Use of neoadjuvant and adjuvant therapy to prevent or delay recurrence of prostate cancer in patients undergoing surgical treatment for prostate cancer

Cancer and Leukemia Group B 90203 (Alliance): Radical Prostatectomy With or Without Neoadjuvant Chemohormonal Therapy in Localized, High-Risk Prostate Cancer

PURPOSE

Radical prostatectomy (RP) alone is often inadequate in curing men with clinically localized, high-risk prostate cancer (PC). We hypothesized that chemohormonal therapy (CHT) with androgen-deprivation therapy plus docetaxel before RP would improve biochemical progression-free survival (BPFS) over RP alone.

PATIENTS AND METHODS

Men with clinically localized, high-risk PC were assigned to RP alone or neoadjuvant CHT with androgen deprivation plus docetaxel (75 mg/m² body surface area every 3 weeks for 6 cycles) and RP. The primary end point was 3-year BPFS. Biochemical failure was defined as a serum prostate-specific antigen level > 0.2 ng/mL that increased on 2 consecutive occasions that were at least 3 months apart. Secondary end points included 5-year BPFS, overall BPFS, local recurrence, metastasis-free survival (MFS), PC-specific mortality, and overall survival (OS).

RESULTS

In total, 788 men were randomly assigned. Median follow-up time was 6.1 years. The overall rates of grade 3 and 4 adverse events during chemotherapy were 26% and 19%, respectively. No difference was seen in 3-year BPFS between neoadjuvant CHT plus RP and RP alone (0.89 v 0.84, respectively; 95% CI for the difference, -0.01 to 0.11; P = .11). Neoadjuvant CHT was associated with improved overall BPFS (hazard ratio [HR], 0.69; 95% CI, 0.48 to 0.99), improved MFS (HR, 0.70; 95% CI, 0.51 to 0.95), and improved OS (HR, 0.61; 95% CI, 0.40 to 0.94) compared with RP alone.

CONCLUSION

The primary study end point, 3-year BPFS, was not met. Although some improvement was seen in secondary end points, any potential benefit must be weighed against toxicity. Our data do not support the routine use of neoadjuvant CHT and RP in patients with clinically localized, high-risk PC at this time.

Statins and prostate cancer recurrence following radical prostatectomy or radiotherapy: a systematic review and meta-analysis

BACKGROUND

In this meta-analysis, we evaluated associations between statins and recurrence-free survival (RFS) following treatment of localized prostate cancer, with attention to potential benefits among patients treated primarily with radiotherapy (RT) versus radical prostatectomy.

PATIENTS AND METHODS

We identified original studies examining the effect of statins on men who received definitive treatment of localized prostate cancer using a systematic search of the PubMed and EMBASE databases through August 2012. Our search yielded 17 eligible studies from 794 references; 13 studies with hazard ratios (HRs) for RFS were included in the formal meta-analysis.

RESULTS

Overall, statins did not affect RFS (HR 0.90, 95% CI 0.74-1.08). However, in RT patients (six studies), statins were associated with a statistically significant improvement in RFS (HR 0.68; 95% CI 0.49-0.93); this benefit was not observed in radical prostatectomy patients (seven studies). Sensitivity analyses suggested that primary treatment modality may impact the effect of statins on prostate cancer recurrence.

CONCLUSIONS

Our meta-analysis suggests a potentially beneficial effect of statins on prostate cancer patients treated with RT but not among radical prostatectomy patients. Although limited by the lack of randomized data, these results suggest that primary treatment modality should be considered in future studies examining associations between statins and oncologic outcomes.

Parameters derived from the postoperative decline in ultrasensitive PSA improve the prediction of radical prostatectomy outcome

PURPOSE

Contemporary tools estimating increased risk of prostate cancer (PCa) relapse after radical prostatectomy (RP) are far from perfect and there has been an intensive search for additional predictive variables. We aimed to explore whether the parameters of postoperative ultrasensitive prostate-specific antigen (PSA) decline provide additional information for predicting PCa progression.

METHODS

A total of 319 consecutive men, with at least 2 years of follow-up after RP for clinically localized PCa were subjected to this study. Intensive postoperative measurements of ultrasensitive PSA resulted in total of 4028 PSA values available for statistical evaluation. Biochemical recurrence (BCR) was defined as PSA ≥0.2 ng/ml. The accuracy of predictive models was quantified with the area under the curve.

RESULTS

Over a median follow-up of 43 months (24-99 months), 107 patients (34%) experienced BCR after RP. In patients with BCR, significantly higher values of PSA nadir (p < 0.001) and a decreased time interval from surgery to reach PSA nadir (p < 0.001) were observed. A multivariable Cox regression model confirmed that PSA nadir >0.01 ng/ml (HR 6.01, 95% CI: 3.89-9.52) and time to PSA nadir <3 months (HR 2.86, 95% CI: 1.74-5.01) were independent predictors of BCR. The inclusion of PSA nadir and the time to PSA nadir into the model resulted in improvement of predictive accuracy by 16% over the model designed on the basis of established parameters.

CONCLUSIONS

Our results demonstrate that the level of PSA nadir and the time to PSA nadir determined by ultrasensitive assay significantly improve the identification of patients who are at high risk of disease recurrence after RP.

Neoadjuvant hormonal deprivation for patients undergoing radical prostatectomy

The purpose of this study is to evaluate the therapeutic effect of radical prostatectomy combined with preoperative neoadjuvant hormonal ablation therapy for prostate cancer (PCa). In this study, a total of 31 patients with local PCa underwent radical prostatectomy; of these, 12 patients underwent preoperative hormonal deprivation with a combination of goserelin and flutamide for a period of 5.6 months. Data regarding clinical characteristics were compared between the neoadjuvant therapy and radical prostatectomy groups. A total of 31 patients received pelvic lymph node clearance, and the rate of positive lymph nodes was 12.9% (4/31). Serum prostate-specific antigen (PSA) was 8.9 +/- 1.2 microg L(-1) after the neoadjuvant therapy and 0.4 +/- 0.3 microg L(-1) one month after the radical prostatectomy. There were significant differences in the positive surgical margins, seminal vesicle invasion and lymph node metastasis between the neoadjuvant therapy group (n = 12) and the radical prostatectomy group (n = 19, P < 0.01). The resulsts indicates that preoperative hormonal deprivation induced by goserelin and flutamide can decrease clinical and pathological staging, but assessment of its influence on long-term prognosis requires further study.

Chemokine markers predict biochemical recurrence of prostate cancer following prostatectomy

PURPOSE

Stratifying patients who have a high risk of prostate cancer recurrence following prostatectomy can potentiate the use of adjuvant therapy at an early stage. Inflammation has emerged as a mediator of prostate cancer metastatic progression. We hypothesized that chemokines can be biomarkers for distinguishing patients with high risk for biochemical recurrence of prostate cancer.

EXPERIMENTAL DESIGN

In a nested case-control study, 82 subjects developed biochemical recurrence within 5 years of prostatectomy. Prostate tissues from 98 age-matched subjects who were recurrence-free following prostatectomy in the same period were the controls. A high-throughput lectin-based enrichment of prostate tissue enabled multiplex ELISA to identify the expression of three chemokines to discriminate the two patient populations.

RESULTS

The expression of CX3CL1 and IL-15 in prostate tissue was associated with 5-year biochemical recurrence-free survival following prostatectomy. However, the expression of chemokine ligand 4 (CCL4) was associated with biochemical recurrence. Multivariable logistic regression model combining preoperative prostate-specific antigen, Gleason score, surgical margin, and seminal vesicle status with the three chemokines doubled the specificity of prediction at 90% sensitivity compared with use of the clinicopathologic variables alone (P < 0.0001). Survival analysis yielded a nomogram that supported the use of CX3CL1, IL-15, and CCL4 in predicting 1-, 3-, and 5-year recurrence-free survival after prostatectomy.

CONCLUSIONS

Each of the three chemokines can serve as independent predictors of biochemical recurrence. However, the combination of chemokine biomarkers plus clinicopathologic variables discriminated prostatectomy subjects for the probability of biochemical recurrence significantly better than clinicopathologic variables alone.

Improved prediction of disease relapse after radical prostatectomy through a panel of preoperative blood-based biomarkers

PURPOSE

The preoperative blood levels of biomarkers may allow accurate identification of patients who are likely to fail radical prostatectomy as a first-line therapy for localized prostate cancer, thereby allowing more efficient delivery of neoadjuvant and adjuvant therapy. The aim of this study was to determine the added value of biomarkers relative to established predictors of biochemical recurrence, such as clinical stage, biopsy Gleason sum, and preoperative prostate-specific antigen.

EXPERIMENTAL DESIGN

The preoperative plasma levels of transforming growth factor-beta1 (TGF-beta1), interleukin-6 (IL-6), soluble IL-6 receptor (sIL-6R), vascular endothelial growth factor (VEGF), vascular cell adhesion molecule-1 (VCAM-1), endoglin, urokinase-type plasminogen activator (uPA), plasminogen activator inhibitor-1, and uPA receptor were measured with the use of commercially available enzyme immunoassays in 423 consecutive patients treated with radical prostatectomy and bilateral lymphadenectomy for clinically localized prostate cancer. Multivariable models were used to explore the gain in the predictive accuracy of the models. This predictive accuracy was quantified by the concordance index statistic and was validated with 200 bootstrap resamples.

RESULTS

In standard multivariable analyses, TGF-beta1 (P < 0.001), sIL-6R (P < 0.001), IL-6 (P < 0.001), VCAM-1 (P < 0.001), VEGF (P = 0.008), endoglin (P = 0.002), and uPA (P < 0.001) were associated with biochemical recurrence. The multivariable model containing standard clinical variables alone had an accuracy of 71.6%. The addition of TGF-beta1, sIL-6R, IL-6, VCAM-1, VEGF, endoglin, and uPA increased the predictive accuracy by 15% to 86.6% (P < 0.001) and showed excellent calibration.

CONCLUSIONS

A nomogram based on these biomarkers improves the accuracy of standard predictive models and could help counsel patients about their risk of biochemical recurrence following radical prostatectomy.

Identification of Patients With Prostate Cancer Who Benefit From Immediate Postoperative Radiotherapy: EORTC 22911

Purpose

The randomized controlled European Organisation for Research and Treatment of Cancer (EORTC) trial 22911 studied the effect of radiotherapy after prostatectomy in patients with adverse risk factors. Review pathology data of specimens from participants in this trial were analyzed to identify which factors predict increased benefit from adjuvant radiotherapy.

Patients and Methods

After prostatectomy, 1,005 patients with stage pT3 and/or positive surgical margins were randomly assigned to a wait-and-see (n = 503) and an adjuvant radiotherapy (60 Gy conventional irradiation) arm (n = 502). Pathologic review data were available for 552 patients from 11 participating centers. The interaction between the review pathology characteristics and treatment benefit was assessed by log-rank test for heterogeneity (P < .05).

Results

Margin status assessed by review pathology was the strongest predictor of prolonged biochemical disease-free survival with immediate postoperative radiotherapy (heterogeneity, P < .01): by year 5, immediate postoperative irradiation could prevent 291 events/1,000 patients with positive margins versus 88 events/1,000 patients with negative margins. The hazard ratio for immediate irradiation was 0.38 (95% CI, 0.26 to 0.54) and 0.88 (95% CI, 0.53 to 1.46) in the groups with positive and negative margins, respectively. We could not identify a significant impact of the positive margin localization.

Conclusion

Provided careful pathology of the prostatectomy is performed, our results suggest that immediate postoperative radiotherapy might not be recommended for prostate cancer patients with negative surgical margins. These findings require validation on an independent data set.

Preoperative Plasma HER2 and Epidermal Growth Factor Receptor for Staging and Prognostication in Patients with Clinically Localized Prostate Cancer

PURPOSE

Human epidermal growth factor receptor-2 (HER2) and epidermal growth factor receptor (EGFR) expression have been associated with disease progression in patients with prostate cancer. We tested the hypothesis that plasma levels of HER2 and/or EGFR are associated with prostate cancer stage and prognosis in patients with clinically localized disease.

EXPERIMENTAL DESIGN

We measured preoperative plasma HER2 and EGFR levels using commercially available ELISAs on banked plasma from 227 patients treated with radical prostatectomy and bilateral lymphadenectomy for clinically localized prostate adenocarcinoma.

RESULTS

Median preoperative plasma EGFR and HER2 levels were 31.4 ng/mL (interquartile range, 19.2 ng/mL) and 10.0 ng/mL (interquartile range, 2.7 ng/mL), respectively. HER2 was elevated in patients with seminal vesicle invasion (P = 0.033). In separate multivariate analyses that adjusted for the effects of standard preoperative predictors, lower EGFR, higher HER2, and higher HER2/EGFR ratio were associated with prostate-specific antigen (PSA) progression (P = 0.003, P < 0.001, and P < 0.001, respectively). In separate multivariate analyses that adjusted for the effects of standard postoperative predictors, lower EGFR and higher HER2/EGFR ratio were associated with PSA progression (P = 0.027 and P < 0.001, respectively). Among the patients who experienced PSA progression, HER2 was significantly higher (P = 0.023) and EGFR was lower (P = 0.04) in those with features of aggressive disease (i.e., development of metastasis, PSA doubling time <10 months, and/or failure to respond to local salvage radiation therapy).

CONCLUSION

Preoperative plasma HER2 and EGFR were associated with prostate cancer progression after radical prostatectomy. Plasma HER2 and EGFR may provide a tool for predicting long-term recurrence-free survival and early metastasis.

Early effects of pharmacological androgen deprivation in human prostate cancer

OBJECTIVES

To assess the early histological effects of pharmacological androgen deprivation (AD), which have been assessed only over longer periods, as surgical castration leads rapidly to diminished cell proliferation and enhanced cell death within the prostate.

PATIENTS AND METHODS

With Institutional Review Board approval, 35 patients were randomly assigned (seven in each group) to receive 0, 7, 14, 21 and 28 days of AD (flutamide, 250 mg orally three times/day, and one injection with leuprolide acetate 7.5 mg) before radical prostatectomy. The surgical specimens were assessed by conventional histology and immunohistochemistry, while macroarray analysis and quantitative real-time polymerase chain reaction (QRT-PCR) were used to examine gene expression.

RESULTS

There were morphological changes within the prostatic tissues as early as 7 days after initiating AD, similar to the response to castration. There was tumour cell vacuolization indicating cellular injury, glandular atrophy and mononuclear cell infiltration as prominent and progressive effects but, by contrast with castration studies, there were no changes in epithelial proliferation or apoptosis. Macroarray analysis, validated by QRT-PCR and immunohistochemistry, showed up-regulation of numerous and potentially counter-effective genes involved in the cell cycle and apoptosis.

CONCLUSIONS

Pharmacological AD induces significant involution within prostatic tissues over 7-28 days, but allows the persistence of some viable tumour cells capable of proliferation.

Management of prostate cancer. Part 2: localized and locally advanced disease

Prostate cancer is the most prevalent nondermatological malignancy affecting men in the Western world. An increase in public awareness has led to earlier detection. Accepted treatments for localized prostate cancer include active surveillance, radical prostatectomy, interstitial brachytherapy, external beam radiotherapy and watchful waiting. The authors discuss the rationale for the different approaches together with outcomes including toxicity. Novel approaches are also explored. The management of locally advanced disease has long been a challenge and the evolving evidence is reviewed.

Radical prostatectomy for clinical T4 prostate cancer

BACKGROUND

Occasionally, patients with clinical T4 (cT4) prostate cancer undergo surgery. Published data on outcomes after radical prostatectomy (RP) in patients with such advanced stage disease and on the impact of adjuvant radiation therapy (RT) and hormone therapy (HT) are nonexistent.

METHODS

Data from the Surveillance Epidemiology and End Results (SEER) data base were reviewed for the 7-year period from 1995 to 2001. Specifically, data were analyzed for 1093 patients with cT4, lymph node-negative or lymph node-positive, M0 prostate cancer without distant lymph node involvement or a history of other cancer. Using follow-up data through 2002, postdiagnosis survival was examined in 5 treatment groups: radical prostatectomy (RP) either alone or in combination with other therapy, radiation therapy (RT) alone, hormone therapy (HT) alone, RT plus HT, and no treatment (NT). All results were expressed as 1-year, 3-year, and 5-year observed survival and corresponding relative survival. Mortality across treatment categories was compared by using a Cox proportionate hazards model controlling for age, year of diagnosis, race, tumor grade, regional lymph node involvement, clinical tumor extension, and SEER registry.

RESULTS

Observed and relative survival rates were lowest among patients who received NT and highest among patients who underwent RP. Adding adjuvant RT or HT to RP conferred no survival benefit. Multivariate survival analyses revealed a significant increase in mortality among HT-only patients and among patients who received NT compared with patients who underwent RP. The differences in survival among treatment types were most pronounced in a relatively small group of patients who had positive regional lymph node extension. In all other patients, the results suggested a modest (but not significant) improvement in survival after RT plus HT.

CONCLUSIONS

SEER data revealed that patients who underwent RP for cT4 prostate cancer had increased survival compared with patients who received RT alone or HT alone and had a survival comparable to that of patients who received RT plus HT. The benefit of RP appears to be limited to a relatively small subset of patients who have regional lymph node extension.

Transforming growth factor beta and prostate cancer

The TGF-beta superfamily is the most versatile considering the ability of its members to regulate proliferation, growth arrest, differentiation, and apoptosis of prostatic stromal and epithelial cells as well as the formation of osteoblastic metastases. TGF-beta mediated action in prostate cells follows a complex signaling pathway from binding and phosphorylation of receptor type II to the TbetaRI kinase to Smad activation, resulting in ligand-induced transcription. TGF-beta as an indirect tumor suppressor, its role of regulating tumor induction, as well as tumor suppression depending on the tissue microenvironment merits further exploration. The rationale for targeting growth factors and their receptors for therapeutic intervention is based upon the fact that these proteins represent the most proximate component of the signal transduction cascade. The alternate targeting of intracellular effectors in the signal transduction may be thwarted by cross talk between signaling pathways (such as the Smads in a dynamic interplay with the androgen receptor). TGF-beta within the context of its well-documented apoptosis regulatory actions in the prostate and the significance its key receptor TbetaRII as a potential tumor suppressor, provides a highly attractive candidate for such targeting with high clinical significance for the treatment and diagnosis of prostate cancer.

Sociodemographic factors associated with postprostatectomy radiotherapy

PURPOSE

To determine if nonclinical factors affect the use of adjuvant radiation therapy after surgical resection of the prostate gland.

METHODS

Using the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) public use data files, we identified men with localized/regional prostate cancer who underwent postprostatectomy radiotherapy within 4 months of surgery. We used 2000 Census information to ascribe a median education and income level to these men based on the county of residence and ethnicity.

RESULTS

Of 34,763 men who underwent surgical resection, 1549 received postprostatectomy radiotherapy. Those with higher tumor grade and from certain geographic regions (Seattle and Hawaii) had significantly higher rates of radiotherapy while being older and from other geographic regions (Detroit, Utah, and New Mexico) was protective. The use of additional radiation therapy was not affected by ethnicity, income level, or educational attainment.

CONCLUSIONS

We found no socioeconomic or demographic disparities in the receipt of postprostatectomy radiotherapy. Geographic variation in postprostatectomy radiotherapy may be explained by limited evidence supporting its use in clinical practice.

Surgical management of prostate cancer: Advances based on a rational approach to the data

The management of localised prostate cancer has undergone important changes in the past two decades, with major improvements in surgical technique, a greater emphasis on structured assessment of quality of life, and a greater attempt to tailor treatment to biological risk. Disease diagnosis is predicated on identification of demographic risk factors, serum levels of prostate-specific antigen and its derivatives, and extended biopsy techniques. Surgical removal of the prostate may be accomplished by open or minimally invasive techniques and in experienced hands results in good functional outcomes a high rate of cure for those with organ confined disease. Radical prostatectomy is also appropriate in selected patients with locally advanced disease and after failed radiation therapy.

Therapieinduzierte Tumorregression des Prostatakarzinoms

Regressive changes following pretreatment of prostate cancer may represent a big challenge for the histopathologist not familiar with the assessment of pretreated specimens. Characteristic changes after antiandrogen therapy in non-malignant prostate tissue include glandular atrophy, basal cell prominence and/or basal cell hyperplasia as well as a hypercellular stroma. Morphologic changes in prostate cancer include cytoplasmic clearing and vacuolization, nuclear pyknosis and even complete cell destruction. On the glandular level, changes are characterized by various degrees of involutional changes, ranging from almost non-regressive tumor glands to complete glandular disruption with scattered isolated tumor cells dispersed in the stroma. Knowledge about these changes, the selective use of immunohistochemistry as well as a very thorough histological workup is essential for the correct assessment of these specimens.