Androgen deprivation therapy: monitoring and managing the complications

Impacts of Neoadjuvant Hormonal Therapy Prior to Robot-Assisted Radical Prostatectomy on Postoperative Hormonal- and Sexual-Related Quality of Life – Assessment by Patient-Reported Questionnaire

Purpose

Neoadjuvant hormonal therapy (HT) before radical prostatectomy (RP) is not recommended by current guidelines in terms of oncological outcomes. Despite this, neoadjuvant HT is sometimes conducted before RP for a small proportion of patients in clinical practice. This study evaluated the impacts of neoadjuvant HT on hormonal- and sexual-related quality of life (QOL) among patients who underwent robot-assisted RP (RARP).

Materials and Methods

Participants comprised 470 patients divided into a non-neoadjuvant HT group (n = 408) and a neoadjuvant HT group (n = 62). Hormonal- and sexual-related QOL were measured using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire.

Results

Hormonal summary scores at 6 and 9 months, function scores before and 3, 6, and 9 months and bother score at 6 months after RARP were significantly lower in the neoadjuvant HT group than in the non-neoadjuvant HT group. Sexual function scores were decreased in the neoadjuvant HT group compared to the non-neoadjuvant HT group before and 6 months after RARP. In the neoadjuvant HT group, sexual function at 3 months after RARP was significantly worse in patients with >5 months of neoadjuvant HT than in patients with ≤5 months of neoadjuvant HT. Conversely, sexual bother at 3 months after RARP was significantly worse in patients with ≤5 months of neoadjuvant HT than in patients with >5 months of neoadjuvant HT.

Conclusion

Vintage neoadjuvant HT prior to RARP should not be recommended due to not only oncological outcomes, but also the impacts on postoperative hormonal- and sexual-related QOL.

Recommendations on the diagnosis, treatment and monitoring of testosterone deficiency in men

The relative proportional increase of the elderly population within many countries will become one of the most significant social transformations of the twenty-first century and, for the first time in history, persons aged 65 or above outnumbered children under five years of age globally. One in four persons living in Europe and Northern America will be aged 65 or over. One of the goals of ISSAM is to raise awareness of the special health needs of older men. Since a significant number of aging men will eventually become testosterone deficient, the Hypogonadism panel of ISSAM updates its guidelines.

Update on cardiovascular and metabolic risk profiles of hormonal agents used in managing advanced prostate cancer

PURPOSE

Androgen deprivation therapy (ADT), a mainstay of therapy for advanced prostate cancer (CaP), may raise patients' risk of cardiovascular disease (CVD) and related adverse events. The new androgen receptor (AR)-targeted agents are associated with hypertension and cardiovascular events. The most common non-CaP cause of death in men with CaP is CVD. The purpose of this review is to raise awareness of the metabolic and CV risks of ADT and to encourage proper monitoring of patients treated with hormonal agents.

MATERIALS AND METHODS

To review the cardiovascular and metabolic risk profiles of hormonal agents in managing patients with advanced CaP, the author searched PubMed, meeting abstracts, and clinicaltrials.gov from 1941 through early 2020 using search terms such as locally advanced CaP guidelines, gonadotropin-releasing hormone (GnRH) agonist/antagonist, ADT, CaP, CVD, abdominal obesity metabolic syndrome, and cerebrovascular disorder. The author ultimately selected 42 of the most relevant publications for inclusion in this paper.

RESULTS

Data regarding cardiovascular risk in patients with CaP on ADT are inconsistent, though there may be evidence of less risk in GnRH antagonists than GnRH agonists in men with pre-existing CVD. Observational post hoc studies generally show higher risks for GnRH agonists than GnRH antagonists. A review of 6 phase 3 trials found that patients treated with GnRH antagonists had lower cardiovascular risk than those treated with agonists during the first year of ADT, and these differences were especially significant among men with pre-existing CVD. Additionally, a small prospective randomized phase 2 study, as well as a large phase 3 trial, showed that there were significantly more major adverse cardiovascular events in patients treated with a GnRH agonist compared to a GnRH antagonist. In addition, the AR-targeted agents in conjunction with ADT have been shown to have more hypertension and/or cardiovascular risk than ADT plus placebo in numerous phase 3 trials.

CONCLUSIONS

Whether there is a difference in CVD risk between GnRH agonists and antagonists is the subject of an ongoing phase 3 trial with cardiovascular endpoints. Addition of newer AR-targeted agents may confer additional risk over ADT alone. Clinicians treating advanced CaP should be aware of underlying comorbidities of their patients before choosing either conventional ADT or adding AR-targeted agents. Physicians should monitor patients for hypertension, diabetes, and cardiovascular side effects that may require intervention in order to minimize downstream adverse events and should communicate with other colleagues on the patient's health care team to ensure the best outcomes.

Is there still a role for bilateral orchidectomy in androgen-deprivation therapy for metastatic prostate cancer?

Objective: To compare bilateral orchidectomy, as the classical ‘gold standard’ androgen-deprivation therapy (ADT), and ADT using a luteinising hormone-releasing hormone (LHRH) antagonist (degarelix) for the treatment of metastatic prostate cancer regarding their short-term biochemical efficacy, testosterone castrate level, tolerability, and effect on health-related quality of life (HRQoL).

Patients and methods: A total of 60 patients with newly diagnosed metastatic prostate cancer were managed by either bilateral orchidectomy or degarelix injection as ADT. Both groups were compared according to their prostate-specific antigen (PSA) nadir and testosterone level at the 6-month follow-up. HRQoL was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30) after 12 months.

Results: Bilateral orchidectomy and degarelix showed comparable results for PSA reduction, but there was a statistically significantly lower castrate level of testosterone in the bilateral orchidectomy group. Using the EROTC QLQC-30, bilateral orchidectomy was associated with better HRQoL, better global health status, and better functional status.

Conclusion: Bilateral orchidectomy resulted in lower castrate levels of testosterone, which may be associated with better disease control, together with better HRQoL and general health status compared to LHRH antagonist (degarelix). These results indicate that we should consider revisiting bilateral orchidectomy as a valuable and effective treatment option for ADT.

Abbreviations: ADT: androgen-deprivation therapy; EORTC (QLQ-C30): European Organisation for Research and Treatment of Cancer (Quality of Life Questionnaire-Core 30); HRQoL: health-related quality of life

Predictive values of miR-129 and miR-139 for efficacy on patients with prostate cancer after chemotherapy and prognostic correlation

Predictive values of miR-129 and miR-139 for efficacy on patients with prostate cancer (PC) after chemotherapy and prognostic correlation were explored. Eighty-four patients with PC undergoing chemotherapy in The Third Affiliated Hospital of Qiqihar Medical University from January 2016 to January 2017 were enrolled as the observation group treated with DP regimen, and further 100 healthy individuals undergoing physical examination were enrolled as the control group. RT-qPCR was used to detect expression of serum miR-129 and miR-139. According to the clinical efficacy after treatment, patients with complete remission (CR) and partial remission (PR) were considered as a good curative effect group, whereas those with stable disease (SD) and progressive disease (PD) were considered as a poor curative effect group. In the observation group, miR-129 and miR-139 expression after treatment was significantly lower and higher, respectively, than that before treatment (P<0.05). After treatment, there were 15 patients with CR, 30 with PR, 26 with SD, and 13 with PD in the observation group. Before treatment, compared with the poor curative effect group, patients in the good curative effect group had significantly higher miR-129 expression but significantly lower miR-139 expression (P<0.05). The overall survival rate (OSR) of patients was 64.29%. The survival of patients in the miR-129 high expression group was significantly better than that in the miR-129 low expression group (P=0.001), whereas the survival in the miR-139 low expression group was significantly better than that in the miR-139 high expression group (P=0.012). According to multivariate Cox regression analysis, Gleason score, prostate specific antigen (PSA), bone metastasis, TNM staging, miR-129, and miR-139 were independent prognostic factors affecting patients. In conclusion, miR-129 and miR-139 are expected to be potential indicators for the diagnosis, prognosis, and efficacy prediction of PC.

Changes in cerebral metabolic activity in men undergoing androgen deprivation therapy for non-metastatic prostate cancer

OBJECTIVE

Androgen deprivation therapy (ADT) is a common treatment option for men with biochemical relapse from prostate cancer. ADT is associated with changes in mood, cognition, and quality of life, and most recently with increased risk for Alzheimer's disease (AD). This study examined changes in brain metabolism using positron emission tomography (PET) in men undergoing intermittent ADT.

METHODS

Nine men with prostate cancer and a rising PSA (biochemical recurrence) without evidence of metastases were treated with intermittent ADT consisting of 9 months of complete androgen blockade achieved with combined leuprolide acetate and flutamide. Patients underwent resting [Fuorine-18] fluorodeoxyglucose PET (18F-FDGPET) at baseline (before treatment) and again after 9 months of ADT.

RESULTS

Whole-brain mapping analysis after 9 months of androgen deprivation compared to pretreatment baseline revealed decreased regional cerebral glucose metabolism in the cerebellum, posterior cingulate, and medial thalamus bilaterally. Associations of brain metabolism with measurements of cognition and mood while on androgen deprivation revealed positive correlations between the posterior cingulate, left inferior parietal lobule (BA40), and left mid temporal gyrus (BA39) and spatial reasoning and a negative correlation between left inferior parietal lobule and verbal memory. Several mood indices were negatively correlated with hypothalamus and brainstem.

CONCLUSION

These findings suggest that complete androgen deprivation may result in changes in regional brain metabolism associated with variation in mood, verbal memory, and spatial performance. Brain regions that were impacted from ADT are similar and overlap with brain regions with metabolic decline found in early AD and diabetes, suggesting possible common mechanisms.

Recommendations on the diagnosis, treatment and monitoring of hypogonadism in men

Hypogonadism or Testosterone Deficiency (TD) in adult men as defined by low levels of serum testosterone accompanied by characteristic symptoms and/or signs as detailed further on can be found in long-recognized clinical entities such as Klinefelter syndrome, Kallmann syndrome, pituitary or testicular disorders, as well as in men with idiopathic, metabolic or iatrogenic conditions that result in testosterone deficiency. These recommendations do not encompass the full range of pathologies leading to hypogonadism (testosterone deficiency), but instead focus on the clinical spectrum of hypogonadism related to metabolic and idiopathic disorders that contribute to the majority of cases that occur in adult men.

Pharmacological inhibition of myostatin and changes in lean body mass and lower extremity muscle size in patients receiving androgen deprivation therapy for prostate cancer

CONTEXT

Myostatin is a negative regulator of muscle growth. Androgen deprivation (ADT) is associated with muscle loss and increased body fat, and currently available therapies have limited efficacy to treat this complication. The antimyostatin peptibody (AMG 745/Mu-S) markedly attenuated muscle loss and decreased fat accumulation in orchiectomized mice.

OBJECTIVE

The objective of the study was to evaluate the safety, pharmacokinetics, and muscle efficacy of AMG 745 in men undergoing ADT for nonmetastatic prostate cancer.

METHODS

This was a randomized, blinded, placebo-controlled, multiple-dose, phase 1 study of AMG 745 given for 28 days. The end point of percentage change from baseline in lean body mass (LBM) as assessed by dual x-ray absorptiometry was prespecified.

RESULTS

Rates of adverse events (AMG 745 vs placebo) were the following: diarrhea (13% vs 9%), fatigue (13% vs 4%), contusion (10% vs 0%), and injection site bruising (6% vs 4%). Exposure increased linearly from 0.3 mg/kg to 3 mg/kg. AMG 745 significantly increased LBM in the 3 mg/kg vs the placebo groups on day 29 by 2.2% (±0.8% SE, P = 0.008); in exploratory fat mass analysis, a decrease of -2.5% (±1.0% SE, P = 0.021) was observed. Pharmacodynamic changes in muscle and fat were maintained at follow-up, 1 month after day 29.

CONCLUSION

Four weekly s.c. doses of AMG 745 were well tolerated and were associated with increased LBM and decreased fat in the men receiving ADT for nonmetastatic prostate cancer. RESULTS support further investigation of AMG 745 in clinical settings with muscle loss and atrophy.

Development and validation of a prognostic index for fracture risk in older men undergoing prostate cancer treatment

OBJECTIVES

Men treated with androgen deprivation therapy (ADT) or radiation therapy (RT) for prostate cancer have an increased risk for fractures. Given uncertainty as to whether specific clinical factors can identify men at increased risk, we sought to develop a prognostic index for risk of fracture in this population.

MATERIALS AND METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify men who received ADT or RT after being diagnosed with localized prostate cancer in 2007-2009. Cox proportional hazards models tested the association of potential risk factors with fracture. In a derivation group, hazard ratios were used to assign points for factors independently related to fracture. The prognostic index was then applied to a validation group.

RESULTS

The sample of 5824 men had a median age of 73.0 years; 82.9% were white and 8.6% had a fracture within 2 years of treatment for prostate cancer. The Cox model identified 8 variables (age, race, hormone treatment, Elixhauser score, anxiety, Parkinson's, fall-inducing medications and disability status) independently associated with fracture. In the derivation cohort, 4.3% of the sample experienced a fracture in the low-risk group, 8.9% in the intermediate group, and 19.2% in the high-risk group (C statistic, 0.749). The index was applied to the validation cohort (C statistic, 0.782).

CONCLUSION

The prognostic index can help to identify patients at increased risk for fracture. This underscores the importance of identifying risk factors for fracture, given the substantial variation in fracture risk in men treated with ADT or RT.

Quality of life of 1276 elderly patients with prostate cancer, starting treatment with a gonadotropin-releasing hormone agonist: results of a French observational study

This French observational, longitudinal, prospective study described the health-related quality of life (HRQoL) of elderly men (≥75 years old) with prostate cancer after initiating gonadotropin-releasing hormone (GnRH) agonist therapy. At baseline and 3-6 months after baseline, European Organisation for Research and Treatment of Cancer quality of life questionnaire-core 30 (QLQ-C30) and prostate-specific (QLQ-PR25) questionnaires were completed by patients. Data from 1276 patients were analyzed. At baseline, mean (±SD) age was 80 (±4.1) years, 29.1% of patients had Gleason scores ≥8 and 24.9% had metastases. At baseline, increasing age, presence of metastasis and presence of comorbidity had a negative impact on QLQ-C30 and QLQ-PR25 scores. At follow-up, improvement in emotional-functioning (2.8; p < 0.001), social-functioning (1.7; p = 0.011), global HRQoL (1.6; p = 0.029), sleep-disturbance (-2.1; p = 0.011), appetite-loss (-4.0; p < 0.001) and pain (-4.1; p < 0.001) QLQ-C30 scores were observed. In addition, there was a worsening in treatment-related symptom (8.6; p < 0.001), sexual-activity (-5.5; p < 0.001) and sexual-functioning (-22.6; p < 0.001) QLQ-PR25 scores, and an improvement in urinary symptoms (-3.7; p < 0.001) and incontinence aid (-2.9; p = 0.023) QLQ-PR25 scores. This study shows that, apart from the expected impact on sexual functioning domains, HRQoL is not adversely affected by 3-6 months of GnRH agonist therapy in older men with prostate cancer.

Recommendations on the diagnosis, treatment and monitoring of late-onset hypogonadism in men - a suggested update

Recommendations on the diagnosis, treatment and monitoring of late-onset hypogonadism (LOH) in men were first published by ISSAM in 2002 In 2005, and, in 2008, updated recommendations were published in the International Journal of Andrology, the Journal of Andrology, the Aging Male and European Urology. Towards discussions at the next ISSAM/ESSAM meeting in Moscow, 29 November 2013, we suggest the following update.

[Current evidence about intermittent androgenic deprivation in prostate cancer]

OBJECTIVES

To identify clinical application of intermittent hormonotherapy in prostatic carcinoma.

MATERIAL AND METHODS

We conducted a systematic review in MEDLINE database and COCHRANE Library using the words MeSH "prostate cancer, androgenic deprivation and intermittent". There were included those with the best level of evidence and published in the last 10 years.

RESULTS

Intermittent hormone therapy is one of the tools we use in urological armamentarium for special circumstances. This analysis highlights: possibility to regain sexual function during the period of suspension of treatment (time off) due to the recovery of testosterone levels also demonstrating an improvement in symptoms, decreased costs preserving the same oncological control compared to complete androgenic deprivation.

CONCLUSIONS

There is still controversy about the benefits in quality of life and the emergence of long-term side effects typical of continuous hormonal therapy. Therefore and until now, we should only propose intermittent therapy in selected patients.

The language of prostate cancer treatments and implications for informed decision making by patients

Previous research has shown that cancer patients lack knowledge about treatments particularly for reproductive system cancers. Focusing on prostate cancer, we explored how the language used to describe treatments and their side effects is understood by both men and women. Since the language around prostate cancer is often euphemised to reduce distress and stigma, our aim was to elucidate how language (e.g. hormone therapy vs. androgen deprivation therapy) affects both patients' and partners' attitudes towards treatment decision making. We surveyed 690 male and female cancer patients and non-patients through an online questionnaire. A large proportion of participants did not understand the terminology used to describe prostate cancer treatments. Most did not know that the terms 'chemical castration', 'hormonal therapy' and 'androgen deprivation' are synonymous. Male respondents stated that they would more readily agree to hormonal therapy than to castration to treat prostate cancer and felt significantly more strongly than women about how androgen deprivation therapy, described in various terms, affected masculinity. Men and women differed substantially in their opinion about the impact of androgen deprivation. For patients and partners to make informed decisions and cope effectively with treatment side effects, it is important that healthcare practitioners provide accurate information using language that is unambiguous.

Safety and tolerability of intermittent androgen deprivation therapy: a literature review

Androgen deprivation therapy is commonly used in men with advanced prostate cancer; however, it is associated with many short- and long-term side-effects. Intermittent androgen deprivation therapy was first suggested as an alternative regimen in the early 1990s and is now part of treatment guidelines as a result of its ability to reduce adverse events associated with continuous androgen deprivation therapy without decreasing its efficacy. Although many publications evaluated intermittent androgen deprivation therapy's efficacy, the safety and tolerability information of this regimen is relatively limited. The goal of this literature review was to analyze clinical trials that have reported safety and tolerability data in prostate cancer patients treated with intermittent androgen deprivation therapy, as well as assessing quality of life outcomes. A literature search was carried out using biomedical and pharmaceutical databases for published information comparing intermittent androgen deprivation therapy with continuous androgen deprivation therapy. A total of 13 randomized and non-randomized studies were selected and reviewed based on their relevance to the safety, tolerability and quality of life of intermittent androgen deprivation therapy. Benefits for intermittent androgen deprivation therapy were observed for the short-term side-effects (hot flushes and sexual functions) mainly during the off-treatment phase, whereas the data for the long-term side-effects were not as conclusive. Quality of life evaluations are more in support of intermittent androgen deprivation therapy. Although there are some safety, tolerability and quality of life benefits associated with intermittent androgen deprivation therapy, the overall evidence is still limited.

Long-term quality of life in disadvantaged men with prostate cancer on androgen-deprivation therapy

BACKGROUND

To explore the effects of androgen-deprivation therapy (ADT) on general, disease-specific and hormone-specific health-related quality of life (HRQOL) among minority men.

METHODS

Men enrolled in a state-funded program, providing free prostate cancer treatment for underserved men, were recruited, if they had received at least 3 months of continuous ADT and/or other forms of primary treatment. HRQOL was assessed with validated measures including the RAND Medical Outcomes Study 12-item Health Short Form Survey (SF-12), the UCLA Prostate Cancer Index Survey and the Expanded Prostate Cancer Index Composite Survey. Repeated measures analysis was performed to evaluate the association between clinical and sociodemographic covariates with HRQOL.

RESULTS

We enrolled 322 men, including 94 on ADT and 228 who received other forms of treatment. When controlling for patient characteristics, men receiving ADT had poorer outcomes relative to sexual function (P<0.01), sexual bother (P<0.01), hormonal function (P<0.01) and hormonal bother (P=0.02). ADT use was significantly associated with worsening sexual function (P<0.01) and sexual bother (P=0.01) over two years compared with non-ADT users. Analysis also demonstrated significant differences between whites, Hispanics and Others (African American (n=43, 16%), Asian (n=13, 5%), multiracial (n=1, 0.4%), Native American (n=1, 0.4%) and other (n=9, 3%)) relative to urinary bother (P=0.01), urinary function (P=0.01) and hormonal bother (P=0.03). ADT users had better urinary function and less bother than non-ADT users among the Other group, while the opposite was true for whites and Hispanics. For hormonal bother, ADT use was associated with worse outcomes across all three race/ethnicity groups; however, Hispanics were less bothered by their hormonal symptoms than whites or Others.

CONCLUSION

Men of disadvantaged backgrounds on hormone therapy for prostate cancer experience declines in sexual and hormonal HRQOL. Whites and non-whites on ADT have significantly different HRQOL outcomes.

The health and well-being of prostate cancer patients and male-to-female transsexuals on androgen deprivation therapy: a qualitative study with comments on expectations and estrogen

Both male-to-female transsexuals and advanced prostate cancer (PCa) patients are treated with androgen-suppressing drugs that have emasculating effects. Additionally, transsexuals take estrogenic compounds to feminize their bodies. We explore the quality of life of these populations, based on interviews with 12 individuals from each group. Overall, the transsexuals had a better psychological response to chemical castration than the PCa patients. The transsexuals showed more enthusiasm about the changes in their life; they viewed their lives as beginning anew, accepted their reduced libido, and were more comfortable with their increased emotionality. Different responses in the two groups are not surprising given that they undergo androgen deprivation under very different medical contexts. However, the fact that the transwomen are able to conceptualize the effects as positive suggests that some androgen-deprived PCa patients may benefit from reconceptualizing their changes within a positive framework. Additionally, difference in the two populations may be attributed, in part, to the fact that the transsexuals take supplemental estrogen. Circumstantial evidence suggests that estrogen in androgen-deprived males may improve sleep quality, help retain sexual interest, and protect cognitive function. This suggests that PCa patients may benefit from using estradiol for androgen suppression.

Changes in neuronal activation patterns in response to androgen deprivation therapy: a pilot study

BACKGROUND

A common treatment option for men with prostate cancer is androgen deprivation therapy (ADT). However, men undergoing ADT may experience physical side effects, changes in quality of life and sometimes psychiatric and cognitive side effects.

METHODS

In this study, hormone naïve patients without evidence of metastases with a rising PSA were treated with nine months of ADT. Functional magnetic resonance imaging (fMRI) of the brain during three visuospatial tasks was performed at baseline prior to treatment and after nine months of ADT in five subjects. Seven healthy control patients, underwent neuroimaging at the same time intervals.

RESULTS

ADT patients showed reduced, task-related BOLD-fMRI activation during treatment that was not observed in control subjects. Reduction in activation in right parietal-occipital regions from baseline was observed during recall of the spatial location of objects and mental rotation.

CONCLUSIONS

Findings, while preliminary, suggest that ADT reduces task-related neural activation in brain regions that are involved in mental rotation and accurate recall of spatial information.

Passing through the wall: on outings, exodus, angels, and the ark

Classicists have argued that angels in Christian theology were modeled on the eunuchs of antiquity; with angels providing the same services to the Lord in Heaven that eunuchs provided to emperors on Earth. I apply this idea toward understanding the cherubim on the ark in Exodus 25 and the death of Aaron's sons in Leviticus 10. I also suggest that the angel-eunuch analogy can help us understand the psychological impact of androgen deprivation therapy on modern prostate cancer patients. Appreciating this analogy can help prostate cancer patients accept and adapt to the changes they experience.

Potential benefits of intermittent androgen suppression therapy in the treatment of prostate cancer: a systematic review of the literature

CONTEXT

The well-known side-effect profile of androgen-deprivation therapy (ADT) has significant quality-of-life (QoL) implications. Intermittent androgen deprivation (IAD) alternates androgen blockade with treatment cessation to allow hormonal recovery between treatment cycles, thus potentially improving tolerability and QoL.

OBJECTIVE

To evaluate available evidence regarding the efficacy and tolerability of IAD and assess its value in the treatment of prostate cancer (PCa).

EVIDENCE ACQUISITION

Key phase 2/3 clinical trials of IAD in PCa published within the last 10 yr were identified on Medline using the terms prostatic neoplasms [MeSH], intermittent androgen suppression, intermittent hormonal deprivation, intermittent androgen deprivation, and intermittent hormonal therapy. Abstracts from trials reported at 2008-2009 conferences were also included.

EVIDENCE SYNTHESIS

Data from 19 phase 2 studies are discussed with respect to prostate-specific antigen values for treatment suspension/reinitiation, treatment regimens, cycle lengths, testosterone normalisation, and tolerability. Outcome data were promising: Most trials reported an improvement in QoL during the off-therapy periods. Interim data from eight phase 3 trials comparing IAD and continuous androgen deprivation (CAD) support the phase 2 results. IAD generally showed comparable efficacy to CAD with respect to various outcomes, including biochemical progression, progression-free survival, and overall survival. However, IAD was significantly better than CAD with respect to 3-yr risk of progression in one study, and it demonstrated tolerability benefits, particularly with respect to sexual function. Patients most likely to benefit from IAD and factors predictive of poor response are also discussed.

CONCLUSIONS

IAD seems to be as effective as CAD while showing tolerability and QoL advantages, especially recovery of sexual potency; however, there are as yet insufficient data to determine whether IAD has the potential to prevent or reverse the long-term complications associated with ADT.

Management of complications of androgen deprivation therapy in the older man

Prostate cancer is the most common malignancy in older men. With the aging of the population, the number of older men with prostate cancer will grow rapidly. Androgen deprivation therapy (ADT) is the mainstay of treatment for men with systemic disease and is increasingly utilized as primary therapy or in combination with other therapies for localized disease. Side effects of therapy are multifold and include hot flashes, osteoporosis, and adverse psychological and metabolic effects. Recent research has illustrated that ADT can negatively impact the functional, cognitive, and physical performance of older men. Patients with prostate cancer, despite recurrence of the disease, have a long life expectancy and may be subjected to the side effects of ADT for many years. This review highlights the complications of ADT and approaches to management. We also provide recommendations for assessment and management of ADT complications among the most vulnerable and frail older male patients.

Cognitive and mood changes in men undergoing intermittent combined androgen blockade for non-metastatic prostate cancer

PURPOSE

Men with prostate-specific antigen (PSA)-only relapse of prostate cancer after primary therapy are generally fully functional and asymptomatic with a life expectancy of up to 10 or more years. Androgen deprivation therapy (ADT) is a common treatment option. This study examined mood and cognitive changes in otherwise healthy men with prostate cancer prior to, during and after ADT.

EXPERIMENTAL DESIGN

Twenty hormone naïve, eugonadal prostate cancer patients without evidence of metastases and with a rising PSA were treated with intermittent ADT consisting of 9 months of complete androgen blockade (CAB) achieved with combined leuprolide and flutamide followed by an 'off treatment' period. Cognitive function tests and mood measures were administered at baseline, after 3 and 9 months of ADT and after 3 months of no treatment. Twenty healthy control patients without prostate cancer range matched for age and education were tested at the same time intervals.

RESULTS

ADT patients evidenced a significant decline in spatial reasoning, spatial abilities and working memory during treatment compared with baseline. No changes were noted for measures of verbal or spatial memory, selective attention or language. Significant changes in self-rated mood such as increased depression, tension, anxiety, fatigue and irritability were evident during treatment compared with baseline for ADT patients. No significant changes in either cognitive tests or mood measures were noted for the healthy control group.

CONCLUSIONS

These findings, suggest that 9 months of combined androgen blockade may result in some adverse changes in cognition and mood. However, many but not all of these changes can return to baseline after cessation of ADT.

Prostaglandin E2 regulates tumor angiogenesis in prostate cancer

In cancer management, the cyclooxygenase (COX)-targeted approach has shown great promise in anticancer therapeutics. However, the use of COX-2 inhibitors has side effects and health hazards; thus, targeting its major metabolite prostaglandin E(2) (PGE(2))-mediated signaling pathway might be a rational approach for the next generation of cancer management. Recent studies on several in vitro and in vivo models have revealed that elevated expression of COX-2 correlates with prostate tumor growth and angiogenesis. In this study, we have shown the in-depth molecular mechanism and the PGE(2) activation of the epidermal growth factor receptor and beta3 integrin through E prostanoid 2 (EP2)-mediated and EP4-mediated pathways, which lead to activator protein-1 (AP-1) activation. Moreover, PGE(2) also induces activating transcription factor-4 (ATF-4) activation and stimulates cross-talk between ATF-4 and AP-1, which is unidirectional toward AP-1, which leads to the increased expressions of urokinase-type plasminogen activator and vascular endothelial growth factor and, eventually, regulates prostate tumor cell motility. In vivo Matrigel angiogenesis assay data revealed that PGE(2) induces angiogenesis through EP2 and EP4. Human prostate cancer specimen analysis also supported our in vitro and in vivo studies. Our data suggest that targeting PGE(2) signaling pathway (i.e., blocking EP2 and EP4 receptors) might be a rational therapeutic approach for overcoming the side effects of COX-2 inhibitors and that this might be a novel strategy for the next generation of prostate cancer management.

The social context for psychological distress from iatrogenic gynecomastia with suggestions for its management

INTRODUCTION

Gynecomastia (breast development in males) is a side effect of androgen deprivation therapy (ADT) for prostate cancer (PCa). Medical interventions to prevent or treat gynecomastia carry risk of additional detrimental side effects. However, untreated gynecomastia can be physically uncomfortable and psychologically distressing. Shame from gynecomastia can lead patients to stop otherwise beneficial exercise.

AIMS

Our first aim is to explore the social context for gynecomastia and how it is interpreted by men with the condition, as well as by others, both male and female. Subsequently, we use our understanding of why gynecomastia is psychologically distressing to propose psychosocial interventions that could help men accept this side effect of ADT.

METHODS

We draw on academic literature, media accounts, and web-based testimonials from men with gynecomastia, to understand how gynecomastia is perceived by both patients and the medical community. We examine these resources in light of gynecomastia's impact on sex roles, sexuality, and gender identity issues.

MAIN OUTCOME MEASURES

By exploring what breasts in a male mean to the individual, we produce an understanding of the social context for distress from gynecomastia. From this understanding, we derive hypotheses about who might be most distressed from gynecomastia and strategies for alleviating this distress.

RESULTS

The shame and stigma of gynecomastia is linked to the objectification of women. We suggest that men fear that their breasts will marginalize and subordinate them within gender hierarchies. There is little evidence that breasts on a male erotically attract either men or women. Novel options for living with gynecomastia are contrasted with medicalized strategies including mastectomy.

CONCLUSION

Assessment instruments need to be developed to identify patients most likely to experience distress from gynecomastia and seek out medical interventions. Surgical, radiological, or pharmacological interventions may not be universally necessary if greater acceptance of gynecomastia is made available through psychosocial support programs. For example, PCa patients may learn to accept gynecomastia through reconceptualizing their breasts as autoerotic. Support programs modeled on those of the breast cancer community, including Encore and dragon boat racing, may also help to build communities to serve patients with gynecomastia while defending individuals against shame, isolation, and loss of self-esteem.

Multidisciplinary management of bone complications in prostate cancer and optimizing outcomes of bisphosphonate therapy

Prostate cancer is the second most common cancer diagnosed in men worldwide and, although advances in treatment options have extended the overall survival of these patients, bone health issues remain a challenge throughout the continuum of care. Patients with prostate cancer are at high risk of skeletal complications from bone metastases and bone loss induced by cancer treatments, such as androgen-deprivation therapy. The preservation of skeletal health might require the cooperation of urologists, oncologists, pain specialists, and other physicians specializing in the treatment of prostate cancer. Complications resulting from bone loss and bone metastases can result in increased risk of fracture and death. Implementation of a multidisciplinary approach for the management of bone health can, therefore, provide clinically meaningful benefits to patients with skeletal complications. The early diagnosis and treatment of bone loss and bone metastases with bisphosphonates are critical for the maintenance of skeletal wellness and prevention of bone complications in patients with prostate cancer.