Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with prostate cancer

A case report of urethral corpus cavernosum pseudoaneurysm formation after ultrasound-guided transperineal prostate biopsy

BACKGROUND

Prostate biopsy is a critical procedure for diagnosing prostate cancer, with severe complications being relatively uncommon. This report presents a complex case of an elderly patient who developed urethral cavernous pseudoaneurysm, persistent bleeding, and disseminated intravascular coagulation (DIC) following ultrasound-guided transperineal prostate biopsy. The patient was managed through timely diagnosis and intervention by a multidisciplinary team, ultimately achieving bleeding control and clinical stabilization.

CONCLUSION

Prompt imaging evaluation, an individualized treatment plan, and effective multidisciplinary collaboration are essential for managing such complex cases.

Psychological Resilience in Newly Diagnosed Prostate Cancer Survivors: A Longitudinal Study

BACKGROUND

Psychological resilience is considered a dynamic process or outcome. Most studies that have examined the psychological resilience of prostate cancer survivors have used cross-sectional designs, limiting the understanding of changes in psychological resilience across different stages of the disease.

OBJECTIVES

To investigate changes in psychological resilience and demoralization among newly diagnosed prostate cancer survivors from before treatment to 1 year after treatment initiation as well as the associated influencing factors.

METHODS

A longitudinal design was adopted, and cases were collected from the outpatient department. Data collection occurred at four time points: prior to treatment after the treatment decision was made and at 3, 6, and 12 months after treatment. Study variables included demographic characteristics, disease characteristics, physical symptoms, fear of cancer recurrence, social participation, cancer-related self-efficacy, psychological resilience, and demoralization.

RESULTS

The psychological resilience and demoralization scores of prostate cancer survivors at 3, 6, and 12 months after treatment were similar to their scores before treatment. Survivors with higher fear of cancer recurrence and lower cancer-related self-efficacy had poorer psychological resilience and more severe demoralization. Severe hormonal symptoms and lower interpersonal relationship activity participation were associated with more severe demoralization in survivors with prostate cancer.

CONCLUSIONS

Fear of cancer recurrence, self-efficacy, hormonal symptoms, and interpersonal activity participation are associated with psychological resilience and demoralization.

IMPLICATIONS FOR PRACTICE

Assessing psychological resilience and demoralization is crucial in prostate cancer care. Integrated self-management interventions that address physical, psychological, and social aspects can enhance survivors' resilience.

LncRNA LINC01128 promotes prostate cancer cell proliferation, metastasis, and epithelial-mesenchymal transition by modulating miR-27b-3p

BACKGROUND

Prostate cancer (PCa) is a prevalent malignancy within the male reproductive system that poses a significant threat to patients' lives. The function of long non-coding RNA LINC01128 in PCa progression remains to be elucidated.

OBJECTIVE

The objective was to evaluate the significance of LINC01128 in PCa and to elucidate the underlying mechanisms, thereby identifying a potential target for PCa treatment.

METHODS

The clinical significance of LINC01128 in PCa was investigated by bioinformatics methods and data analysis. The expression of LINC01128 was quantified using real-time quantitative PCR. The impact of LINC01128 on PCa cell viability and metastasis was evaluated through Cell Counting Kit-8 and Transwell assays. The expression of epithelial-mesenchymal transition markers was analyzed by Western blot analysis. Bioinformatics methods and dual-luciferase reporter assay were employed to explore the mechanisms underlying the role of LINC01128 in PCa progression.

RESULTS

LINC01128 demonstrated significant upregulation in PCa and exhibited a strong correlation with tumor-node-metastasis (TNM) stage, Gleason score, and lymph node metastasis. The upregulation of LINC01128 was found to be linked to a poorer prognosis for PCa. In PCa cells, silencing LINC01128 resulted in the suppression of cell proliferation, migration, and invasion. Furthermore, the knockdown of LINC01128 enhanced the expression of E-cadherin while concurrently repressing the expression of N-cadherin and Vimentin. Mechanistically, the negative regulation of miR-27b-3p by LINC01128 mediated the role of LINC01128 in PCa progression.

CONCLUSIONS

In PCa, high expression of LINC01128 may predict patients' unfavorable prognosis. LINC01128 promoted PCa cellular processes by negatively regulating miR-27b-3p.

Role of MRI in Active Surveillance of Prostate Cancer

Magnetic resonance imaging (MRI) plays an important role in the management of patients with prostate cancer on active surveillance. In this review, we will explore the incorporation of MRI into active surveillance protocols, detailing its impact on clinical decision-making and patient management and discussing how it aligns with current guidelines and practice patterns. The role of MRI in this patient population continues to evolve over time, and we will discuss some of the recent advancements in the field and highlight potential areas for future research endeavors.

An MRI radiomics model for predicting a prostate-specific antigen response following abiraterone treatment in patients with metastatic castration-resistant prostate cancer

Objective

To establish a combined radiomics-clinical model for the early prediction of a prostate-specific antigen(PSA) response in patients with metastatic castration-resistant prostate cancer(mCRPC) after treatment with abiraterone acetate(AA).

Methods

The data of a total of 60 mCRPC patients from two hospitals were retrospectively analyzed and randomized into a training group(n=48) or a validation group(n=12). By extracting features from biparametric MRI, including T2-weighted imaging(T2WI), diffusion-weighted imaging(DWI), and apparent diffusion coefficient(ADC) maps, radiomics features from the training dataset were selected using least absolute shrinkage and selection operator(LASSO) regression. Four predictive models were developed to assess the efficacy of abiraterone in treating patients with mCRPC. The primary outcome variable was the PSA response following AA treatment. The performance of each model was evaluated using the area under the receiver operating characteristic curve(AUC). Univariate and multivariate analyses were performed using Cox regression to identify significant predictors of the efficacy of abiraterone treatment in patients with mCRPC.

Results

The integrated model was constructed from seven radiomics features extracted from the T2WI, DWI, and ADC sequence images of the training data. This model demonstrated the highest AUC in both the training and validation cohorts, with values of 0.889 (95% CI, 0.764-0.961) and 0.875 (95% CI, 0.564-0.991). The Rad-score served as an independent predictor of the response to abiraterone treatment in patients with mCRPC (HR: 2.21, 95% CI: 1.01-4.44).

Conclusion

The biparametric MRI-based radiomics model has the potential to predict the PSA response in patients with mCRPC following abiraterone treatment.

Clinical relevance statement

The MRI-based radiomics model could be used to noninvasively identify the AA response in mCRPC patients, which is helpful for early clinical decision-making.

Early Versus Delayed Androgen Deprivation Therapy for Biochemical Recurrence After Local Curative Treatment in Non-Metastatic Hormone-Sensitive Prostate Cancer: A Systematic Review of the Literature

BACKGROUND

The ideal timing of androgen deprivation therapy (ADT) for patients with biochemical recurrence (BCR) of prostate cancer (PCa) remains controversial due to its side effects and uncertain impact on survival outcomes.

METHODS

We performed a review of the current literature by comprehensively searching the PubMed, Embase, and Cochrane databases to determine the optimal timing of ADT initiation after biochemical recurrence. We selected 26 studies including systematic reviews, randomized controlled trials (RCTs), and retrospective studies, while also reviewing practice guidelines.

RESULTS

Not all patients with BCR cancer experience clinical or radiological progression. While early ADT may delay progression, evidence of its effect on PCa-specific mortality remains inconclusive. The PSA thresholds for initiating ADT vary, complicating decision-making. Key predictors of progression include a short PSA doubling time (PSADT), a high Gleason score (GS), and a brief interval to BCR of PCa post-radiotherapy (RT). Combining ADT with androgen receptor pathway inhibitors (ARPIs) has been shown to improve metastasis-free survival in high-risk patients.

CONCLUSION

The ideal timing of ADT initiation in BCR PCa remains uncertain. Early ADT can help control the progression, but its effect on PCa-specific mortality is unclear. Stratifying patients by their risk factors, such as their PSADT, GS, and time to BCR can guide individualized treatment. In high-risk patients, delaying ADT should be avoided, while combining ADT with an androgen receptor pathway inhibitor (ARPI) may further improve outcomes.

International Variations in Adherence to Quality Metrics for Locoregional Prostate Cancer

BACKGROUND AND OBJECTIVE

Adherence to guideline recommendations can improve the quality of care for patients with prostate cancer (PCa). Our aim was to assess adherence to guidelines for locoregional PCa by international region.

METHODS

The study cohort comprised patients diagnosed with locoregional PCa in the 10-country Movember TrueNTH Global Registry (n = 62 688; 2013-2022). We assessed adherence to four quality metrics: (1) active surveillance for low-risk PCa; (2) definitive treatment within 12 mo of diagnosis for unfavorable-risk PCa; (3) no staging imaging for favorable-risk PCa; and (4) staging imaging for unfavorable-risk PCa. For χ2 analyses, we combined the three most recent years of data entered by region for each outcome, with adjustment for multiple tests (p = 0.05 ÷ 4 = 0.0125). We also conducted multivariable logistic regression and temporal analyses.

KEY FINDINGS AND LIMITATIONS

Active surveillance rates for low-risk PCa ranged from 85% in Australia/New Zealand (vs USA: adjusted odds ratio [aOR] 1.042, 95% confidence interval [CI] 0.740-1.520) to 14% in Central Europe (aOR 0.028, 95% CI 0.022-0.036). For patients with unfavorable-risk disease, the highest uptake rate for treatment within 12 mo of diagnosis was in Central Europe (98%; aOR 2.885, 95% CI 1.260-6.603), compared to 70% in Italy (aOR 0.031, 95%CI 0.014-0.072). The proportion of patients with favorable-risk disease who did not undergo imaging ranged from 94% in the USA to 30% in Italy (aOR 0.004, 95% CI 0.002-0.008), while the rate of imaging for unfavorable-risk PCa ranged from 8% in Hong Kong (aOR 65.222, 95% CI 43.676-97.398) to 39% in the USA (all χ2p < 0.0125). Regional temporal trends also varied.

CONCLUSIONS AND CLINICAL IMPLICATIONS

In this international study comparing adherence to quality care metrics for the quality of care for locoregional PCa, we identified regional variance, possibly because of regional differences in cultural attitudes and health care structures. These benchmarks highlight opportunities for interventions to improve adherence to evidence-based guidelines.

PATIENT SUMMARY

Our study shows that adherence to recommended management goals for patients with prostate cancer varies greatly by global region.

UFO registry: final analysis of baseline data from patients with advanced prostate cancer in Asia

Background

The incidence of prostate cancer (PC) is increasing in Asian countries. The epidemiology of PC, its treatment including the use of novel therapeutic options, impacts on quality of life, and clinical outcomes of patients with PC in Asia, are not well documented.

Objectives

To describe the demographic and disease features of the full cohort of patients enrolled in the United in Fight against prOstate cancer (UFO) registry.

Design

The UFO registry was a multi-national, longitudinal, observational study of patients with PC presenting to participating tertiary care hospitals in eight Asian countries/regions.

Methods

Patients with high-risk localized PC (HRL), non-metastatic biochemically recurrent, or metastatic PC were consecutively enrolled from September 14, 2015 until September 1, 2020 and followed for up to 5 years.

Results

Among the full cohort of 3635 patients, 425 had HRL, 389 had non-metastatic biochemically recurrent, and 2821 had metastatic PC. Median follow-up time was 4.2, 4.2, and 2.6 years, respectively. At first diagnosis, the mean age ranged from 65.7 to 69.1 years, 38.5% had extra-capsular tumor extension, 34.0% had regional lymph node metastases, and 65.1% had distant metastases. Quality-of-life scores at enrollment were significantly worse in patients with metastatic disease. Decisions to start therapy were mainly driven by treatment guidelines and disease progression. The decision to discontinue hormonal therapy was often due to disease progression. Few patients received novel hormonal therapies despite their availability.

Conclusion

The UFO registry provides a detailed, contemporary picture of the characteristics, treatment, and outcomes of patients with PC in Asia. There is an unmet medical need to improve access to novel agents in Asia, aiming to improve quality of life and clinical outcomes.

Trial registration

Clinicaltrials.gov Identifier: NCT02546908, Registry Identifier: NOPRODPCR4001.

The Dose Difference of Dominant Intraprostatic Lesions (DILs) Defined by Magnetic Resonance-Guided and arc-based Intensity Modulated Radiation Therapy (IMRT), and the Association between Dose Difference and Recurrent Prostate Cancer

BACKGROUND

There is growing evidence that local recurrence after radiotherapy often occurs within the dominant intraprostatic lesions (DILs) in prostate cancer. This study aimed to evaluate the dose difference between DILs defined by Magnetic Resonance-guided and arc-based Intensity Modulated Radiation Therapy (IMRT) and to assess the association between the dose difference and biochemical recurrence-free survival.

MATERIALS AND METHODS

Between 2015 and 2019, 48 prostate cancer patients with DILs visible from multiparametric Magnetic Resonance Imaging (mpMRI) underwent arc-based IMRT with 70 Gy (2.5 Gy each fraction) to the prostate gland. Pretreatment mpMRI DILs contoured the prostate gland retrospectively.

RESULTS

Biochemical recurrence was 8.3%. There was a significant difference between the median dose of DILs from MRI-guided imaging, 69.22 Gy, and the median dose of the whole prostate from arc-based IMRT which was 67.09 Gy (p < 0.001*). The Kaplan-Meier survival curve compared by log-rank test showed an escalation dose of at least 2 Gy tends to improve biochemical recurrence-free survival. However, this tendency did not reach statistical significance (p = 0.2).

CONCLUSIONS

The dose distribution within DILs defined by mpMRI is significantly higher than the whole prostate dose from arc-based IMRT. Escalation doses in DILs tend to improve biochemical recurrence-free survival, further validation in larger patient cohorts with extended follow-up is warranted.

The combination of immune checkpoint inhibitors and antibody-drug conjugates in the treatment of urogenital tumors: a review insights from phase 2 and 3 studies

With the high incidence of urogenital tumors worldwide, urinary system tumors are among the top 10 most common tumors in men, with prostate cancer ranking first and bladder cancer fourth. Patients with resistant urogenital tumors often have poor prognosis. In recent years, researchers have discovered numerous specific cancer antigens, which has led to the development of several new anti-cancer drugs. Using protein analysis techniques, researchers developed immune checkpoint inhibitors (ICIs) and antibody-conjugated drugs (ADCs) for the treatment of advanced urogenital tumors. However, tumor resistance often leads to the failure of monotherapy. Therefore, clinical trials of the combination of ICIs and ADCs have been carried out in numerous centers around the world. This article reviewed phase 2 and 3 clinical studies of ICIs, ADCs, and their combination in the treatment of urogenital tumors to highlight safe and effective methods for selecting individualized therapeutic strategies for patients. ICIs activate the immune system, whereas ADCs link monoclonal antibodies to toxins, which can achieve a synergistic effect when the two drugs are combined. This synergistic effect provides multiple advantages for the treatment of urogenital tumors.

Protocol for CHAMPION study: a prospective study of maximal-cytoreductive therapies for patients with de novo metastatic hormone-sensitive prostate cancer who achieve oligopersistent metastases during systemic treatment with apalutamide plus androgen deprivation therapy

BACKGROUND

The proposed trial is to examine the feasibility of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT)-guided cytoreduction plus apalutamide and androgen deprivation therapy (ADT) for newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC) at oligometastatic state.

METHODS

CHAMPION (NCT05717582) is an open-label, single-arm, phase II trial, planning to enroll newly diagnosed mHSPC cases with oligometastases (≤ 10 distant metastatic sites in conventional imaging). Patients will receive 6 cycles of apalutamide plus ADT. Patients with oligometastatic disease at PSMA PET/CT after 3 treatment cycles will receive cytoreductive radical prostatectomy. PSMA PET/CT-guided metastasis-directed external radiation therapy will be determined by the investigators. Apalutamide plus ADT will be continued for 2 weeks postoperatively. The primary endpoint is the proportion of patients with undetectable prostate-specific antigen (PSA), no disease progression, and no symptom deterioration after 6 cycles of apalutamide plus ADT. Secondary endpoints include the percentage of patients with PSA ≤ 0.2 ng/mL and oligometastases by the end of 3 treatment cycles, PSA response rate, and safety. Fleming's two-stage group sequential design will be adopted in the study, where the null hypothesis is that the rate of patients with an undetectable PSA is ≤ 40% after 6 cycles of treatment, while the alternate hypothesis is an undetectable PSA of > 60%; with one-sided α = 0.05, power = 0.80, and an assumed dropout rate of 10%, the required number of patients for an effective analysis is 47. Enrolment in the study commenced in May 2023.

DISCUSSION

The multi-modal therapy based on treatment response may improve the prognosis of newly diagnosed mHSPC patients with oligometastases.

TRIAL REGISTRATION

The study is registered with Clinical Trials.Gov (NCT05717582). Registered on 8th February 2023.

Cost-Effectiveness Analysis of Systemic Therapy for Intensification of Treatment in Metastatic Hormone-Sensitive Prostate Cancer in India

BACKGROUND AND OBJECTIVE

Androgen-deprivation therapy is the mainstay of treatment for patients with newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC). However, the intensification of treatment with either docetaxel or novel anti-androgens (abiraterone-acetate plus prednisone [AAP], enzalutamide, and apalutamide) is being recommended based on the improved clinical outcomes and quality of life among patients. This study aimed to determine the most cost-effective drug for treatment intensification for patients with mHSPC in India.

METHODS

A Markov model was developed with four health states: progression-free survival, progressive disease, best supportive care, and death. Lifetime costs and consequences were estimated for four treatment sequences: AAP-first, enzalutamide-first, apalutamide-first, and docetaxel-first. Incremental cost per quality-adjusted life-year (QALY) gained with a given treatment option was compared against the next best alternative and assessed for cost effectiveness using a willingness to pay threshold of 1 × per capita gross domestic product in India.

RESULTS

We estimated that the total lifetime cost per patient was ₹1,367,454 (US$17,487), ₹2,168,885 (US$27,735), ₹7,678,501 (US$98,190), and ₹1,358,746 (US$17,375) in the AAP-first, enzalutamide-first, apalutamide-first, and docetaxel-first treatment sequence, respectively. The mean quality-adjusted life-years lived per patient were 4.78, 5.03, 3.22, and 2.61, respectively. The AAP-first sequence incurs an incremental cost of ₹4014 (US$51) per quality-adjusted life-year gained as compared with the docetaxel-first sequence, with a 87% probability of being cost effective at the willingness-to-pay threshold of 1 × per-capita gross domestic product of India. The use of AAP-first also incurs an incremental net monetary benefit of ₹396,491 (US$5070) as compared with the docetaxel-first treatment sequence. Nearly a 48% reduction in the price of enzalutamide is required to make it a cost-effective treatment sequence as compared with AAP-first in India.

CONCLUSIONS

We concur with the inclusion of standard-dose AAP in India's publicly financed health insurance scheme for the intensification of treatment in mHSPC as it is the only cost-effective sequence among the various novel anti-androgens when compared with the docetaxel-first treatment sequence. Furthermore, a systematic reduction in the price of enzalutamide would further help to improve clinical outcomes among patients with mHSPC.

Development and validation of a deep learning-based microsatellite instability predictor from prostate cancer whole-slide images

Microsatellite instability-high (MSI-H) is a tumor-agnostic biomarker for immune checkpoint inhibitor therapy. However, MSI status is not routinely tested in prostate cancer, in part due to low prevalence and assay cost. As such, prediction of MSI status from hematoxylin and eosin (H&E) stained whole-slide images (WSIs) could identify prostate cancer patients most likely to benefit from confirmatory testing to evaluate their eligibility for immunotherapy and need for Lynch syndrome testing. Prostate biopsies and surgical resections from prostate cancer patients referred to our institution were analyzed. MSI status was determined by next-generation sequencing. Patients sequenced before a cutoff date formed an algorithm development set (n = 4015, MSI-H 1.8%) and a paired validation set (n = 173, MSI-H 19.7%) that consisted of two serial sections from each sample, one stained and scanned internally and the other at an external site. Patients sequenced after the cutoff date formed a temporally independent validation set (n = 1350, MSI-H 2.3%). Attention-based multiple instance learning models were trained to predict MSI-H from H&E WSIs. The predictor achieved area under the receiver operating characteristic curve values of 0.78 (95% CI [0.69-0.86]), 0.72 (95% CI [0.63-0.81]), and 0.72 (95% CI [0.62-0.82]) on the internally prepared, externally prepared, and temporal validation sets, respectively, showing effective predictability and generalization to both external staining/scanning processes and temporally independent samples. While MSI-H status is significantly correlated with Gleason score, the model remained predictive within each Gleason score subgroup.

Investigating the Current Harmonization Status of Tumor Markers Using Global External Quality Assessment Programs: A Feasibility Study

BACKGROUND

The harmonization status of most tumor markers (TMs) is unknown. We report a feasibility study performed to determine whether external quality assessment (EQA) programs can be used to obtain insights into the current harmonization status of the tumor markers α-fetoprotein (AFP), prostate specific antigen (PSA), carcinoembryonic antigen (CEA), cancer antigen (CA)125, CA15-3 and CA19-9.

METHODS

EQA sample results provided by 6 EQA providers (INSTAND [Germany], Korean Association of External Quality Assessment Service [KEQAS, South Korea], National Center for Clinical Laboratories [NCCL, China], United Kingdom National External Quality Assessment Service [UK NEQAS, United Kingdom], Stichting Kwaliteitsbewaking Medische Laboratoriumdiagnostiek [SKML, the Netherlands], and the Royal College of Pathologists of Australasia Quality Assurance Programs [RCPAQAP, Australia]) between 2020 and 2021 were used. The consensus means, calculated from the measurement procedures present in all EQA programs (Abbott Alinity, Beckman Coulter DxI, Roche Cobas, and Siemens Atellica), was used as reference values. Per measurement procedure, the relative difference between consensus mean for each EQA sample and the mean of all patient-pool-based EQA samples were calculated and compared to minimum, desirable, and optimal allowable bias criteria based on biological variation.

RESULTS

Between 19040 (CA15-3) and 25398 (PSA) individual results and 56 (PSA) to 76 (AFP) unique EQA samples were included in the final analysis. The mean differences with the consensus mean of patient-pool-based EQA samples for all measurement procedures were within the optimum bias criterion for AFP, the desirable bias for PSA, and the minimum bias criterion for CEA. However, CEA results <8 µg/L exceeded the minimum bias criterion. For CA125, CA15-3, and CA19-9, the harmonization status was outside the minimum bias criterion, with systematic differences identified.

CONCLUSIONS

This study provides relevant information about the current harmonization status of 6 tumor markers. A pilot harmonization investigation for CEA, CA125, CA15-3, and CA19-9 would be desirable.

A territory-wide real-world efficacy and toxicity analysis of abiraterone acetate versus docetaxel in 574 Asian patients with metastatic hormone-sensitive prostate cancer

INTRODUCTION

Abiraterone acetate (ABI) or docetaxel (DOC), in addition to androgen-deprivation therapy (ADT), are current treatment options for metastatic hormone-sensitive prostate cancer (mHSPC). No randomized head-to-head trial has compared these 2 mHSPC treatments, and real-world data regarding their outcomes in Asian patients are lacking.

PATIENTS AND METHODS

The medical records of mHSPC patients who began upfront ABI or DOC treatment in addition to ADT at seven public oncology centers in Hong Kong between 2015 and 2021 were reviewed. The primary endpoint was progression-free survival (PFS). Secondary endpoints included overall survival (OS), prostate-specific antigen (PSA) response, and toxicities. Kaplan-Meier and multivariate Cox regression analyses were performed.

RESULTS

A total of 574 patients were included, of whom 419 received DOC and 155 received ABI. The median follow-up duration was 22.4 (DOC group: 23.8; ABI group: 17.3) months. The ABI group demonstrated significantly better PFS than the DOC group (not reached vs. 15.1 months: hazard ratio = 0.37; 95% confidence interval = 0.28-0.50; P < .001). No significant OS difference was observed (P = .58). Failure to achieve a ≥ 90% decline in PSA level at 3 months and failure to achieve an undetectable PSA nadir were each associated with unfavorable PFS and OS. Patients who received DOC had a higher rate of febrile neutropenia, whereas those who received ABI had higher rates of grade ≥ 3 hypokalemia and elevated alanine transaminase. Treatment discontinuation due to toxicities was more common in the DOC (3.6%) than the ABI (0.6%) group.

CONCLUSION

In Asian mHSPC patients, upfront ABI + ADT was associated with better PFS than DOC + ADT, with no significant OS difference. PSA kinetics may help stratify the prognosis for treatment intensification. Toxicity profiles were different, with a higher rate of toxicity-related treatment discontinuation in the DOC group.

Prostate cancer management in Southeast Asian countries: a survey of clinical practice patterns

Background

Prostate cancer (PC) has a serious public health impact, and its incidence is rising due to the aging population. There is limited evidence and consensus to guide the management of PC in Southeast Asia (SEA). We present real-world data on clinical practice patterns in SEA for advanced PC care.

Method

A paper-based survey was used to identify clinical practice patterns and obtain consensus among the panelists. The survey included the demographics of the panelists, the use of clinical guidelines, and clinical practice patterns in the management of advanced PC in SEA.

Results

Most panelists (81%) voted prostate-specific antigen (PSA) as the most effective test for early PC diagnosis and risk stratification. Nearly 44% of panelists agreed that prostate-specific membrane antigen positron emission tomography-computed tomography imaging for PC diagnostic and staging information aids local and systemic therapy decisions. The majority of the panel preferred abiraterone acetate (67%) or docetaxel (44%) as first-line therapy for symptomatic mCRPC patients. Abiraterone acetate (50%) is preferred over docetaxel as a first-line treatment in metastatic castration-sensitive prostate cancer patients with high-volume disease. However, the panel did not support the use of abiraterone acetate in non-metastatic castration-resistant prostate cancer (nmCRPC) patients. Apalutamide (75%) is the preferred treatment option for patients with nmCRPC. The cost and availability of modern treatments and technologies are important factors influencing therapeutic decisions. All panelists supported the use of generic versions of approved therapies.

Conclusion

The survey results reflect real-world management of advanced PC in a SEA country. These findings could be used to guide local clinical practices and highlight the financial challenges of modern healthcare.

Long-term findings of rectal endoscopy and rectal bleeding after moderately hypofractionated, intensity-modulated radiotherapy for prostate cancer

To present rectal endoscopic findings and toxicity after definitive moderately hypofractionated, intensity-modulated radiotherapy (IMRT) for prostate cancer. We retrospectively reviewed patients who underwent IMRT for prostate cancer and underwent post-radiotherapy endoscopies between 2008 and 2018. Endoscopic findings were reviewed and graded using Vienna Rectoscopy Score (VRS). We have analyzed the association between endoscopic findings and rectal bleeding, and investigated risk factors for rectal bleeding. Total 162 patients met the inclusion criteria of this study. There was a trend of VRS worsening during the initial 3 years after radiotherapy followed by recovery. Rectal bleeding was highest at 1 year after radiotherapy and improved thereafter. The 5-year cumulative incidence of grade ≥ 2 rectal bleeding was 14.8%. In the multivariable Cox regression analysis, cardiovascular disease (hazard ratio [HR] 2.732, P = 0.037), rectal wall V65 (HR 1.158, P = 0.027), and VRS ≥ 3 in first post-radiotherapy endoscopy (HR 2.573, P = 0.031) were significant risk factors for rectal bleeding. After IMRT for prostate cancer, VRS and rectal bleeding worsened over 1-3 years after radiotherapy and recovered. Cardiovascular disease, rectal wall V65, and VRS ≥ 3 in first post-radiotherapy endoscopy were significant risk factors for rectal bleeding.

Apalutamide for metastatic castration-sensitive prostate cancer: final analysis of the Asian subpopulation in the TITAN trial

The final analysis of the phase 3 Targeted Investigational Treatment Analysis of Novel Anti-androgen (TITAN) trial showed improvement in overall survival (OS) and other efficacy endpoints with apalutamide plus androgen deprivation therapy (ADT) versus ADT alone in patients with metastatic castration-sensitive prostate cancer (mCSPC). As ethnicity and regional differences may affect treatment outcomes in advanced prostate cancer, a post hoc final analysis was conducted to assess the efficacy and safety of apalutamide in the Asian subpopulation. Event-driven endpoints were OS, and time from randomization to initiation of castration resistance, prostate-specific antigen (PSA) progression, and second progression-free survival (PFS2) on first subsequent therapy or death. Efficacy endpoints were assessed using the Kaplan-Meier method and Cox proportional-hazards models without formal statistical testing and adjustment for multiplicity. Participating Asian patients received once-daily apalutamide 240 mg ( n = 111) or placebo ( n = 110) plus ADT. After a median follow-up of 42.5 months and despite crossover of 47 placebo recipients to open-label apalutamide, apalutamide reduced the risk of death by 32% (hazard ratio [HR]: 0.68; 95% confidence interval [CI]: 0.42-1.13), risk of castration resistance by 69% (HR: 0.31; 95% CI: 0.21-0.46), PSA progression by 79% (HR: 0.21; 95% CI: 0.13-0.35) and PFS2 by 24% (HR: 0.76; 95% CI: 0.44-1.29) relative to placebo. The outcomes were comparable between subgroups with low- and high-volume disease at baseline. No new safety issues were identified. Apalutamide provides valuable clinical benefits to Asian patients with mCSPC, with an efficacy and safety profile consistent with that in the overall patient population.

[18F]FDG PET-TC radiomics and machine learning in the evaluation of prostate incidental uptake

AIM

To evaluate the relevance of incidental prostate [18F]FDG uptake (IPU) and to explore the potential of radiomics and machine learning (ML) to predict prostate cancer (PCa).

METHODS

We retrieved [18F]FDG PET/CT scans with evidence of IPU performed in two institutions between 2015 and 2021. Patients were divided into PCa and non-PCa, according to the biopsy. Clinical and PET/CT-derived information (comprehensive of radiomic analysis) were acquired. Five ML models were developed and their performance in discriminating PCa vs non-PCa IPU was evaluated. Radiomic analysis was investigated to predict ISUP Grade.

RESULTS

Overall, 56 IPU were identified and 31 patients performed prostate biopsy. Eighteen of those were diagnosed as PCa. Only PSA and radiomic features (eight from CT and nine from PET images, respectively) showed statistically significant difference between PCa and non-PCa patients. Eight features were found to be robust between the two institutions. CT-based ML models showed good performance, especially in terms of negative predictive value (NPV 0.733-0.867). PET-derived ML models results were less accurate except the Random Forest model (NPV = 0.933). Radiomics could not accurately predict ISUP grade.

CONCLUSIONS

Paired with PSA, radiomic analysis seems to be promising to discriminate PCa/non-PCa IPU. ML could be a useful tool to identify non-PCa IPU, avoiding further investigations.

Magnetic resonance fingerprinting based comprehensive quantification of T1 and T2 values of the background prostatic peripheral zone: Correlation with clinical and demographic features

PURPOSE

To quantify and assess the distribution of MR fingerprinting (MRF)-derived T1 and T2 values of the whole prostatic peripheral zone (PZ), and perform subgroup analyses according to clinical and demographic features.

METHOD

One hundred and twenty-four patients with prostate MR exams and MRF-based T1 and T2 maps of the prostatic apex, mid gland, and base were identified from our database and included. Regions of interest encompassing the right and left lobes of the PZ were drawn for each axial slice on the T2 map and copied to the T1 map. Clinical data were obtained from medical records. Kruskal-Wallis test was used for assessing differences between subgroups and the Spearman coefficient was used for assessing any correlations.

RESULTS

Mean T1 and T2 values were 1941 and 88 ms, respectively, for the whole-gland, 1884 and 83 ms for the apex, 1974 and 92 ms for the mid-gland, 1966 and 88 ms for the base. T1 values were weakly negatively correlated with PSA values, while T1 and T2 values were weakly positively correlated with prostate weight and moderately positively correlated with PZ width. Finally, patients with PI-RADS 1 scores had higher T1 and T2 values of the whole PZ, compared with those with scores 2-5.

CONCLUSION

Mean T1 and T2 values of the background PZ of the whole gland were 1941 ± 313 and 88 ± 39 ms, respectively. Among clinical and demographic factors, there was a significant positive correlation between T1 and T2 values and PZ width.

Current Routine Testosterone Immunoassays Are Unsuitable for Lowering the General Castration Cutoff Recommendation to <0.7 nmol/l (20 ng/dl)

Testosterone measurements are essential in the management of patients with prostate cancer undergoing castration and androgen deprivation therapy. There has been an ongoing discussion on the testosterone castration cutoff (TCC), with the primary focus on large cohort studies in which the testosterone measurement system was not specified or studies that used individual testosterone measurement systems. Here we present a post hoc analysis of a study comparing testosterone measurement systems in a cohort of 120 castrated patients with prostate cancer. We investigated the suitability of general, measurement system-independent, TCC values recommended in all clinical guidelines. We show that the four testosterone immunoassays commonly used are unsuitable to support lowering of TCC to 0.7 nmol/l (20 ng/dl) testosterone, since testosterone levels are falsely quantified as higher than this cutoff in 4.2-29.2% of the castrated cohort, depending on the testosterone immunoassay used. When using 1.0 nmol/l (30 ng/dl) as the TCC for the Beckman immunoassay, 13.3% of the results were falsely quantified as being higher than this value. The results suggest that the measurement systems used in current practice do not support lowering the TCC to 0.7 nmol/l. Furthermore, a more local, immunoassay-dependent TCC should be considered.

Patient summary

Patients with advanced prostate cancer who are treated to reduce their testosterone to a castration level are monitored using testosterone measurements. The testing systems currently used for measurement do not support lowering of the testosterone cutoff value to 0.7 nmol/l. Testosterone cutoff values to define castration status should preferably be based on the measurement system in local use.

Combination therapy for high-volume versus low-volume metastatic hormone-sensitive prostate cancer: A systematic review and network meta-analysis

Purpose: To conduct a systematic review and network meta-analysis (NMA) to compare the efficacy of currently available combination therapies in patients with metastatic hormone-sensitive prostate cancer (mHSPC). Methods: Qualified publications were searched in the PubMed, Embase, and Cochrane CENTRAL databases. Overall survival (OS) and radiographic progression-free survival (rPFS) were indirectly compared and assessed using NMA and the surface under the cumulative ranking curve, respectively. Adverse events (AEs) were also compared. Results: Eighteen publications from 12 trials were analyzed in the NMA. In the overall population, triplet therapy was ranked first for OS (hazard ratio [HR]: 0.57, 95% credible interval [CrI]: 0.48-0.67) and rPFS (HR: 0.33, 95% CrI:0.26-0.41) compared with androgen deprivation therapy (ADT) with or without standard non-steroidal antiandrogen. In high-volume mHSPC, triplet therapy was also ranked first in OS (HR, 0.57; 95% CrI:0.44-0.75) and rPFS(HR, 0.29; 95% CrI: 0.23-0.37). Specifically, abiraterone triplet therapy was ranked first in OS (HR, 0.52; 95% CrI:0.38-0.72) and rPFS (HR, 0.28; 95% CrI:0.21-0.38) among all therapies. ADT plus rezvilutamide was ranked first among doublet therapies (OS: HR, 0.58; 95% CrI:0.44-0.77; rPFS: HR, 0.44; 95% CrI:0.33-0.58). In low-volume mHSPC, doublet and triplet therapies were ranked first in OS (HR:0.68, 95% CrI:0.58-0.80) and rPFS (HR:0.37, 95% CrI:0.25-0.55), respectively. ADT plus apalutamide was ranked first in OS among all therapies (HR:0.53, 95% CrI:0.35-0.79), whereas enzalutamide triplet therapy was ranked first in rPFS (HR:0.27, 95% CrI:0.15-0.51). ADT plus rezvilutamide showed a relatively lower incidence of AE among all therapies (OR:1.00, 95% CrI:0.31-3.15), and a lower risk of specific AEs among doublet therapies, particularly regarding seizure (OR, 0.29; 95% CrI:0.01-8.18) and fatigue (OR, 0.96; 95% CrI:0.63-1.46). Docetaxel-based doublet or triplet therapies significantly increased the risk of any AEs or grade ≥3 AEs. Conclusion: Triplet therapy was the best treatment option for the overall population. In high-volume mHSPC, triplet therapy and ADT plus rezvilutamide had the greatest potential to benefit patients. Patients with low-volume mHSPC were most likely to benefit from ADT plus androgen receptor-targeted agents. Triplet therapy was associated with a higher risk of AEs than the other therapies. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022375347, identifier PROSPERO:CRD42022375347.