Neoadjuvant androgen deprivation for prostate volume reduction: the optimal duration in prostate cancer radiotherapy

Effect of androgen deprivation therapy after radical prostatectomy on urinary symptoms

INTRODUCTION

Salvage intermittent ADT has been demonstrated to be a potentially effective treatment option for BCR following RP. Although ADT improves urinary symptoms by reducing prostate volume, no studies have been conducted to investigate its effect on urinary symptoms after RP. We retrospectively examined changes in urinary symptoms in patients who developed BCR after RP and underwent salvage intermittent ADT.

METHODS

OABSS, IPSS, and ICIQ-SF scores were compared before ADT, 3 months after the start of ADT, 12 months after the start of ADT, at the end of ADT, and 1 year after the end of ADT in patients who received intermittent ADT following RARP. In addition, changes in urinary symptoms were compared between the group with pre-ADT testosterone levels <400 ng/dL (low testosterone group) and the group with levels ⩾400 ng/dL (high testosterone group).

RESULTS

Three months after the initiation of ADT, the IPSS total score, IPSS urine storage score, and ICIQ-SF score were significantly higher compared to their pre-treatment levels. In the low testosterone group, the ICIQ-SF score was significantly worse only at 12 months after the start of ADT compared to before the start of ADT. In the high testosterone group, the IPSS total score, storage IPSS score, and ICIQ-SF score were significantly higher at both 3 and 12 months after initiating ADT compared to their pre-treatment levels.

CONCLUSIONS

ADT for BCR after RARP has been shown to significantly worsen urinary storage symptoms while not improving voiding symptoms, particularly in patients with high testosterone levels pre-ADT.

Online correction of intrafraction motion during volumetric modulated arc therapy for prostate radiotherapy using fiducial-based kV imaging: A cohort study quantifying the frequency of shifts and analysis of men at highest risk

BACKGROUND

Various methods exist to correct for intrafraction motion (IFM) of the prostate during radiotherapy. We sought to characterize setup corrections in our practice informed by the TrueBeam Advanced imaging package, and analyze factors associated with IFM.

METHODS

132 men received radiation therapy for prostate cancer with a volumetric modulated arc therapy technique. All patients underwent planning CT immediately following transrectal placement of 3 fiducial markers. The most common RT course was 20 fractions (range: 17-44). Triggered kV images were acquired every 15 seconds over 2-3 full arcs using an onboard imaging system. IFM correction was considered when if any two fiducial markers in a single kV image were observed to be outside beyond a 3 mm tolerance margin. A manual 2D/3D match was performed using the fiducial markers from the single triggered kV image to obtain a suggested couch shift. Shift data for three (x, y, z) planes were extracted from the record and verify system and expressed as a single 3-dimensional translation. Shift percent (SP) was defined as the number of instances of an intrafraction correction divided by the total number of fractions for a given patient.

RESULTS

Over 2659 fractions of radiation, IFM was observed and corrected for 582 times across 463 (17%) fractions, and at least one shift was made over the course of treatment in 77% of men. Univariate analysis revealed that larger rectal volume or width, smaller prostate volume, and use of ADT were associated with SP > 20% (p < 0.05). Men with a rectal width >3.6 cm were more likely to have IFM corrected (SP > 20% 47% vs 18%, p = 0.0016). On multivariate analysis, only rectal volume and width were associated with IFM.

CONCLUSIONS

In this cohort study, 17% of fractions were interrupted to apply at least one couch shift. Men treated with shorter courses of therapy, such as stereotactic body radiation therapy, or men at high risk for IFM (e.g. larger rectal size) may warrant more careful consideration regarding the implications of IFM.

The Role of Transurethral BPH Surgeries in Management of Urinary Symptoms in Prostate Cancer Patients, Narrative Review

PURPOSE OF REVIEW

Prostate cancer and benign prostate hyperplasia (BPH) are two ubiquitous pathologies that may coexist. A significant percentage of patients with different stages of prostate cancer suffer lower urinary tract symptoms (LUTS) due to associated BPH. We aimed to review the literature regarding the role of transurethral surgeries in the management of prostate cancer patients and the different available management options.

RECENT FINDINGS

The evidence in literature for the use of BPH surgeries in prostate cancer patients is based mainly on low-quality retrospective studies. In patients on active surveillance, BPH surgeries are beneficial in relieving LUTS without oncological risk and can eliminate the contribution of adenoma to PSA level. In patients with advanced prostate cancer, palliative BPH surgery can relieve LUTS and urinary retention with unclear oncological impact; however some reports depict that the need for BPH surgery in advanced prostate cancer is associated with poorer prognosis. In patients receiving radiotherapy, various studies showed that transurethral resection of prostate (TURP) is associated with increased radiotoxicity despite some recent reports encouraging the use of Holmium Laser Enucleation of the Prostate (HoLEP) to improve urinary symptom scores before radiotherapy. The most commonly reported techniques utilized are TURP, photoselective vaporization of prostate (PVP) and HoLEP. The use of BPH surgery is justified for relieving LUTS in selected prostate cancer patients on active surveillance or in advanced stages, however the use in the pre-radiotherapy settings remains controversial. Future prospective and randomized controlled trials are required for validating the benefits and assessing potential hazards.

Impact of neoadjuvant androgen deprivation therapy on toxicity in intensity-modulated radiation therapy for prostate cancer

This study aimed to compare toxicities, prostate volume and dosimetry, between patients who underwent intensity-modulated radiation therapy (IMRT) combined with ≥3 months of neoadjuvant androgen deprivation therapy (NADT) and those without NADT for prostate cancer. In total, 449 patients with intermediate- and high-risk prostate cancer received 78 Gy IMRT in 39 fractions, of which 129 were treated without any ADT (non-ADT group) and 320 with NADT ≥3 months (NADT group). Adverse events and dose-volume indices were compared between the two groups retrospectively. The NADT group had a lower rate of acute grade 2 gastrointestinal (GI) toxicities (17% vs 25%, P = 0.063) and late grade 2 GI toxicities (P = 0.055), including a significantly lower rate of late grade 2 rectal hemorrhage (P = 0.033), compared with the non-ADT group. There were no cases of late grade 3 or higher GI toxicities. The average volume of the prostate in the NADT group was 38% smaller than that in the non-ADT group (43.7 vs 27.0 cm3, P < 0.001). Bladder V40Gy and V50Gy, and rectum V40Gy, V50Gy, V60Gy and V70Gy were significantly smaller in the NADT group. In the NADT group, no significant difference was observed in adverse events or dosimetry between the subgroups with NADT ≥12 and <12 months. Acute and late rectal toxicities were reduced by NADT within ≥3 months in accordance with reduced prostate volume and improved rectal dosimetry. This suggests a merit of administering neoadjuvant ADT ≥3 months for reducing rectal toxicities.

Stereotactic Body Radiation Therapy for the Curative Treatment of Prostate Cancer in Ultralarge (≥100 cc) Glands

PURPOSE

Historically, toxicity concerns have existed in patients with large prostate glands treated with radiation therapy, particularly brachytherapy. There are questions whether this risk extends to stereotactic body radiation therapy (SBRT). In this retrospective review, we examine clinical outcomes of patients with prostate glands ≥100 cc treated curatively with SBRT.

METHODS AND MATERIALS

We retrospectively analyzed a large institutional database to identify patients with histologically confirmed localized prostate cancer in glands ≥100 cc, who were treated with definitive-robotic SBRT. Prostate volume (PV) was determined by treatment planning magnetic resonance imaging. Toxicity was measured using Common Terminology Criteria for Adverse Events, version 5.0. Many patients received the Expanded Prostate Cancer Index Composite Quality of Life questionnaires. Minimum follow-up (FU) was 2 years.

RESULTS

Seventy-one patients were identified with PV ≥100 cc. Most had grade group (GG) 1 or 2 (41% and 37%, respectively) disease. All patients received a total dose of 3500 to 3625 cGy in 5 fractions. A minority (27%) received androgen deprivation therapy (ADT), which was used for gland size downsizing in only 10% of cases. Nearly half (45%) were taking GU medications for urinary dysfunction before RT. Median toxicity FU was 4.0 years. Two-year rates of grade 1+ genitourinary (GU), grade 1+ gastrointestinal (GI), and grade 2+ GU toxicity were 43.5%, 15.9%, and 30.4%, respectively. Total grade 3 GU toxicities were very limited (2.8%). There were no grade 3 GI toxicities. On logistic regression analysis, pretreatment use of GU medications was significantly associated with increased rate of grade 2+ GU toxicity (odds ratio, 3.19; P = .024). Furthermore, PV (analyzed as a continuous variable) did not have an effect on toxicity, quality of life, or oncologic outcomes.

CONCLUSIONS

With early FU, ultra large prostate glands do not portend increased risk of high-grade toxicity after SBRT but likely carry an elevated risk of low-grade GU toxicity.

Neoadjuvant versus Concurrent Androgen Deprivation Therapy in Localized Prostate Cancer Treated with Radiotherapy: A Systematic Review of the Literature

BACKGROUND

There is an ongoing debate on the optimal sequencing of androgen deprivation therapy (ADT) and radiotherapy (RT) in patients with localized prostate cancer (PCa). Recent data favors concurrent ADT and RT over the neoadjuvant approach.

METHODS

We conducted a systematic review in PubMed, EMBASE, and Cochrane Databases assessing the combination and optimal sequencing of ADT and RT for Intermediate-Risk (IR) and High-Risk (HR) PCa.

FINDINGS

Twenty randomized control trials, one abstract, one individual patient data meta-analysis, and two retrospective studies were selected. HR PCa patients had improved survival outcomes with RT and ADT, particularly when a long-course Neoadjuvant-Concurrent-Adjuvant ADT was used. This benefit was seen in IR PCa when adding short-course ADT, although less consistently. The best available evidence indicates that concurrent over neoadjuvant sequencing is associated with better metastases-free survival at 15 years. Although most patients had IR PCa, HR participants may have been undertreated with short-course ADT and the absence of pelvic RT. Conversely, retrospective data suggests a survival benefit when using the neoadjuvant approach in HR PCa patients.

INTERPRETATION

The available literature supports concurrent ADT and RT initiation for IR PCa. Neoadjuvant-concurrent-adjuvant sequencing should remain the standard approach for HR PCa and is an option for IR PCa.

Clinical significance of prostate volume and testosterone reduction on lower urinary tract symptoms in patients with prostate cancer undergoing androgen deprivation therapy

To investigate the effect of both prostate volume and serum testosterone changes on lower urinary tract symptoms in patients with prostate cancer undergoing androgen deprivation therapy. A total of 167 patients who received androgen deprivation therapy for prostate cancer treatment from January 2010 to August 2020 were enrolled in this retrospective study. Changes in the International Prostate Symptom Score (IPSS) in the patient groups stratified by prostate volume and the amount of testosterone reduction were assessed every 4 weeks until 12 weeks after androgen deprivation therapy initiation. Longitudinal mixed models were used to assess the adjusted effects of prostate volume and testosterone reduction on IPSS change. All mean values of IPSS-total score (IPSS-total), voiding subscore (IPSS-vs), and storage subscore (IPSS-ss) significantly decreased from baseline to week 12 in both patients with small (< 33 mL) and large (≥ 33 mL) prostates. The mean values of IPSS-total, IPSS-vs, and IPSS-ss similarly decreased in patients with large prostate with a baseline IPSS-total of ≥ 13. However, in those with small prostate, IPSS-ss specifically remained unchanged, while IPSS-total and IPSS-vs significantly decreased. In addition, only in patients with small prostate (< 33 mL), patients with lesser testosterone reduction (< Δ400 ng/dL) showed greater improvement in IPSS-ss by 7.5% compared with those with greater testosterone reduction (≥ Δ400 ng/dL). In conclusion, although androgen deprivation therapy generally improves lower urinary tract symptoms, it may worsen specifically storage symptoms in patients with relatively small prostate and greater testosterone reduction. Our finding suggests that testosterone may influence lower urinary tract symptoms in these patients.

Initial Management of Noncastrate Advanced, Recurrent, or Metastatic Prostate Cancer: ASCO Guideline Update

PURPOSE

Update all preceding ASCO guidelines on initial hormonal management of noncastrate advanced, recurrent, or metastatic prostate cancer.

METHODS

The Expert Panel based recommendations on a systematic literature review. Recommendations were approved by the Expert Panel and the ASCO Clinical Practice Guidelines Committee.

RESULTS

Four clinical practice guidelines, one clinical practice guidelines endorsement, 19 systematic reviews with or without meta-analyses, 47 phase III randomized controlled trials, nine cohort studies, and two review papers informed the guideline update.

RECOMMENDATIONS

Docetaxel, abiraterone, enzalutamide, or apalutamide, each when administered with androgen deprivation therapy (ADT), represent four separate standards of care for noncastrate metastatic prostate cancer. Currently, the use of any of these agents in any particular combination or series cannot be recommended. ADT plus docetaxel, abiraterone, enzalutamide, or apalutamide should be offered to men with metastatic noncastrate prostate cancer, including those who received prior therapies, but have not yet progressed. The combination of ADT plus abiraterone and prednisolone should be considered for men with noncastrate locally advanced nonmetastatic prostate cancer who have undergone radiotherapy, rather than castration monotherapy. Immediate ADT may be offered to men who initially present with noncastrate locally advanced nonmetastatic disease who have not undergone previous local treatment and are unwilling or unable to undergo radiotherapy. Intermittent ADT may be offered to men with high-risk biochemically recurrent nonmetastatic prostate cancer. Active surveillance may be offered to men with low-risk biochemically recurrent nonmetastatic prostate cancer. The panel does not support use of either micronized abiraterone acetate or the 250 mg dose of abiraterone with a low-fat breakfast in the noncastrate setting at this time.Additional information is available at www.asco.org/genitourinary-cancer-guidelines.

The Impact of Neoadjuvant Hormone Therapy on Surgical and Oncological Outcomes for Patients With Prostate Cancer Before Radical Prostatectomy: A Systematic Review and Meta-Analysis

Objective

This systematic study aimed to assess and compare the comprehensive evidence regarding the impact of neoadjuvant hormone therapy (NHT) on surgical and oncological outcomes of patients with prostate cancer (PCa) before radical prostatectomy (RP).

Methods

Literature searches were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using PubMed, Web of Science, Chinese National Knowledge Infrastructure, and Wanfang databases, we identified relevant studies published before July 2020. The pooled effect sizes were calculated in terms of the odds ratios (ORs)/standard mean differences (SMDs) with 95% confidence intervals (CIs) using the fixed or random-effects model.

Results

We identified 22 clinical trials (6 randomized and 16 cohort) including 20,199 patients with PCa. Our meta-analysis showed no significant differences in body mass index (SMD = 0.10, 95% CI: -0.08-0.29, p = 0.274) and biopsy Gleason score (GS) (OR = 1.33, 95% CI: 0.76-2.35 p = 0.321) between the two groups. However, the NHT group had a higher mean age (SMD = 0.19, 95% CI: 0.07-0.31, p = 0.001), preoperative prostate-specific antigen (OR = 0.47, 95% CI: 0.19-0.75, p = 0.001), and clinic tumor stage (OR = 2.24, 95% CI: 1.53-3.29, p < 0.001). Compared to the RP group, the NHT group had lower positive surgical margins (PSMs) rate (OR = 0.44, 95% CI: 0.29-0.67, p < 0.001) and biochemical recurrence (BCR) rate (OR = 0.47, 95% CI: 0.26-0.83, p = 0.009). Between both groups, there were no significant differences in estimated blood loss (SMD = -0.06, 95% CI: -0.24-0.13, p = 0.556), operation time (SMD = 0.20, 95% CI: -0.12-0.51, p = 0.219), pathological tumor stage (OR = 0.76, 95% CI: 0.54-1.06, p = 0.104), specimen GS (OR = 0.91, 95% CI: 0.49-1.68, p = 0.756), and lymph node involvement (OR = 0.76, 95% CI: 0.40-1.45, p = 0.404).

Conclusions

NHT prior to RP appeared to reduce the tumor stage, PSMs rate, and risk of BCR in patients with PCa. According to our data, NHT may be more suitable for older patients with higher tumor stage. Besides, NHT may not increase the surgical difficulty of RP.

Optimal Androgen Deprivation Therapy Combined with Proton Beam Therapy for Prostate Cancer: Results from a Multi-Institutional Study of the Japanese Radiation Oncology Study Group

Background: Androgen deprivation therapy (ADT) combined with radiation therapy benefits intermediate- and high-risk prostate cancer (PC) patients. The optimal ADT duration in combination with high-dose proton beam therapy (PBT) remains unknown. Methods: Intermediate- and high-risk PC patients treated with PBT combined with ADT for various durations were analyzed retrospectively. To assess the relationship between ADT and biochemical relapse-free (bRF) rate, Cox proportional hazards models including T stage, prostate specific antigen (PSA) level, Gleason score (GS), and total radiation dose were used. Results: In the intermediate-risk PC patients (n = 520), ADT use improved bRF (HR 0.49, 95% CI 0.26–0.93; p = 0.029), especially in those with multiple intermediate-risk factors (T2b–2c, PSA 10–20 ng/mL, and GS 7). In the high-risk PC patients (n = 555), a longer ADT duration (>6 months) conferred a benefit for bRF (HR 0.54, 95% CI 0.32–0.90; p = 0.018), which was most apparent in patients with multiple high-risk factors (T3a–4, PSA > 20 ng/mL, and GS ≥ 8) treated with ADT for ≥21 months. Conclusions: Short-term (≤6 months) ADT is beneficial for intermediate-risk PC patients, but likely unnecessary for those with a single risk factor, whereas ADT for >6 months is necessary for high-risk PC patients and ADT for ≥21 months might be optimal for those with multiple risk factors in combination of high-dose PBT.

Is prospective MRI mapping of the changes in the volume of the prostate gland in prostate cancer patients undergoing 6 months of neo-adjuvant androgen deprivation therapy a step towards a trial to determine those who may benefit from treatment intensification or extended duration?

INTRODUCTION

Neo-adjuvant androgen deprivation therapy prior to radiotherapy (RT) causes shrinkage of the prostate gland, but the changes in volume have never been mapped over time in detail, nor have the associations between volume reduction and testosterone escape or prostate-specific antigen (PSA) kinetics been determined.

METHODS

Fifty consecutive patients with prostate cancer were treated with 6 months of triptorelin prior to definitive RT. The volume of the prostate gland was measured at the outset and every 6-7 weeks thereafter using MRI scans. The volumes were calculated using a planimetric method, and inter-rater reliability was checked. Factors associated with a large initial volume and greater reductions in it were assessed.

RESULTS

The median volume at the outset was 45 cc, and the median reductions every 6 weeks thereafter were 23, 18, 9 and 5%. The inter-rater agreement was high (r > 0.9, P < 0.001). There were no baseline clinical factors associated with a high initial prostate volume, but the initial volume was associated with greater volume reduction. Testosterone escape had no effect on the reduction, and changes in volume were not reflected in PSA response kinetics.

CONCLUSIONS

Reductions in volume continue throughout a 6-month course of neo-adjuvant therapy but are greatest during the first 6 weeks. Although individualisation of the duration or intensity of the hormone treatment warrants further investigation, the role of prostate gland volume reduction remains uncertain. More detailed studies of tumour volume might be possible if the imaging required was acceptable and accessible to patients.

[Combination of radiotherapy and androgen deprivation therapy for localized prostate cancer]

Combination of radiotherapy and androgen deprivation is now considered as the standard of care for patients with a localized prostate cancer but poor prognosis factors. Two groups of randomized trials have led to this recommendation: some have compared radiotherapy alone versus hormonal treatment and radiotherapy: these trials demonstrated, now with a long follow-up, an improvement in 10-year survival for the combined treatment. Three recent trials compared androgen deprivation alone or combined with radiotherapy; a benefit in survival was also demonstrated in favour of the combination. Some questions remained concerning the optimal duration of hormonal treatment, in view of its potential side effects. Patients in the intermediate prognostic groups could receive a short-term androgen deprivation, but those with a high Gleason score must be treated with a long-term hormonal treatment. Modalities of radiotherapy, regarding volumes and dose must also be précised in the next years.

The impact of androgen deprivation therapy on setup errors during external beam radiation therapy for prostate cancer

PURPOSE

To determine whether setup errors during external beam radiation therapy (RT) for prostate cancer are influenced by the combination of androgen deprivation treatment (ADT) and RT.

MATERIALS AND METHODS

Data from 175 patients treated for prostate cancer were retrospectively analyzed. Treatment was as follows: concurrent ADT plus RT, 33 patients (19%); neoadjuvant and concurrent ADT plus RT, 91 patients (52%); RT only, 51 patients (29%). Required couch shifts without rotations were recorded for each megavoltage (MV) cone beam computed tomography (CBCT) scan, and corresponding alignment shifts were recorded as left-right (x), superior-inferior (y), and anterior-posterior (z). The nonparametric Mann-Whitney test was used to compare shifts by group. Pearson's correlation coefficient was used to measure the correlation of couch shifts between groups. Mean prostate shifts and standard deviations (SD) were calculated and pooled to obtain mean or group systematic error (M), SD of systematic error (Σ), and SD of random error (σ).

RESULTS

No significant differences were observed in prostate shifts in any direction between the groups. Shifts on CBCT were all less than setup margins. A significant positive correlation was observed between prostate volume and the z‑direction prostate shift (r = 0.19, p = 0.04), regardless of ADT group, but not between volume and x‑ or y‑direction shifts (r = 0.04, p = 0.7; r = 0.03, p = 0.7). Random and systematic errors for all patient cohorts and ADT groups were similar.

CONCLUSION

Hormone therapy given concurrently with RT was not found to significantly impact setup errors. Prostate volume was significantly correlated with shifts in the anterior-posterior direction only.

Clinical evaluation of tamsulosin in the relief of lower urinary tract symptoms in advanced prostate cancer patients

PURPOSE

To assess the effectiveness and safety of tamsulosin combined with androgen deprivation therapy (ADT) for lower urinary tract symptoms (LUTS) in advanced prostate cancer (PC) patients.

METHODS

Ninety PC patients with moderate-to-severe LUTS randomized into two groups of 45 each. One group received ADT (group 1), and the other received ADT plus tamsulosin (group 2) for 24 weeks. The outcome measures were changes in the International Prostate Symptom Score (IPSS), IPSS obstructive and irritative subscores, quality of life (QoL), maximum urinary flow rate (Q _max), post-voiding residual (PVR) and prostate-specific antigen (PSA) from baseline. The treatment response was monitored at 8, 16 and 24 weeks.

RESULTS

Both ADT monotherapy and ADT plus tamsulosin significantly improved IPSS,QoL score, Q _max and PVR at the end of the treatment period. ADT plus tamsulosin had a greater impact on total IPSS, IPSS obstructive subscore, QoL and PVR at week 8 and week 16 than ADT monotherapy. Tamsulosin group showed greater improvement in Q _max than ADT group. Significant improvements of IPSS, IPSS obstructive subscore and QoL were achieved at early treatment stage (week 8) in group 2, whereas similar improvements were achieved at week 16 in group 1. There were no significant differences in IPSS, IPSS subscores, QoL and PVR between the two groups at week 24.

CONCLUSIONS

Additional administration of tamsulosin showed significantly greater and sooner relief in LUTS than ADT monotherapy, with good acceptability. It is feasible that ADT is used alone after 16-24 weeks of combination therapy.

The Influence of Androgen Deprivation Therapy on Prostate Size and Voiding Symptoms in Prostate Cancer Patients in Korea

Purpose

The goal of this study is to investigate the effects of androgen deprivation therapy (ADT) on total prostate volume and lower urinary tract symptoms (LUTS).

Methods

Between January 2007 and June 2014, 110 patients who received androgen deprivation treatment were enrolled in this retrospective study. Clinical parameters and urodynamic parameters along with changes at follow-up were analyzed. Factors such as reduction in prostate volume, changes in LUTS, and prostate volume tertiles were compared 1 year after ADT.

Results

After ADT, the total International Prostate Symptom Score (IPSS) score decreased from 17.45 to 12.21 and the IPSS voiding subscore decreased from 9.16 to 6.24. Maximal uroflow rate increased from 8.62 to 11.50 mL/sec and residual urine also reduced significantly by 29.34 mL. Change in prostate size was more prominent (–51.14%) in the patients with less than 1 year of ADT (n=21) than those who had more than 1 year of treatment (n=89, –44.12%). The decrease in the IPSS voiding subscore was greater within 1 year of ADT than after 1 year of treatment (–4.10 vs. –2.65). The differences were more significant in the 30–50 g group (n=59) and >50 g group (n=11) than the <30 g group (n=40) of the IPSS voiding subscore improvement (–3.76 , –4.91 vs. –2.10), and maximal uroflow rate improvement (2.78, 2.90 vs 1.49).

Conclusion

ADT resulted in statistically significant clinical improvement in terms of prostate volume, urodynamic parameters, and LUTS for patients with prostate cancer when analyzed by ADT duration and prostate volume.

Predictors of prostate volume reduction following neoadjuvant cytoreductive androgen suppression

Purpose

Limited duration cytoreductive neoadjuvant hormonal therapy (NHT) is used prior to definitive radiotherapeutic management of prostate cancer to decrease prostate volume. The purpose of this study is to examine the effect of NHT on prostate volume before permanent prostate brachytherapy (PPB), and determine associated predictive factors.

Material and methods

Between June 1998 and April 2012, a total of 1,110 patients underwent PPB and 207 patients underwent NHT. Of these, 189 (91.3%) underwent detailed planimetric transrectal ultrasound before and after NHT prior to PPB. Regression analysis was used to assess predictors of absolute and percentage change in prostate volume after NHT.

Results

The median duration of NHT was 4.9 months with inter quartile range (IQR), 4.2-6.6 months. Prostate-specific antigen (PSA) reduced by a median of 97% following NHT. The mean prostate volume before NHT was 62.5 ± 22.1 cm³ (IQR: 46-76 cm³), and after NHT, it was 37.0 ± 14.5 cm³ (IQR: 29-47 cm³). The mean prostate volume reduction was 23.4 cm³ (35.9%). Absolute prostate volume reduction was positively correlated with initial volume and inversely correlated with T-stage, Gleason score, and NCCN risk group. In multivariate regression analyses, initial prostate volume (p < 0.001) remained as a significant predictor of absolute and percent prostate volume reduction. Total androgen suppression was associated with greater percent prostate volume reduction than luteinizing hormone releasing hormone agonist (LHRHa) alone (p = 0.001).

Conclusions

Prostate volume decreased by approximately one third after 4.9 months of NHT, with total androgen suppression found to be more efficacious in maximizing cytoreduction than LHRHa alone. Initial prostate volume is the greatest predictor for prostate volume reduction.

The Effect of Androgen Deprivation Therapy Before Salvage Whole-gland Cryoablation After Primary Radiation Failure in Prostate Cancer Treatment

OBJECTIVE

To define the effects of androgen deprivation therapy (ADT) used prior to salvage cryoablation (SC) for the treatment of recurrent localized prostate cancer after radiation.

METHODS

Patients from the Cryo On-Line Database registry undergoing SC after radiation failure were divided according to whether they had previously received or not received ADT. Baseline characteristics including demographics and presalvage cancer risk were compared. Biochemical progression-free survival (bPFS) as defined by the Phoenix criteria was compared between the 2 groups as a whole and also in D'Amico risk-stratified subgroups. In addition, postsurgical complications such as urinary fistula, retention, incontinence, and erectile dysfunction were compared.

RESULTS

Two groups consisting of 254 and 486 patients with and without pre-SC ADT were analyzed. The patients who received ADT were younger (P = .003) and had higher presalvage D'Amico risks (P <.001). The 5-year bPFS was 63.8% and 39.3% for the hormone-naïve and the pre-SC ADT patients, respectively (P <.001). On subgroup analysis, the difference in 5-year bPFS was significant only for patients with a high D'Amico cancer risk (54.3% vs 30.5%; P = .013). On multivariate analysis, presalvage prostate-specific antigen (hazard ratio [HR], 1.7), Gleason score ≥ 8 (HR, 2.5), and use of pre-SC ADT (HR, 1.7) correlated with biochemical recurrence. Additionally, patients receiving pre-SC ADT experienced less urinary retention (P = .001) and incontinence (P = .008) but were more likely to be impotent (P = .010).

CONCLUSION

Patients receiving ADT before SC, especially those with high-risk prostate cancer, had worse 5-year bPFS. Added caution is needed when selecting patients having previously received ADT for salvage cryotherapy.

Intermittent hormone therapy versus continuous hormone therapy for locally advanced prostate cancer: a meta-analysis

Few randomized studies have compared intermittent hormone therapy (IHT) with continuous hormone therapy (CHT) for the treatment of locally advanced prostate cancer (PCa). Here, we report the results of a meta-analysis of a randomized controlled trial, evaluating the effectiveness of IHT versus CHT for patients with locally advanced PCa. Types of intervention were IHT versus CHT. The primary endpoint of this study is overall mortality and the secondary endpoints are any progression of disease, quality of life (QOL) and adverse effects between two groups. Six randomized controlled trials totaling 2996 patients were included. Results are as follows: after hormone therapy, patients undergoing IHT demonstrated no significant difference from those undergoing CHT in terms of the overall mortality (OR = 1.0, 95% CI [0.86, 1.17]) and disease progression (OR = 1.16, 95% CI [0.86, 1.57]). Men treated with IHT also reported better QOL, fewer adverse effects and considerable economic benefit for the individual and the community. With no difference in overall mortality and incidence of progression, current clinical studies confirm that both therapeutic methods were safe and effective. However, our study also takes into account QOL. When these secondary measures are considered, IHT may be a better option over CHT as patients report a more affordable treatment with improved QOL and fewer adverse effects.

Improved irritative voiding symptoms 3 years after stereotactic body radiation therapy for prostate cancer

Background: Irritative voiding symptoms are common in elderly men and following prostate radiotherapy. There is limited clinical data on the impact of hypofractionated treatment on irritative voiding symptoms. This study sought to evaluate urgency, frequency, and nocturia following stereotactic body radiation therapy (SBRT) for prostate cancer.

Methods: Patients treated with SBRT monotherapy for localized prostate cancer from August 2007 to July 2011 at Georgetown University Hospital were included in this study. Treatment was delivered using the CyberKnife^® with doses of 35–36.25 Gy in five fractions. Patient-reported urinary symptoms were assessed using the International Prostate Symptom Score (IPSS) before treatment and at 1, 3, 6, 9, and 12 months post-treatment and every 6 months thereafter.

Results: Two hundred four patients at a median age of 69 years received SBRT with a median follow-up of 4.8 years. Prior to treatment, 50.0% of patients reported moderate to severe lower urinary tract symptoms (LUTS) and 17.7% felt that urinary frequency was a moderate to big problem. The mean prostate volume was 39 cc and 8% had prior procedures for benign prostatic hyperplasia. A mean baseline IPSS-irritative (IPSS-I) score of 4.8 significantly increased to 6.5 at 1 month (p < 0.0001), however returned to baseline at 3 months (p = 0.73). The IPSS-I score returned to baseline in 91% of patients by 6 months and 96% of patients by 2 years. Transient increases in irritative voiding symptoms were common at 1 year. The mean baseline IPSS-I score decreased to 4.4 at 24 months (p = 0.03) and 3.7 at 36 months (p < 0.0001). In men with moderate to severe LUTS (IPSS ≥ 8) at baseline, the mean IPSS-I decreased from a baseline score of 6.8–4.9 at 3 years post-SBRT. This decrease was both statistically (p < 0.0001) and clinically significant (minimally important difference = 1.45). Only 14.6% of patients felt that urinary frequency was a moderate to big problem at 3 years post-SBRT (p = 0.23).

Conclusion: Treatment of prostate cancer with SBRT resulted in an acute increase in irritative urinary symptoms that peaked within the first month post-treatment. Irritative voiding symptoms returned to baseline in the majority of patients by 3 months post-SBRT and were actually improved from baseline at 3 years post-SBRT.

[Radiation therapy in locally advanced and/or relapsed urological tumors]

Radiation therapy (RT) plays a fundamental role in the treatment of locally advanced and/or relapsed urological tumors, as well as in palliation, or as definitive treatment, and even where integrated into a multi-modal approach. In operated renal tumors, positive margins or extracapsular extension show a positive impact of postoperative RT, with a reduction of relapses between 100% and 30%, while, in the case of palliation, treatments with RT at high doses are preferred. In advanced cancers of the upper urinary tract, RT plays a limited role, even if it seems to increase the level of disease control locally and, with the combination of cisplatin, survival rates too. An important reduction in the recurrence is also observed in locally advanced tumors of the urethra, with a recurrence of 60% after surgery, 36% after RT and 25% after pairing of the two. In locally advanced tumors of the penis, RT shows poorer results than surgery, and the addition of postoperative RT does not seem to add any further outcome, except where, in the presence of a positive inguinal dissection, the postoperative RT reduces lymph node recurrences by 60%-11%. Interesting data for the preservation of the organ are reported with reference to the combination with chemotherapy. In the tumors of the testis, it is still disputable whether the treatment of residual masses after chemotherapy may be appropriate, with a view to a possible salvage radiotherapy. In the treatment of the prostate, the role of RT is consolidated and evolving with the progress of dose escalation, the association with hormonal therapy, new technologies, new possibilities of IMRT and proton therapy and various studies on multi-modal approaches (hormone therapy, surgery, radiotherapy, chemotherapy). Cystectomy is the gold standard for the treatment of locally advanced bladder cancer, even though there is a revived interest in multimodal treatments (transurethral resection, chemotherapy, RT) that may allow the organ preservation. Postoperative radiotherapy, which can reduce by 50% to 20%-5% local recurrences that are highly correlated with distance failure and with survival, should be revised in the light of modern RT techniques that can further increase local control levels and reduce the toxicity significantly.

Current role of neoadjuvant and adjuvant systemic therapy for high-risk localized prostate cancer

PURPOSE OF REVIEW

Although most men are diagnosed with readily curable localized prostate cancer, those with high-risk features face a significant mortality risk. Androgen deprivation therapy (ADT) is a standard adjunct to radiotherapy for high-risk prostate cancer, but its role around prostatectomy has not been as clearly defined, and concerns over cardiovascular toxicity have led to decreasing use. The use of chemotherapy for localized disease remains experimental. We review the most recently published trials of neoadjuvant or adjuvant systemic therapy for prostate cancer.

RECENT FINDINGS

The optimal duration of ADT with higher dose modern radiation techniques is under active investigation, but current data support the use of longer duration as standard. Prostate-specific antigen (PSA) and MRI changes may be useful in future studies optimizing duration of neoadjuvant ADT. Two years of combined ADT after prostatectomy is associated with a lower risk of disease recurrence and better prostate cancer specific mortality than predicted. Persistence of intraprostatic androgens during neoadjuvant ADT may contribute to resistance.

SUMMARY

Androgen deprivation added to definitive radiation or surgery improves outcomes for high-risk prostate cancer, although the role of chemotherapy remains undefined. Molecular classification is needed to improve risk stratification.

Castration therapy results in decreased Ku70 levels in prostate cancer

PURPOSE

Neoadjuvant castration improves response to radiotherapy of prostate cancer. Here, we determine whether castration therapy impairs nonhomologous end-joining (NHEJ) repair of DNA double-strand breaks (DSB) by downregulating Ku70 protein expression.

EXPERIMENTAL DESIGN

Twenty patients with locally advanced prostate cancer were enrolled, and 6 to 12 needle core biopsy specimens were taken from the prostate of each patient before treatment. Bilateral orchidectomy was conducted in eight patients and 12 patients were treated with a GnRH agonist. After castration, two to four similar biopsies were obtained, and the levels of Ku70 and γ-H2AX foci were determined by immunofluorescence in verified cancer tissues.

RESULTS

We observed that the androgen receptor binds directly to Ku70 in prostate tissue. We also found a reduction of the Ku70 protein levels in the cell nuclei in 12 of 14 patients (P < 0.001) after castration. The reduction in Ku70 expression correlated significantly with decreased serum prostate-specific antigen (PSA) levels after castration, suggesting that androgen receptor activity regulates Ku70 protein levels in prostate cancer tissue. Furthermore, a significant correlation between the reductions of Ku70 after castration versus changes induced of castration of γ-H2AX foci could be seen implicating a functional linkage of decreased Ku70 levels and impaired DNA repair.

CONCLUSIONS

Castration therapy results in decreased levels of the Ku70 protein in prostate cancer cells. Because the Ku70 protein is essential for the NHEJ repair of DSBs and its downregulation impairs DNA repair, this offers a possible explanation for the increased radiosensitivity of prostate cancer cells following castration.

Neoadjuvant androgen deprivation therapy for prostate volume reduction, lower urinary tract symptom relief and quality of life improvement in men with intermediate- to high-risk prostate cancer: a randomised non-inferiority trial of degarelix versus goserelin plus bicalutamide

AIMS

The treatment of intermediate- to high-risk prostate cancer with radical radiotherapy is usually in combination with neoadjuvant androgen deprivation therapy. The aim of the present trial was to investigate whether degarelix achieves comparable efficacy with that of goserelin plus bicalutamide as neoadjuvant therapy before radiotherapy.

MATERIALS AND METHODS

The study was a randomised, parallel-arm, active-controlled, open-label trial in 244 men with a UICC prostate cancer TNM category T2b-T4, N0, M0, Gleason score ≥7, or prostate-specific antigen ≥10 ng/ml and a total prostate volume >30 ml, who were scheduled to undergo radical radiotherapy and in whom neoadjuvant androgen deprivation therapy was indicated. Eligible patients received treatment with either monthly degarelix (240/80 mg) or goserelin (3.6 mg) for 12 weeks, the latter patients also receiving bicalutamide (50 mg) for 17 days initially. The primary efficacy measure was the mean percentage reduction in total prostate volume from baseline at week 12 measured by transrectal ultrasound. The severity and relief of lower urinary tract symptoms were assessed by the International Prostate Symptom Score questionnaire. Quality of life was assessed by the eighth question of the International Prostate Symptom Score. About 50% of the patients had moderate to severe lower urinary tract symptoms at baseline.

RESULTS

The total prostate volume decreased significantly from baseline to week 12 in both treatment groups, reaching -36.0 ± 14.5% in degarelix-treated patients and -35.3 ± 16.7% in goserelin-treated patients (adjusted difference: -0.3%; 95% confidence interval: -4.74; 4.14%). At the end of the therapy, more degarelix- than goserelin-treated patients reported International Prostate Symptom Score decreases of ≥3 points (37% versus 27%, P = 0.21). In addition, in patients with a baseline International Prostate Symptom Score of ≥13, the magnitude of the decrease was larger in degarelix- (n = 53) versus goserelin-treated patients (n = 17) (6.04 versus 3.41, P = 0.06).

CONCLUSIONS

The efficacy of degarelix in terms of prostate shrinkage is non-inferior to that of goserelin plus bicalutamide. The added benefits of degarelix in terms of more pronounced lower urinary tract symptom relief in symptomatic patients could be the reflection of differences in the direct effects on extra-pituitary receptors in the lower urinary tract [Clinicaltrials.gov ID: NCT00833248].

Degarelix versus goserelin (+ antiandrogen flare protection) in the relief of lower urinary tract symptoms secondary to prostate cancer: results from a phase IIIb study (NCT00831233)

INTRODUCTION

No studies to date have assessed the efficacy/tolerability of degarelix in the relief of lower urinary tract symptoms (LUTS) secondary to prostate cancer (PrCa).

METHODS

Patients were randomised to degarelix 240/80 mg or goserelin 3.6 mg + bicalutamide flare protection (G+B); both treatments were administered for 3 months. The primary endpoint was change in International Prostate Symptom Score (IPSS) at week 12 compared with baseline.

RESULTS

This study was stopped early due to recruitment difficulties. 40 patients received treatment (degarelix n = 27; G+B n = 13); most had locally advanced disease and were highly symptomatic. Degarelix was non-inferior to G+B in reducing IPSS at week 12 in the full analysis set (p = 0.20); the significantly larger IPSS reduction in the per-protocol analysis (p = 0.04) was suggestive of superior reductions with degarelix. Significantly more degarelix patients had improved quality of life (IPSS question) at week 12 (85 vs. 46%; p = 0.01). Mean prostate size reductions at week 12 were 42 versus 25% for patients receiving degarelix versus G+B, respectively (p = 0.04; post hoc analysis). Most adverse events were mild/moderate; more degarelix patients experienced injection site reactions whereas more G+B patients had urinary tract infections/cystitis.

CONCLUSION

In 40 men with predominantly locally advanced PrCa and highly symptomatic LUTS, degarelix was at least non-inferior to G+B in reducing IPSS at week 12.

Androgen deprivation therapy for volume reduction, lower urinary tract symptom relief and quality of life improvement in patients with prostate cancer: degarelix vs goserelin plus bicalutamide

Study Type--Therapy (RCT) Level of Evidence 1b. What's known on the subject? and What does the study add? Androgen deprivation therapy (ADT) is commonly used as a primary treatment for patients with prostate cancer (PCa) who are not eligible for radical treatment options. ADT is also used in patients with PCa as neo-adjuvant hormone therapy to reduce prostate volume and down-stage the disease before radiotherapy with curative intent. The present study showed that ADT with the gonadotropin hormone-releasing hormone (GhRH) antagonist degarelix is non-inferior to combined treatment with the LHRH agonist goserelin and bicalutamide in terms of reducing prostate volume during the treatment period of 3 months. Degarelix treatment evokes, however, significantly better relief of lower urinary tract symptoms in patients having moderate and severe voiding problems.

OBJECTIVE

• To assess the efficacy of monthly degarelix treatment for reduction of total prostate volume (TPV), relief of lower urinary tract symptoms (LUTS) and improvement of quality of life (QoL) in patients with prostate cancer (PCa) using monthly goserelin as active control.

METHODS

• This was a randomized, parallel-arm, active-controlled, open-label, multicentre trial on 182 patients treated with either monthly degarelix (240/80 mg) or goserelin (3.6 mg) for 12 weeks. • For flare protection, goserelin-treated patients also received daily bicalutamide (50 mg) during the initial 28 days. • Key trial variables monitored monthly were TPV (primary endpoint), serum testosterone, prostate-specific antigen (PSA), the International Prostate Symptom Score (IPSS) and the Benign Prostate Hyperplasia Impact Index.

RESULTS

• In all, 175 patients completed the trial (96.1%). • At week 12, changes in TPV for degarelix and goserelin were similar (-37.2% vs -39.0%) and met the predefined non-inferiority criterion. • Decreases in IPSS were greater in degarelix than in goserelin-treated patients, differences being statistically significant in patients with baseline IPSS > 13 (-6.7 ± 1.8 vs -4.0 ± 1.0; P = 0.02). • The number of patients with an IPSS change of ≥ 3 over baseline was also significantly higher in patients treated with degarelix (61.0 vs 44.3%, P = 0.02). • Both treatments were safe and well tolerated.

CONCLUSIONS

• Medical castration reduces TPV and could also improve LUTS in patients with PCa. • While the short-term efficacy of degarelix and goserelin + bicalutamide was the same in terms of TPV reduction, degarelix showed superiority in LUTS relief in symptomatic patients, which could highlight the different actions of these drugs on extrapituitary gonadotrophin-releasing hormone (GnRH) receptors in the bladder and/or the prostate.

Androgen deprivation therapy in combination with radiotherapy for high-risk clinically localized prostate cancer

Androgen deprivation therapy (ADT) has remained the main therapeutic option for patients with advanced prostate cancer (PCa) for about 70 years. Several reports and our findings revealed that aggressive PCa can occur under a low dihydrotestosterone (DHT) level environment where the PCa of a low malignancy with high DHT dependency cannot easily occur. Low DHT levels in the prostate with aggressive PCa are probably sufficient to propagate the growth of the tumor, and the prostate with aggressive PCa can produce androgens from the adrenal precursors more autonomously than that with non-aggressive PCa does under the low testosterone environment with testicular suppression. In patients treated with ADT the pituitary-adrenal axis mediated by adrenocorticotropic hormone has a central role in the regulation of androgen synthesis. Several experimental studies have confirmed the potential benefits from the combination of ADT with radiotherapy (RT). A combination of external RT with short-term ADT is recommended based on the results of phase III randomized trials. In contrast, the combination of RT plus 6 months of ADT provides inferior survival as compared with RT plus 3 years of ADT in the treatment of locally advanced PCa. Notably, randomized trials included patients with diverse risk groups treated with older RT modalities, a variety of ADT scheduling and duration and, importantly, suboptimal RT doses. The use of ADT with higher doses of RT or newer RT modalities has to be properly assessed.

A comparison of preplan MRI and preplan CT-based prostate volume with intraoperative ultrasound-based prostate volume in real-time permanent brachytherapy

Purpose

The present study compared the difference between intraoperative transrectal ultrasound (iTRUS)-based prostate volume and preplan computed tomography (CT), preplan magnetic resonance imaging (MRI)-based prostate volume to estimate the number of seeds needed for appropriate dose coverage in permanent brachytherapy for prostate cancer.

Materials and Methods

Between March 2007 and March 2011, among 112 patients who underwent permanent brachytherapy with ¹²⁵I, 60 image scans of 56 patients who underwent preplan CT (pCT) or preplan MRI (pMRI) within 2 months before brachytherapy were retrospectively reviewed. Twenty-four cases among 30 cases with pCT and 26 cases among 30 cases with pMRI received neoadjuvant hormone therapy (NHT). In 34 cases, NHT started after acquisition of preplan image. The median duration of NHT after preplan image acquisition was 17 and 21 days for cases with pCT and pMRI, respectively. The prostate volume calculated by different modalities was compared. And retrospective planning with iTRUS image was performed to estimate the number of ¹²⁵I seed required to obtain recommended dose distribution according to prostate volume.

Results

The mean difference in prostate volume was 9.05 mL between the pCT and iTRUS and 6.84 mL between the pMRI and iTRUS. The prostate volume was roughly overestimated by 1.36 times with pCT and by 1.33 times with pMRI. For 34 cases which received NHT after image acquisition, the prostate volume was roughly overestimated by 1.45 times with pCT and by 1.37 times with pMRI. A statistically significant difference was found between preplan image-based volume and iTRUS-based volume (p < 0.001). The median number of wasted seeds is approximately 13, when the pCT or pMRI volume was accepted without modification to assess the required number of seeds for brachytherapy.

Conclusion

pCT-based volume and pMRI-based volume tended to overestimate prostate volume in comparison to iTRUS-based volume. To reduce wasted seeds and cost of the brachytherapy, we should take the volume discrepancy into account when we estimate the number of ¹²⁵I seeds for permanent brachytherapy.

Hormone therapy in the management of prostate cancer: evidence-based approaches

Hormonal therapy has been the standard for advanced prostate cancer for over 60 years. Recently, the utility of androgen ablation through various means has been demonstrated for earlier stages of disease. In particular, the strongest evidence to date involves the use of hormonal therapy in combination with radiation therapy. In this article we review the basic concepts in hormonal ablation for prostate cancer and review the evidence-based studies that support the use of hormonal therapy in early stage prostate cancer.