PSA decline but limited rPFS after cabazitaxel in a real-life setting. Adverse baseline characteristics, baseline positron-emission tomography parameters, and quality of PSA response may help identify patients less likely to benefit from Lu-PSMA.

PATIENT SUMMARY

Lutetium-177 prostate-specific membrane antigen (Lu-PSMA) improved outcomes in patients with castration-resistant prostate cancer, but there are limited data about its activity after cabazitaxel, a chemotherapy that is also the standard of care in this setting. We conducted a study across eight European centers and showed substantial responses on Lu-PSMA after cabazitaxel, although activity was short lived in a heavily pretreated population. Our findings prompt for real-life evaluation of Lu-PSMA in earlier settings to define the best therapeutic sequence.

177Lu-PSMA-617 versus a change of androgen receptor pathway inhibitor therapy for taxane-naive patients with progressive metastatic castration-resistant prostate cancer (PSMAfore): a phase 3, randomised, controlled trial

BACKGROUND

[177Lu]Lu-PSMA-617 (177Lu-PSMA-617) prolongs radiographic progression-free survival and overall survival in patients with metastatic castration-resistant prostate cancer previously treated with androgen receptor pathway inhibitor (ARPI) and taxane therapy. We aimed to investigate the efficacy of 177Lu-PSMA-617 in patients with taxane-naive metastatic castration-resistant prostate cancer.

METHODS

In this phase 3, randomised, controlled trial conducted at 74 sites across Europe and North America, taxane-naive patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer who had progressed once on a previous ARPI were randomly allocated (1:1) to open-label, intravenous 177Lu-PSMA-617 at a dosage of 7·4 GBq (200 mCi) ± 10% once every 6 weeks for six cycles, or a change of ARPI (to abiraterone or enzalutamide, administered orally on a continuous basis per product labelling). Crossover from ARPI change to 177Lu-PSMA-617 was allowed after centrally confirmed radiographic progression. The primary endpoint was radiographic progression-free survival, defined as the time from randomisation until radiographic progression or death, assessed in the intention-to-treat population. Safety was a secondary endpoint. This study is registered with ClinicalTrials.gov (NCT04689828) and is ongoing. In this primary report of the study, we present primary (first data cutoff) and updated (third data cutoff) analyses of radiographic progression-free survival; all other data are based on the third data cutoff.

FINDINGS

Overall, of the 585 patients screened, 468 met all eligibility criteria and were randomly allocated between June 15, 2021 and Oct 7, 2022 to receive 177Lu-PSMA-617 (234 [50%] patients) or ARPI change (234 [50%]). Baseline characteristics were mostly similar between groups; median number of 177Lu-PSMA-617 cycles was 6·0 (IQR 4·0-6·0). Of patients assigned to ARPI change, 134 (57%) crossed over to receive 177Lu-PSMA-617. In the primary analysis (median time from randomisation to first data cutoff 7·26 months [IQR 3·38-10·55]), the median radiographic progression-free survival was 9·30 months (95% CI 6·77-not estimable) in the 177Lu-PSMA-617 group versus 5·55 months (4·04-5·95) in the ARPI change group (hazard ratio [HR] 0·41 [95% CI 0·29-0·56]; p<0·0001). In the updated analysis at time of the third data cutoff (median time from randomisation to third data cutoff 24·11 months [IQR 20·24-27·40]), median radiographic progression-free survival was 11·60 months (95% CI 9·30-14·19) in the 177Lu-PSMA-617 group versus 5·59 months (4·21-5·95) in the ARPI change group (HR 0·49 [95% CI 0·39-0·61]). The incidence of grade 3-5 adverse events was lower in the 177Lu-PSMA-617 group (at least one event in 81 [36%] of 227 patients; four [2%] grade 5 [none treatment related]) than the ARPI change group (112 [48%] of 232; five [2%] grade 5 [one treatment related]).

INTERPRETATION

177Lu-PSMA-617 prolonged radiographic progression-free survival relative to ARPI change, with a favourable safety profile. For patients with PSMA-positive metastatic castration-resistant prostate cancer who are being considered for a change of ARPI after progression on a previous ARPI, 177Lu-PSMA-617 may be an effective treatment alternative.

FUNDING

Novartis.

Current issues and management consensus of advanced prostate cancer: Report of the Advanced Prostate Cancer Consensus Conference-JAPAN 2023

OBJECTIVE

To evaluate and compare the voting results of Japanese urologists with the global panel at the Advanced Prostate Cancer Consensus Conference (APCCC) 2022.

METHODS

Among the 198 questions discussed at the APCCC 2022, the APCCC-JAPAN 2023 focused on 14 key questions related to the management of advanced prostate cancer with insufficient high-level evidence based on their relevance to the Japanese cohort. A panel of six prostate cancer experts addressed these 14 questions and presented the latest evidence to Japanese urologists who voted on-site using a web-based system. The results were compared with those of APCCC 2022.

RESULTS

This study found significant differences in the voting results between Japanese urologists and the global panel regarding several crucial issues related to advanced prostate cancer management. These differences were those observed in treatment preferences, monitoring strategies, and treatment choices in specific clinical scenarios. These findings highlight the need for a nuanced approach tailored to the unique challenges with considerations of the Japanese healthcare environment.

CONCLUSIONS

APCCC-JAPAN 2023 provides valuable insights into the current clinical issues surrounding the management of advanced prostate cancer in Japan. The partial divergence in the consensus between Japanese urologists and the global panel underscores the importance of a context-specific approach. The results of this study provide practical guidance for physicians facing complex challenges and should be used to inform decision-making in the management of advanced prostate cancer.

A Phase II Trial of Stereotactic Body Radiation Therapy and Androgen Deprivation for Oligometastases in Prostate Cancer (SBRT-SG 05)

PURPOSE

SBRT-Spanish Group-05 (ClinicalTrials.gov.Identifier: NCT02192788) is a collaborative (SBRT-SG, Grupo de Investigación Clínica en Oncología Radioterápica, and Sociedad Española de Oncología Radioterápica) prospective multicenter phase II trial testing stereotactic body radiation therapy (SBRT) and androgen deprivation therapy (ADT) in patients with oligorecurrent prostate cancer.

METHODS AND MATERIALS

Two cohorts of patients with prostate cancer in an oligorecurrent stage (hormone-sensitive in the principal cohort and castration-resistant in the exploratory cohort) were assigned to receive ADT and SBRT for at least 24 months from the time of the enrollment. Concomitant treatment with chemotherapy, abiraterone, or enzalutamide was not allowed. Oncologic outcomes were assessed in both cohorts. Toxicity was prospectively analyzed.

RESULTS

From 2014 to 2019, 81 patients with a total of 126 lesions from 14 centers met the inclusion criteria, 14 of whom were castration-resistant. With a median follow-up of 40 months (12-58 months), 3-year local recurrence-free survival was 92.5% (95% CI, 79.9%-96.3%) and 85.7% (95% CI, 48.2%-95.6%) in the principal and exploratory cohorts, respectively. In the principal cohort, biochemical relapse-free survival and metastasis progression-free survival at 1, 2, and 3 years were 91% (95% CI, 81%-95.8%), 73.7% (95% CI, 61.1%-82.8%), 50.6% (95% CI, 36.2%-63.3%), and 92% (95% CI, 83%-97%), 81% (95% CI, 70%-89%), and 67% (95% CI, 53%-77%), respectively. In the exploratory cohort, metastasis progression-free survival at 1, 2, and 3 years was 64% (95% CI, 34%-83%), 43% (95% CI, 18%-66%), and 26% (95% CI, 7%-51%), respectively. None of the patients developed grade III or higher toxicity or symptoms related to local progression, and only 2 (2.4%) patients developed grade II toxicity.

CONCLUSIONS

The combination of SBRT and ADT is safe and shows favorable clinical outcomes in patients with hormone-sensitive and castration-resistant prostate cancer. Validation studies are needed in patients with castration-resistant prostate cancer.

Development and Validation of a Machine Learning Model for Bone Metastasis in Prostate Cancer: Based on Inflammatory and Nutritional Indicators

OBJECTIVE

To establish a predictive model for prostate cancer bone metastasis utilizing multiple machine learning algorithms.

METHODS

Retrospective analysis of the clinical data of prostate cancer initially diagnosed in the Department of Urology of Gansu Provincial People's Hospital from June 2017 to June 2022. Logistic regression (LR) and least absolute shrinkage and selection operator (LASSO) are used to jointly screen the model features. The filtered features are incorporated into algorithms including LR, random forest (RF), extreme gradient boosting (XGBoost), naive Bayes (NB), k-nearest neighbor (KNN), and decision tree (DT), to develop prostate cancer bone metastasis models.

RESULTS

A total of 404 patients were finally screened. Gleason score, T stage, N stage, PSA, and ALP were used as features for modeling. The average AUC of the 5-fold cross-validation for each machine learning model in the training set is as follows: LR (AUC=0.9054), RF (AUC=0.9032), NB (AUC=0.8961), KNN (AUC=0.8704), DT (AUC=0.8526), XGBoost (AUC=0.8066). The AUC of each machine learning model in the test set is KNN (AUC=0.9390, 95%CI: 0.8760-1), RF (AUC=0.9290, 95%CI: 0.8718-0.9861), NB (AUC=0.9268, 95%CI: 0.8615-0.9920), LR (AUC=0.9212, 95%CI: 0.8506-0.9917), XGBoost (AUC=0.8292, 95%CI: 0.7442-0.9141), DT (AUC=0.8057, 95%CI: 0.7100-0.9014). A comprehensive evaluation showed that LR performed well in interpretability and clinical applications.

CONCLUSION

A bone metastasis model of prostate cancer was established, and it was observed that indicators such as inflammation and nutrition had a weak correlation with bone metastasis.

Management of advanced prostate cancer in the Asia-Pacific region: Summary of the Asia-Pacific Advanced Prostate Cancer Consensus Conference 2023

AIM

The aim of the third Asia-Pacific Advanced Prostate Cancer Consensus Conference (APAC APCCC 2023) was to discuss the application in the Asia-Pacific (APAC) region of consensus statements from the 4th Advanced Prostate Cancer Consensus Conference (APCCC 2022).

METHODS

The one-day meeting in July 2023 brought together 27 experts from 14 APAC countries. The meeting covered five topics: (1) Intermediate- and high-risk and locally advanced prostate cancer; (2) Management of newly diagnosed metastatic hormone-sensitive prostate cancer; (3) Management of non-metastatic castration-resistant prostate cancer; (4) Homologous recombination repair mutation testing; (5) Management of metastatic castration-resistant prostate cancer. Pre- and post-symposium polling gathered APAC-specific responses to APCCC consensus questions and insights on current practices and challenges in the APAC region.

RESULTS

APAC APCCC highlights APAC-specific considerations in an evolving landscape of diagnostic technologies and treatment innovations for advanced prostate cancer. While new technologies are available in the region, cost and reimbursement continue to influence practice significantly. Individual patient considerations, including the impact of chemophobia on Asian patients, also influence decision-making.

CONCLUSION

The use of next-generation imaging, genetic testing, and new treatment combinations is increasing the complexity and duration of prostate cancer management. Familiarity with new diagnostic and treatment options is growing in the APAC region. Insights highlight the continued importance of a multidisciplinary approach that includes nuclear medicine, genetic counseling, and quality-of-life expertise. The APAC APCCC meeting provides an important opportunity to share practice and identify APAC-specific issues and considerations in areas of low evidence where clinical experience is growing.

Androgen Receptor Inhibitors in Patients With Nonmetastatic Castration-Resistant Prostate Cancer

Importance

Novel androgen receptor inhibitors (ARIs; darolutamide, enzalutamide, and apalutamide) are standard-of-care treatments for nonmetastatic castration-resistant prostate cancer (nmCRPC). However, there are sparse data comparing their clinical use and tolerability.

Objective

To compare clinical use and outcomes for darolutamide, enzalutamide, and apalutamide in patients with nmCRPC.

Design, Setting, and Participants

This retrospective cohort study reviewed electronic medical records from the Precision Point Specialty network of US urology practices. Eligible patients had nmCRPC and no prior novel hormonal therapy and initiated novel ARI treatment between August 1, 2019, and March 31, 2022. Data were analyzed from February 1, 2019, to December 31, 2022.

Exposures

Patients were prescribed darolutamide, enzalutamide, or apalutamide as their first novel ARI for nmCRPC.

Main Outcomes and Measures

The main outcome was a composite of 2 end points, treatment discontinuation and progression to metastatic CRPC (mCRPC), whichever occurred first. Both end points were also assessed separately.

Results

All 870 patients meeting eligibility criteria were included (362 receiving darolutamide [41.6%]; 382, enzalutamide [43.9%]; 126, apalutamide [14.5%]); mean (SD) age was 78.8 (8.7) years. Self-reported race was Black or African American in 187 patients (21.5%), White in 585 (67.2%), and other or unknown in 98 (11.3%). The darolutamide cohort had lower proportions of patients with a composite end point event (134 [37.0%] vs 201 [52.6%] for enzalutamide and 66 [52.4%] for apalutamide), discontinuation (110 [30.4%] for darolutamide vs 156 [40.8%] for enzalutamide and 58 [46.0%] for apalutamide), and progression to mCRPC (64 [17.7%] for darolutamide vs 108 [28.3%] for enzalutamide and 35 [27.8%] for apalutamide) during the study period. After adjusting for baseline covariates, patients receiving darolutamide had a lower risk of a composite end point event compared with enzalutamide (risk reduction, 33.8%; hazard ratio [HR], 0.66 [95% CI, 0.53-0.84]) and apalutamide (risk reduction, 35.1%; HR, 0.65 [95% CI, 0.48-0.88]). Similarly, patients receiving darolutamide had a lower risk of discontinuation compared with enzalutamide (risk reduction, 27.4%; HR, 0.73 [95% CI, 0.56-0.94]) and apalutamide (risk reduction, 39.1%; HR, 0.61 [95% CI, 0.44-0.85]) and a lower risk of progression to mCRPC compared with enzalutamide (risk reduction, 40.6%; HR, 0.59 [95% CI, 0.43-0.82]) and apalutamide (risk reduction, 35.3%; HR, 0.65 [95% CI, 0.42-0.99]). There was no difference between enzalutamide and apalutamide treatment across outcomes.

Conclusions and Relevance

In this large cohort study of patients with nmCRPC treated with novel ARIs, results suggest better tolerability for darolutamide compared with enzalutamide and apalutamide, which may be associated with a clinical effectiveness advantage. Comparative clinical studies are needed to guide treatment decisions in the absence of head-to-head clinical trials.

Diverse Imaging Methods May Influence Long-Term Oncologic Outcomes in Oligorecurrent Prostate Cancer Patients Treated with Metastasis-Directed Therapy (the PRECISE-MDT Study)

Metastasis-directed therapy (MDT) has been tested in clinical trials as a treatment option for oligorecurrent prostate cancer (PCa). However, there is an ongoing debate regarding the impact of using different imaging techniques interchangeably for defining lesions and guiding MDT within clinical trials. Methods: We retrospectively identified oligorecurrent PCa patients who had 5 or fewer nodal, bone, or visceral metastases detected by choline or prostate-specific membrane antigen (PSMA) PET/CT and who underwent MDT stereotactic body radiotherapy with or without systemic therapy in 8 tertiary-level cancer centers. Imaging-guided MDT was assessed as progression-free survival (PFS), time to systemic treatment change due to polymetastatic conversion (PFS2), and overall survival predictor. Propensity score matching was performed to account for clinical differences between groups. Results: Of 402 patients, 232 (57.7%) and 170 (42.3%) underwent MDT guided by [18F]fluorocholine and PSMA PET/CT, respectively. After propensity score matching, patients treated with PSMA PET/CT-guided MDT demonstrated longer PFS (hazard ratio [HR], 0.49 [95% CI, 0.36-0.67]; P < 0.0001), PFS2 (HR, 0.42 [95% CI, 0.28-0.63]; P < 0.0001), and overall survival (HR, 0.39 [95% CI, 0.15-0.99]; P < 0.05) than those treated with choline PET/CT-guided MDT. Additionally, we matched patients who underwent [68Ga]Ga-PSMA-11 versus [18F]F-PSMA-1007 PET/CT, observing longer PFS and PFS2 in the former subgroup (PFS: HR, 0.51 [95% CI, 0.26-1.00]; P < 0.05; PFS2: HR, 0.24 [95% CI, 0.09-0.60]; P < 0.05). Conclusion: Diverse imaging methods may influence outcomes in oligorecurrent PCa patients undergoing MDT. However, prospective, head-to-head studies, ideally incorporating a randomized design, are necessary to provide definitive evidence and facilitate the practical application of these findings.

Environmental explanation of prostate cancer progression based on the comprehensive analysis of polychlorinated biphenyls

OBJECTIVE

Polychlorinated biphenyls (PCBs) have caused great environmental concerns. The study aims to investigate underlying molecular mechanisms between PCBs exposure and prostate cancer (PCa).

METHODS

To investigate the association between PCBs exposure and prostate cancer by using CTD, TCGA, and GEO datasets. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were conducted to explore pathways associated with PCBs-related genes (PRGs). Using Lasso regression analysis, a novel PCBs-related prognostic model was developed. Both internal and external validations were conducted to assess the model's validity. Molecular docking was utilized to assess the binding capacity of PCBs to crucial genes. At last, preliminary experimental validations were conducted to confirm the biological roles of Aroclor 1254 in PCa cells.

RESULTS

The GO enrichment analysis of PRGs revealed that the biological processes were most enriched in the regulation of transcription from the RNA polymerase II promoter and signal transduction. The KEGG enrichment analysis showed that of the pathways in cancer is the most significantly enriched. Next, a PCBs-related model was constructed. In the training, test, GSE70770, and GSE116918 cohorts, the biochemical recurrences free survival of the patients with high-risk scores was considerably lower. The AUCs at 5 years were 0.691, 0.718, 0.714, and 0.672 in the four cohorts, demonstrating the modest predictive ability. A nomogram that incorporated clinical characteristics was constructed. The results of the anti-cancer drug sensitivity analysis show chemotherapy might be more beneficial for patients at low risk. The molecular docking analysis demonstrated PCBs' ability to bind to crucial genes. PCa cells exposed to Aroclor 1254 at a concentration of 1 μM showed increased proliferation and invasion capabilities.

CONCLUSIONS

This study provides new insights into the function of PCBs in PCa and accentuates the need for deeper exploration into the mechanistic links between PCBs exposure and PCa progression.