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Qazi SU, Altaf Z, Zafar M, Tariq MA, Khalid A, Kaleem A, Saad E, Qazi S. Development of depression in patients using androgen deprivation therapy: A systemic review and meta-analysis. Prostate 2024; 84:525-538. [PMID: 38372065 DOI: 10.1002/pros.24676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/29/2023] [Accepted: 02/02/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Androgen deprivation therapy (ADT) is an effective treatment for advanced prostate cancer (PCa). Multiple studies have highlighted serious consequences this therapy poses to mental health, particularly depression. We aimed to review the incidence and association between ADT in men with PCa and the risk of depression. METHODS We systematically searched multiple databases, including MEDLINE, Scopus till August 2023 for studies that compared ADT versus control for treating PCa reporting depression as outcome. Meta-analysis was performed using random-effects models and results presented as odds ratios (ORs) with 95% confidence interval (CI). Quality assessment of the included studies was conducted using Joanna Briggs Institute critical appraisal checklists. RESULTS A total of 38 studies (17 retrospective studies, 16 prospective studies, two cross-sectional studies and two randomized trials) with 360,650 subjects met the inclusion criteria and were included in this meta-analysis. The estimated pooled incidence of depression among ADT patients is 209.5 (95% CI = 122.3; 312.2) per 1000 patients. There is statistically significant relationship between ADT treatment and depression (OR = 1.46, 95% CI = 1.28, 1.67; p = 0, I2 = 86.4%). The results remained consistent across various subgroups. No risk of publication bias was detected by funnel plot and Eggers's test (p > 0.05). CONCLUSION There is a higher risk of depression for men receiving ADT. Further studies evaluating optimal treatments for depression in men on ADT are warranted.
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Affiliation(s)
- Shurjeel Uddin Qazi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Zahabia Altaf
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mariam Zafar
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Ali Tariq
- Department of Surgery, Dow International Medical College, Karachi, Pakistan
| | - Areesha Khalid
- Department of Surgery, Dow International Medical College, Karachi, Pakistan
| | - Aleesha Kaleem
- Department of Surgery, Dow International Medical College, Karachi, Pakistan
| | - Emaan Saad
- Department of Surgery, Dow International Medical College, Karachi, Pakistan
| | - Sana Qazi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Zhang J, Gallaher J, Cunningham JJ, Choi JW, Ionescu F, Chatwal MS, Jain R, Kim Y, Wang L, Brown JS, Anderson AR, Gatenby RA. A Phase 1b Adaptive Androgen Deprivation Therapy Trial in Metastatic Castration Sensitive Prostate Cancer. Cancers (Basel) 2022; 14:5225. [PMID: 36358643 PMCID: PMC9656891 DOI: 10.3390/cancers14215225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background: We hypothesize that cancer survival can be improved through adapting treatment strategies to cancer evolutionary dynamics and conducted a phase 1b study in metastatic castration sensitive prostate cancer (mCSPC). Methods: Men with asymptomatic mCSPC were enrolled and proceeded with a treatment break after achieving > 75% PSA decline with LHRH analog plus an NHA. ADT was restarted at the time of PSA or radiographic progression and held again after achieving >50% PSA decline. This on-off cycling of ADT continued until on treatment imaging progression. Results: At data cut off in August 2022, only 2 of the 16 evaluable patients were off study due to imaging progression at 28 months from first dose of LHRH analog for mCSPC. Two additional patients showed PSA progression at 12.4 and 20.5 months and remain on trial. Since none of the 16 patients developed imaging progression at 12 months, the study succeeded in its primary objective of feasibility. The secondary endpoints of median time to PSA progression and median time to radiographic progression have not been reached at a median follow up of 26 months. Conclusions: It is feasible to use an individual’s PSA response and testosterone levels to guide intermittent ADT in mCSPC.
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Affiliation(s)
- Jingsong Zhang
- Department of Genitourinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Jill Gallaher
- Department of Integrated Mathematical Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | | | - Jung W. Choi
- Department of Radiology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Filip Ionescu
- Department of Oncological Science, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Monica S. Chatwal
- Department of Genitourinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Rohit Jain
- Department of Genitourinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Liang Wang
- Department of Tumor Biology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Joel S. Brown
- Department of Integrated Mathematical Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Alexander R. Anderson
- Department of Integrated Mathematical Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Robert A. Gatenby
- Department of Integrated Mathematical Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
- Department of Radiology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
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Kim MS, Jung SI, Chung HS, Chang Hwang E, Kwon D. Effects of leuprolide acetate on the quality of life of patients with prostate cancer: A prospective longitudinal cohort study. Prostate Int 2021; 9:132-139. [PMID: 34692585 PMCID: PMC8498686 DOI: 10.1016/j.prnil.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 11/12/2022] Open
Abstract
Purpose The aim of this study was to investigate the effect of androgen deprivation therapy (ADT) on the health-related quality of life (HRQOL) of patients with prostate cancer (PC) and compare the changes in the HRQOL between ADT alone and ADT plus intensity-modulated radiation therapy (IMRT). Materials and methods Patients with PC were prospectively recruited between October 2018 and April 2020. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and the PC-specific module (PR25) were administered before ADT (baseline) and at 3, 6, and 12 months after ADT. All patients received subcutaneous injections of 45 mg leuprolide acetate at 6-month intervals for 12 months. Results Fifty-five of the 71 patients (77.5%) completed the 12-month study. Twenty-two of the 55 patients received IMRT. There were no differences in the baseline characteristics with respect to IMRT. Compared with baseline, physical function and role function deteriorated after 3 months (p = 0.003, p = 0.019). However, the global quality of life (QOL) did not change over time. The symptom scales of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire indicated that there was a statistically significant deterioration in dyspnea and fatigue symptoms at 12 months (p = 0.004, p = 0.004). Responses to the QLQ-PR25 revealed that patients experienced an increase in hormonal treatment-related symptoms after 3, 6, and 12 months (p = 0.002, 0.001, and 0.004). Comparisons between the ADT group and ADT plus IMRT group showed that body function and role function did not differ between the two groups (p = 0.815, p = 0.759), and there was also no difference in global QOL (p = 0.624). Conclusion Our results indicate that treatment with leuprolide acetate at 6-month intervals was not accompanied by changes in global QOL, despite deterioration of body and role functions and hormonal treatment-related symptoms. The combination of ADT and IMRT did not lead to additional deterioration in the HRQOL.
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Affiliation(s)
| | - Seung Il Jung
- Corresponding author. Department of Urology, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea.
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Werensteijn-Honingh AM, Wevers AFJ, Peters M, Kroon PS, Intven M, Eppinga WSC, Jürgenliemk-Schulz IM. Progression-free survival in patients with 68Ga-PSMA-PET-directed SBRT for lymph node oligometastases. Acta Oncol 2021; 60:1342-1351. [PMID: 34323648 DOI: 10.1080/0284186x.2021.1955970] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prostate cancer oligometastatic disease can be treated using stereotactic body radiotherapy (SBRT) in order to postpone start of systemic treatments such as androgen deprivation therapy (ADT). 68Ga-PSMA-PET/CT imaging allows for diagnosis of oligometastases at lower PSA values. We analysed a cohort of patients with prostate cancer lymph node oligometastases detected on PSMA-PET/CT. MATERIALS AND METHODS Ninety patients with metachronous oligometastatic prostate cancer received SBRT for 1-3 lymph node metastases diagnosed on 68Ga-PSMA-PET/CT. The primary end point was progression free survival (PFS), with disease progression defined as occurrence of either target lesion progression, new metastatic lesion or biochemical progression. Secondary outcomes were biochemical PFS (BPFS), ADT-free survival (ADT-FS), toxicity and quality of life (QoL). Baseline patient characteristics were tested for association with PFS and a preliminary risk score was created. RESULTS Median follow-up was 21 months (interquartile range 10-31 months). Median PFS and BPFS were 16 and 21 months, respectively. Median ADT-FS was not reached (73% (95%-CI 62-86%) at 24 months). In multivariable analysis, younger age, higher PSA prior to SBRT and extrapelvic location were associated with shorter PFS. Grade 1 fatigue was the most predominant acute toxicity (34%). Highest grade toxicity was grade 2 for acute and late events. QoL analysis showed mild, transient increase in fatigue at 1-4 weeks after SBRT. CONCLUSION A median PFS of 16 months was attained after SBRT for patients with PSMA-PET positive oligometastatic lymph nodes from prostate cancer. Higher pre-SBRT PSA, younger age and extrapelvic location were found to be predictors of shorter PFS.
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Affiliation(s)
| | - Anne F. J. Wevers
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Max Peters
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Petra S. Kroon
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn Intven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wietse S. C. Eppinga
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
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Virgo KS, Rumble RB, de Wit R, Mendelson DS, Smith TJ, Taplin ME, Wade JL, Bennett CL, Scher HI, Nguyen PL, Gleave M, Morgan SC, Loblaw A, Sachdev S, Graham DL, Vapiwala N, Sion AM, Simons VH, Talcott J. Initial Management of Noncastrate Advanced, Recurrent, or Metastatic Prostate Cancer: ASCO Guideline Update. J Clin Oncol 2021; 39:1274-1305. [PMID: 33497248 DOI: 10.1200/jco.20.03256] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/23/2020] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - James L Wade
- Cancer Care Specialists of Illinois, Decatur, IL
| | | | - Howard I Scher
- Memorial Sloan Kettering Cancer Center & Weill Cornell Medical College, New York, NY
| | | | - Martin Gleave
- University of British Columbia, Vancouver, BC, Canada
| | | | - Andrew Loblaw
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | | | | - Amy M Sion
- Medical University of South Carolina, Charleston, SC
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Recommandations françaises du Comité de cancérologie de l’AFU – actualisation 2020–2022 : cancer de la prostate. Prog Urol 2020; 30:S136-S251. [DOI: 10.1016/s1166-7087(20)30752-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Perera M, Roberts MJ, Klotz L, Higano CS, Papa N, Sengupta S, Bolton D, Lawrentschuk N. Intermittent versus continuous androgen deprivation therapy for advanced prostate cancer. Nat Rev Urol 2020; 17:469-481. [PMID: 32606361 DOI: 10.1038/s41585-020-0335-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 11/09/2022]
Abstract
Androgen deprivation therapy (ADT) is still a mainstay of treatment for advanced prostate cancer. Continuous ADT causes considerable patient morbidity including sexual dysfunction, poor mood and physical capacity, changes in body composition and health-care-related costs. Intermittent ADT has been used as an approach to ADT monotherapy to limit morbidity by enabling cyclical recovery of serum testosterone levels. To date, a number of well-performed randomized controlled trials and meta-analyses have demonstrated statistically insignificant differences in oncological outcomes between intermittent and continuous ADT monotherapy. Sexual outcomes, morbidity profiles and cost-savings favour intermittent therapy in most randomized trials, but the benefit for clinical practice is unclear. Despite the growing body of evidence, the optimal administration regime for ADT has not been clearly established and incorporation of adjunctive upfront treatments such as chemotherapy and novel anti-androgen agents has further hampered progress. Recommendations by authoritative urological and oncological societies regarding the use of intermittent ADT are limited. The potential benefits of reduced morbidity for a particular patient must be considered in light of the possible oncological outcomes. Although the oncological changes associated with intermittent ADT are controversial, intermittent ADT does seem to provide symptomatic benefit in patients compared with continuous ADT. However, careful selection of suitable patients is crucial.
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Affiliation(s)
- Marlon Perera
- University of Melbourne, Department of Surgery, Austin Health, Melbourne, Victoria, Australia. .,The University of Queensland Centre for Clinical Research, Faculty of Medicine, Brisbane, Queensland, Australia.
| | - Matthew J Roberts
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, Brisbane, Queensland, Australia.,Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Laurence Klotz
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Nathan Papa
- University of Melbourne, Department of Surgery, Austin Health, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Shomik Sengupta
- University of Melbourne, Department of Surgery, Austin Health, Melbourne, Victoria, Australia.,EHCS, Monash University, Box Hill, Melbourne, Victoria, Australia.,Urology Department, Eastern Health, Box Hill, Melbourne, Victoria, Australia
| | - Damien Bolton
- University of Melbourne, Department of Surgery, Austin Health, Melbourne, Victoria, Australia.,Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia
| | - Nathan Lawrentschuk
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Urology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Shevach J, Sydes MR, Hussain M. Revisiting Intermittent Therapy in Metastatic Prostate Cancer: Can Less Be More in the "New World Order"? Eur Urol Focus 2019; 5:125-133. [PMID: 30803926 DOI: 10.1016/j.euf.2019.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/24/2019] [Accepted: 02/04/2019] [Indexed: 01/23/2023]
Abstract
CONTEXT Androgen deprivation therapy (ADT) is the standard of care for men with metastatic hormone-sensitive prostate cancer (HSPC) and a potential treatment option in those with prostate-specific antigen relapse after local therapy. Based on promising biological and preclinical data, several clinical trials compared the efficacy of intermittent androgen deprivation (IAD) versus continuous androgen deprivation (CAD) with the objective of delaying disease progression and improving survival and quality of life (QoL). OBJECTIVE The objective of this review is to revisit the concept of IAD in the "new world order" and reconsider whether it has a potential clinical role in an era where we have seen unprecedented progress in the management of patients with metastatic HSPC. EVIDENCE ACQUISITION MEDLINE, Embase, and the Cochrane Library databases were searched for randomized controlled trials comparing IAD and CAD therapies. References of retrieved articles were also searched. Articles with at least 100 randomized patients, which were published in 2008 or later and had data on overall survival or QoL outcomes, were included. EVIDENCE SYNTHESIS The evidence to date cannot exclude inferiority of IAD compared with CAD with respect to survival outcomes. The hazard ratios in metastatic disease indicate less favorable survival with IAD. No superiority trial conclusively favored IAD or CAD. Two trials demonstrated noninferiority of IAD, although the noninferiority margins (NIMs) are clinically concerning. Another trial could not exclude noninferiority. A modest but temporary QoL and symptom benefit generally favoring IAD was observed. CONCLUSIONS IAD has not conclusively demonstrated an impact on disease progression or survival, and has only modest effects on QoL and symptoms measured in the short term. As such, it is not the standard of care, particularly in the era where we have seen unprecedented survival impact with combination ADT+docetaxel or abiraterone +prednisone. IAD may need to be reassessed in the context of current therapies, ideally driven by biological rationale, with the goal of minimizing physical and financial toxicities with appropriately designed informative clinical trials. PATIENT SUMMARY In this report, we looked at two hormone therapy approaches for prostate cancer that is still sensitive to castration: one with treatment breaks and one without. Patients may tolerate therapy with breaks more easily, but this effect is not sustained and is not associated with better longevity. The best longevity is seen in patients who receive newer hormone therapies or chemotherapy in addition to continuous hormone therapy. Whether these newer therapies would be as effective if given intermittently is an important but unanswered question.
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Affiliation(s)
- Jeffrey Shevach
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Maha Hussain
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Rozet F, Hennequin C, Beauval JB, Beuzeboc P, Cormier L, Fromont-Hankard G, Mongiat-Artus P, Ploussard G, Mathieu R, Brureau L, Ouzzane A, Azria D, Brenot-Rossi I, Cancel-Tassin G, Cussenot O, Rebillard X, Lebret T, Soulié M, Penna RR, Méjean A. RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : cancer de la prostate French ccAFU guidelines – Update 2018–2020: Prostate cancer. Prog Urol 2018; 28:S79-S130. [PMID: 30392712 DOI: 10.1016/j.purol.2018.08.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 12/31/2022]
Abstract
This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy).
Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations.
Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.007.
C’est cette nouvelle version qui doit être utilisée pour citer l’article.
This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published.
The replacement has been published at the DOI:10.1016/j.purol.2019.01.007.
That newer version of the text should be used when citing the article.
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Affiliation(s)
- F Rozet
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, institut mutualiste Montsouris, université René-Descartes, 42, boulevard Jourdan, 75674, Paris, France.
| | - C Hennequin
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service de radiothérapie, Saint-Louis Hospital, AP-HP, 75010, Paris, France
| | - J-B Beauval
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, oncologie médicale, institut universitaire du cancer Toulouse-Oncopole, CHU Rangueil, 31100, Toulouse, France
| | - P Beuzeboc
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital Foch, 92150, Suresnes, France
| | - L Cormier
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, CHU François-Mitterrand, 21000, Dijon, France
| | - G Fromont-Hankard
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; CHU de Tours, 2, boulevard Tonnellé, 37000, Tours, France
| | - P Mongiat-Artus
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, Paris cedex 10, France
| | - G Ploussard
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, clinique La Croix du Sud-Saint-Jean Languedoc, institut universitaire du cancer, 31100, Toulouse, France
| | - R Mathieu
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital de Rennes, 2, rue Henri-le-Guilloux, 35033, Rennes cedex 9, France
| | - L Brureau
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Inserm, U1085, IRSET, 97145 Pointe-à-Pitre, Guadeloupe
| | - A Ouzzane
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital Claude-Huriez, CHRU de Lille, rue Michel-Polonovski, 59000, Lille, France
| | - D Azria
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Inserm U1194, ICM, université de Montpellier, 34298, Montpellier, France
| | - I Brenot-Rossi
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009, Marseille, France
| | - G Cancel-Tassin
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; GRC no 5 ONCOTYPE-URO, institut universitaire de cancérologie, Sorbonne université, 75020, Paris, France
| | - O Cussenot
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital Tenon, AP-HP, Sorbonne université, 75020, Paris, France
| | - X Rebillard
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, clinique mutualiste Beau-Soleil, 119, avenue de Lodève, 34070, Montpellier, France
| | - T Lebret
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital Foch, 92150, Suresnes, France
| | - M Soulié
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Centre hospitalier universitaire Rangueil, 31059, Toulouse, France
| | - R Renard Penna
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; GRC no 5 ONCOTYPE-URO, institut universitaire de cancérologie, Sorbonne université, 75020, Paris, France; Service de radiologie, hôpital Tenon, AP-HP, 75020, Paris, France
| | - A Méjean
- Comité de cancérologie de l'Association française d'urologie, groupe prostate, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital européen Georges-Pompidou, université Paris Descartes, Assistance publique des hôpitaux de Paris (AP-HP), 75015, Paris, France
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Rozet F, Hennequin C, Beauval JB, Beuzeboc P, Cormier L, Fromont-Hankard G, Mongiat-Artus P, Ploussard G, Mathieu R, Brureau L, Ouzzane A, Azria D, Brenot-Rossi I, Cancel-Tassin G, Cussenot O, Rebillard X, Lebret T, Soulié M, Renard Penna R, Méjean A. Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : cancer de la prostate. Prog Urol 2018; 28 Suppl 1:R81-R132. [DOI: 10.1016/j.purol.2019.01.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 01/02/2023]
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11
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Maru S, Uchino H, Osawa T, Chiba S, Mouri G, Sazawa A. Long-term treatment outcomes of intermittent androgen deprivation therapy for relapsed prostate cancer after radical prostatectomy. PLoS One 2018; 13:e0197252. [PMID: 29795595 PMCID: PMC5967753 DOI: 10.1371/journal.pone.0197252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/30/2018] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Intermittent androgen deprivation therapy is an effective treatment for metastatic prostate cancer. However, no study to date has evaluated the long-term outcomes of this treatment among patients with prostate cancer after radical prostatectomy. We retrospectively examined the treatment outcomes of patients with prostate-specific antigen recurrence who underwent radical prostatectomy at our department. MATERIALS AND METHODS Of the 690 patients who underwent radical prostatectomy for local prostate cancer between 1988 and 2011, 129 patients who received androgen deprivation therapy for prostate-specific antigen recurrence were included in this study. Patient characteristics, luteinizing hormone-releasing hormone agonist administration, and outcomes were compared between the intermittent androgen deprivation group (n = 66) and the continuous androgen deprivation therapy group (n = 63). The non-recurrence and overall survival rates were compared between groups. RESULTS Thirty-six patients (27.9%) experienced recurrence after luteinizing hormone-releasing hormone agonist administration. The 5-year non-recurrence rate and 10-year overall survival rate were higher in the intermittent group (92.9%) than in the continuous group (92.9 vs 57.9%, P < 0.001; and 95.9% vs 84.3%, P = 0.047, respectively). Furthermore, 63 patients (48.8%) showed a PSA nadir of less than 0.01 ng/mL after initiation of luteinizing hormone-releasing hormone agonist; among these patients, the non-recurrence rate was significantly higher in the intermittent androgen deprivation group (P = 0.003). CONCLUSIONS Intermittent androgen deprivation therapy for prostate specific antigen recurrence after radical prostatectomy contributed to improvement of the non-recurrence rate and overall survival, and can be considered an effective therapy for better prognosis.
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Affiliation(s)
- Shintaro Maru
- Department of Urology, Obihiro-Kosei General Hospital, Obihiro, Hokkaido, Japan
- Department of Urology, Jinyukai Hospital, Sapporo, Hokkaido, Japan
| | - Hideki Uchino
- Department of Urology, Obihiro-Kosei General Hospital, Obihiro, Hokkaido, Japan
| | - Takahiro Osawa
- Department of Renal and Genitourinary Surgery Graduate School of Medicine, Hokkaido University Sapporo, Hokkaido, Japan
| | - Satoshi Chiba
- Department of Urology, Obihiro-Kosei General Hospital, Obihiro, Hokkaido, Japan
| | - Gaku Mouri
- Department of Urology, Obihiro-Kosei General Hospital, Obihiro, Hokkaido, Japan
| | - Ataru Sazawa
- Department of Urology, Obihiro-Kosei General Hospital, Obihiro, Hokkaido, Japan
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Factors Predicting the Off-treatment Duration in Patients with Prostate Cancer Receiving Degarelix as Intermittent Androgen Deprivation Therapy. Eur Urol Focus 2017; 3:470-479. [DOI: 10.1016/j.euf.2015.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/07/2015] [Accepted: 12/17/2015] [Indexed: 01/20/2023]
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13
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Abrahamsson PA. Intermittent androgen deprivation therapy in patients with prostate cancer: Connecting the dots. Asian J Urol 2017; 4:208-222. [PMID: 29387553 PMCID: PMC5772839 DOI: 10.1016/j.ajur.2017.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/21/2016] [Accepted: 02/14/2017] [Indexed: 11/29/2022] Open
Abstract
Intermittent androgen deprivation therapy (IADT) is now being increasingly opted by the treating physicians and patients with prostate cancer. The most common reason driving this is the availability of an off-treatment period to the patients that provides some relief from treatment-related side-effects, and reduced treatment costs. IADT may also delay the progression to castration-resistant prostate cancer. However, the use of IADT in the setting of prostate cancer has not been strongly substantiated by data from clinical trials. Multiple factors seem to contribute towards this inadequacy of supportive data for the use of IADT in patients with prostate cancer, e.g., population characteristics (both demographic and clinical), study design, treatment regimen, on- and off-treatment criteria, duration of active treatment, endpoints, and analysis. The present review article focuses on seven clinical trials that evaluated the efficacy of IADT vs. continuous androgen deprivation therapy for the treatment of prostate cancer. The results from these clinical trials have been discussed in light of the factors that may impact the treatment outcomes, especially the disease (tumor) burden. Based on evidence, potential candidate population for IADT has been suggested along with recommendations for the use of IADT in patients with prostate cancer.
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Nead KT, Sinha S, Yang DD, Nguyen PL. Association of androgen deprivation therapy and depression in the treatment of prostate cancer: A systematic review and meta-analysis. Urol Oncol 2017; 35:664.e1-664.e9. [PMID: 28803700 DOI: 10.1016/j.urolonc.2017.07.016] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 07/05/2017] [Accepted: 07/17/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is increasing evidence that androgen deprivation therapy (ADT) may be associated with depression. Existing studies have shown conflicting results. METHODS PubMed, Web of Science, Embase, and PsycINFO were queried on April 5, 2017. Eligible studies were in English and reported depression among individuals with prostate cancer exposed to a course of ADT vs. a lesser-exposed group (e.g., any-ADT vs. no ADT and continuous ADT vs. intermittent ADT). We used the MOOSE statement guidelines and the Cochrane Review Group's data extraction template. Study quality was evaluated by Newcastle-Ottawa Scale criteria. We conducted a random-effects meta-analysis to calculate summary statistic risk ratios (RRs) and 95% CIs. Heterogeneity was quantified using the I2 statistic and prespecified subgroup analysis. Small study effects were evaluated using Begg and Egger statistics. RESULTS A total of 1,128 studies were initially identified and evaluated. A meta-analysis of 18 studies among 168,756 individuals found that ADT use conferred a 41% increased risk of depression (RR = 1.41; 95% CI: 1.18-1.70; P<0.001). We found a consistent strong statistically significant association when limiting our analysis to studies in localized disease (RR = 1.85; 95% CI: 1.20-2.85; P = 0.005) and those using a clinical diagnosis of depression (RR = 1.19; 95% CI: 1.08-1.32; P = 0.001). We did not find an association for continuous ADT with depression risk compared to intermittent ADT (RR = 1.00; 95% CI: 0.50-1.99; P = 0.992). There was no statistically significant evidence of small study effects. Statistically significant heterogeneity in the full analysis (I2 = 80%; 95% CI: 69-87; P<0.001) resolved when examining studies using a clinical diagnosis of depression (I2 = 16%; 95% CI: 0-60; P = 0.310). CONCLUSION The currently available evidence suggests that ADT in the treatment of prostate cancer is associated with an increased risk of depression.
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Affiliation(s)
- Kevin T Nead
- Department of Radiation Oncology, Perelman School of Medicine, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Sumi Sinha
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David D Yang
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Abstract
OBJECTIVES The purpose of the guidelines national committee CCAFU was to propose updated french guidelines for localized and metastatic prostate cancer (PCa). METHODS A Medline search was achieved between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of PCa, to evaluate different references with levels of evidence. RESULTS Epidemiology, classification, staging systems, diagnostic evaluation are reported. Disease management options are detailed. Recommandations are reported according to the different clinical situations. Active surveillance is a major option in low risk PCa. Radical prostatectomy remains a standard of care of localized PCa. The three-dimensional conformal radiotherapy is the technical standard. A dose of > 74Gy is recommended. Moderate hypofractionation provides short-term biochemical control comparable to conventional fractionation. In case of intermediate risk PCa, radiotherapy can be combined with short-term androgen deprivation therapy (ADT). In case of high risk disease, long-term ADT remains the standard of care. ADT is the backbone therapy of metastatic disease. In men with metastases at first presentation, upfront chemotherapy combined with ADT should be considered as a new standard. In case of metastatic castration-resistant PCa (mCRPC), new hormonal treatments and chemotherapy provide a better control of tumor progression and increase survival. CONCLUSIONS These updated french guidelines will contribute to increase the level of urological care for the diagnosis and treatment for prostate cancer. © 2016 Elsevier Masson SAS. All rights reserved.
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Casas F, Henríquez I, Bejar A, Maldonado X, Alvarez A, González-Sansegundo C, Boladeras A, Ferrer F, Hervás A, Herruzo I, Caro M, Rodriguez I, Ferrer C. Intermittent versus continuous androgen deprivation therapy to biochemical recurrence after external beam radiotherapy: a phase 3 GICOR study. Clin Transl Oncol 2016; 19:373-378. [DOI: 10.1007/s12094-016-1538-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 07/25/2016] [Indexed: 11/12/2022]
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Zejnullahu K, Arevalo MG, Ryan CJ, Aggarwal R. Approaches to minimize castration in the treatment of advanced prostate cancer. Urol Oncol 2016; 34:368-74. [DOI: 10.1016/j.urolonc.2016.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 01/27/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
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Liede A, Hallett DC, Hope K, Graham A, Arellano J, Shahinian VB. International survey of androgen deprivation therapy (ADT) for non-metastatic prostate cancer in 19 countries. ESMO Open 2016; 1:e000040. [PMID: 27843596 PMCID: PMC5070274 DOI: 10.1136/esmoopen-2016-000040] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/05/2016] [Indexed: 01/15/2023] Open
Abstract
Background Continuous androgen deprivation therapy (CADT) is commonly used for patients with non-metastatic prostate cancer as primary therapy for high-risk disease, adjuvant therapy together with radiation or for recurrence after initial local therapy. Intermittent ADT (IADT), a recently developed alternative strategy for providing ADT, is thought to potentially reduce adverse effects, but little is known about practice patterns relating to it. We aimed to describe factors related to physicians’ ADT use and modality for patients with non-metastatic prostate cancer. Methods A 45 min online survey was completed by urologists and oncologists responsible for treatment decisions for non-metastatic prostate cancer from 19 countries with high or increasing prevalence of non-metastatic prostate cancer. Results There were 441 treating physicians who completed the survey which represented 99 177 patients with prostate cancer under their care, of which 76 386 (77%) had non-metastatic prostate cancer. Of patients with non-metastatic prostate cancer, 38% received ADT (37% gonadotropin-releasing hormone (GnRH), 2% orchiectomy); among patients on GnRH, 54% received CADT (≥6 without >3 months interruption), 23% IADT and 23% <6 months. Highest rates of ADT were reported among oncologists (62%) and in Eastern Europe (Czech Republic, Hungary and Poland). Prostate-specific antigen (PSA) levels (65%), Gleason score (52%) and treatment guidelines (48%) were the most common reasons for CADT whereas PSA levels (54%), patient request (48%), desire to maintain sexual function (40%), patient age and comorbidities (38%) were cited most frequently as reasons for IADT. Conclusions This international survey with 441 treating physicians from 19 countries showed that ADT is commonly used in treating patients with non-metastatic prostate cancer, and type of ADT is influenced by high-risk criteria (PSA and Gleason), treatment guidelines and patient preferences. IADT use was primarily driven by PSA levels, patient request and patient age/comorbidities, likely reflecting an attempt to minimise adverse effects of ADT in patients with lower risk tumours.
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Affiliation(s)
- Alexander Liede
- Center for Observational Research, Amgen Inc. , South San Francisco, California , USA
| | - David C Hallett
- Dalla Lana School of Public Health, University of Toronto , Toronto, Ontario , Canada
| | | | | | - Jorge Arellano
- Global Health Economics , Amgen Inc. , Thousand Oaks, California , USA
| | - Vahakn B Shahinian
- Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
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19
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Intermittent androgen deprivation in prostate cancer cases with biochemical progression after radical prostatectomy: Are we ready to treat? Crit Rev Oncol Hematol 2016; 99:351-61. [DOI: 10.1016/j.critrevonc.2016.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Revised: 01/07/2016] [Accepted: 01/12/2016] [Indexed: 01/22/2023] Open
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20
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Abstract
Since prostate cancer becomes more common with age, at least one-third of men have sexual problems at diagnosis. All localized treatments for prostate cancer greatly increase the prevalence of sexual dysfunction, which include loss of desire, erectile dysfunction, and changes in orgasm. Even men on active surveillance have a higher rate of problems than matched peers without prostate cancer. However, men given androgen deprivation therapy (ADT) have the worst rates of sexual dysfunction. Even after 3 to 4 months of ADT, men's desire for sex is decreased and irreversible damage may occur to the erectile tissue in the penis. Erections do not recover in about one-half of men, even if ADT is discontinued. Although intermittent ADT allows some recovery of sexual function, serum testosterone requires 9 to 12 months off ADT to recover. Again, one-half of men have permanent erectile dysfunction. If ADT causes atrophy of the erectile tissue, blood leaks out of the venous system during erection. This syndrome is difficult to treat except with surgery to implant a penile prosthesis. Despite the high rate of sexual problems in men on ADT, a small group stays sexually active and is able to have reliable erections. To improve men's sexual satisfaction on ADT, it may be important to educate them about getting extra mental and physical sexual stimulation, as well as using penile rehabilitation during hormone therapy. Information on reaching orgasm and coping with problems such as dry orgasm, pain with orgasm, and urinary incontinence during sex also should be provided.
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Affiliation(s)
- Leslie R Schover
- From the Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX
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21
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Park JC, Eisenberger MA. Intermittent Androgen Deprivation in Prostate Cancer: Are We Ready to Quit? J Clin Oncol 2016; 34:211-4. [DOI: 10.1200/jco.2015.64.1019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Jong Chul Park
- Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Mario A. Eisenberger
- Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
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Habchi H, Mottet N. Androgen Deprivation Therapy in Prostate Cancer - Current Status in M1 Patients. Oncol Res Treat 2015; 38:646-52. [PMID: 26633005 DOI: 10.1159/000441734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 10/16/2015] [Indexed: 11/19/2022]
Abstract
Androgen deprivation therapy is the cornerstone treatment for metastatic prostate cancer. It can be done either surgically or medically. Luteinizing hormone-releasing hormone agonists and antagonist are the most effective drugs, with different side effects and modes of action, but no clear efficacy differences. Adding a non-steroidal antiandrogen adds a marginal benefit but also significant side effects and costs. Non-steroidal antiandrogens should not be used as monotherapy. In most patients with metastases, immediate castration is the standard of care. The intermittent modality is apparently non-inferior to the continuous one, with some other benefits. Upfront chemotherapy added to castration should be considered as the new standard of care in many metastatic patients. Castration leads to many adverse effects, some potentially life-threatening such as cardiovascular side effects.
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Affiliation(s)
- Hocine Habchi
- Urology Department, North Hospital, St Etienne cedex, France
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23
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Hussain M, Tangen C, Higano C, Vogelzang N, Thompson I. Evaluating Intermittent Androgen-Deprivation Therapy Phase III Clinical Trials: The Devil Is in the Details. J Clin Oncol 2015; 34:280-5. [PMID: 26552421 DOI: 10.1200/jco.2015.62.8065] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Intermittent androgen deprivation (IAD) has been widely tested in prostate cancer. However, phase III trials testing continuous androgen deprivation (CAD) versus IAD have reached inconclusive and seemingly contradictory results. Different design and conduct issues must be critically evaluated to better interpret the results. PATIENTS AND METHODS Seven published phase III trials were examined for prespecified design and outcomes. Treatment specifications; primary end point; superiority versus noninferiority design assumptions, including magnitude of assumed versus observed noninferiority margin (NIM); duration of follow-up; and quality-of-life (QOL) outcomes were considered in terms of the results and conclusions reported. RESULTS Five trials had a superiority and three had a noninferiority primary hypothesis. Only three trials had a uniform population and overall survival (OS) end point. All trials observed better outcomes in terms of OS and progression-free survival (PFS) than assumed at time of study design, translating into prespecified NIMs or hazard ratios that reflected larger absolute differences in OS or PFS between arms. Lower-than-expected event rates also reduced statistical power for the trials. Other factors, including length of follow-up, cause of death, QOL, and primary end point, and their impact on trial interpretation are discussed. CONCLUSION No trial to date has demonstrated survival superiority of IAD compared with CAD. Trials concluding IAD is noninferior to CAD were based on wide NIMs that included clinically important survival differences, not likely to be considered comparable by physicians or patients. Interim analyses relying on short follow-up and including a majority of non-prostate cancer deaths will favor a noninferiority conclusion and should be interpreted cautiously. Adequate follow-up is required to ensure capture of prostate cancer deaths in both superiority and noninferiority trials.
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Affiliation(s)
- Maha Hussain
- Maha Hussain, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Catherine Tangen, SWOG Statistical Center; Celestia Higano, University of Washington, Seattle, WA; Nicholas Vogelzang, US Oncology, Las Vegas, NV; and Ian Thompson, University of Texas Health Science Center, San Antonio, TX.
| | - Catherine Tangen
- Maha Hussain, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Catherine Tangen, SWOG Statistical Center; Celestia Higano, University of Washington, Seattle, WA; Nicholas Vogelzang, US Oncology, Las Vegas, NV; and Ian Thompson, University of Texas Health Science Center, San Antonio, TX
| | - Celestia Higano
- Maha Hussain, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Catherine Tangen, SWOG Statistical Center; Celestia Higano, University of Washington, Seattle, WA; Nicholas Vogelzang, US Oncology, Las Vegas, NV; and Ian Thompson, University of Texas Health Science Center, San Antonio, TX
| | - Nicholas Vogelzang
- Maha Hussain, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Catherine Tangen, SWOG Statistical Center; Celestia Higano, University of Washington, Seattle, WA; Nicholas Vogelzang, US Oncology, Las Vegas, NV; and Ian Thompson, University of Texas Health Science Center, San Antonio, TX
| | - Ian Thompson
- Maha Hussain, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Catherine Tangen, SWOG Statistical Center; Celestia Higano, University of Washington, Seattle, WA; Nicholas Vogelzang, US Oncology, Las Vegas, NV; and Ian Thompson, University of Texas Health Science Center, San Antonio, TX
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Ku JY, Lee JZ, Ha HK. The effect of continuous androgen deprivation treatment on prostate cancer patients as compared with intermittent androgen deprivation treatment. Korean J Urol 2015; 56:689-94. [PMID: 26495069 PMCID: PMC4610895 DOI: 10.4111/kju.2015.56.10.689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 08/27/2015] [Indexed: 11/18/2022] Open
Abstract
Purpose To investigate the efficacy of androgen deprivation treatment (ADT) between continuous and intermittent ADT. Materials and Methods Between January 2006 and May 2015, 603 patients were selected and divided into continuous ADT (CADT) (n=175) and intermittent ADT (IADT) (n=428) groups. The median follow-up in this study was 48.19 (1.0-114.0) months. The primary end point was time to castration resistant prostate cancer (CRPC). The types of ADT were monotherapy and maximal androgen blockade (i.e., luteinizing hormone-releasing hormone agonist and antiandrogen). Results The characteristics of patients showed no significant differences between the CADT and IADT groups, except for the Gleason score (p<0.001). The median time to CRPC of all enrolled patients with ADT was 20.60±1.60 months. The median time to CRPC was 11.20±1.31 months in the CADT group as compared with 22.60±2.08 months in the IADT group. In multivariate analysis, percentage of positive core (p=0.047; hazard ratio [HR], 0.976; 95% confidence interval [CI], 0.953-1.000), Gleason score (p=0.007; HR, 1.977; 95% CI, 1.206-3.240), lymph node metastasis (p=0.030; HR, 0.498; 95% CI, 0.265-0.936), bone metastasis (p=0.028; HR, 1.921; 95% CI, 1.072-3.445), and CADT vs. IADT (p=0.003; HR, 0.254; 95% CI. 0.102-0.633) were correlated with the duration of progression to CRPC. The IADT group presented a significantly longer median time to CRPC compared with the CADT group. Additionally, patients in the IADT group showed a longer duration in median time to CRPC in subgroup analysis according to the Gleason score. Conclusions This study found that IADT produces a longer duration in median time to CRPC than does CADT.
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Affiliation(s)
- Ja Yoon Ku
- Department of Urology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jeong Zoo Lee
- Department of Urology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hong Koo Ha
- Department of Urology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea. ; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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25
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Liaw BC, Shevach J, Oh WK. Systemic therapy for the treatment of hormone-sensitive metastatic prostate cancer: from intermittent androgen deprivation therapy to chemotherapy. Curr Urol Rep 2015; 16:13. [PMID: 25677235 DOI: 10.1007/s11934-015-0486-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Treatment of advanced prostate cancer has changed considerably in recent years, but the vast majority of advances have been made in patients with metastatic castration-resistant disease. There have been relatively fewer advances in the earlier, hormonally responsive stage of metastatic disease. Since the empiric establishment of androgen deprivation therapy as first-line therapy for metastatic prostate cancer decades ago, there have been multiple studies looking at variations of suppressing testosterone, but the overall paradigm has not been strongly challenged until more recently. In particular, the dramatic results reported by the CHAARTED trial not only bring chemotherapy to an arena historically dominated solely by hormonal therapy but also stimulate renewed efforts into improving upon our management of metastatic hormone-sensitive prostate cancer.
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Affiliation(s)
- Bobby C Liaw
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
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Kratiras Z, Konstantinidis C, Skriapas K. A review of continuous vs intermittent androgen deprivation therapy: redefining the gold standard in the treatment of advanced prostate cancer. Myths, facts and new data on a ″perpetual dispute″. Int Braz J Urol 2014; 40:3-15; discussion 15. [PMID: 24642162 DOI: 10.1590/s1677-5538.ibju.2014.01.02] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/02/2013] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To review the literature and present new data of continuous androgen deprivation therapy (ADT) vs intermittent androgen deprivation (IAD) as therapies for prostate cancer in terms of survival and quality of life and clarify practical issues in the use of IAD. MATERIALS AND METHODS We conducted a systematic search on Medline and Embase databases using ″prostatic neoplasm″ and ″intermittent androgen deprivation″ as search terms. We reviewed meta-analyses, randomised controlled trials, reviews, clinical trials and practise guidelines written in English from 2000 and onwards until 01/04/2013. Ten randomized controlled trials were identified. Seven of them published extensive data and results randomizing 4675 patients to IAD versus CAD. Data from the other three randomized trials were limited. RESULTS Over the last years studies confirmed that IAD is an effective alternative approach to hormonal deprivation providing simultaneously several potential benefits in terms of quality of life and cost effectiveness. Thus, in patients with non metastatic, advanced prostate cancer IAD could be used as standard treatment, while in metastatic prostate cancer IAD role still remains ambiguous. CONCLUSIONS Nowadays, revaluation of the gold standard of ADT in advanced prostate cancer appears essential. Recent data established that IAD should no longer be consi¬dered as investigational, since its effectiveness has been proven, especially in patients suffering from non-metastatic advanced prostate cancer.
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Affiliation(s)
- Zisis Kratiras
- Department of Urology, ″Koutlibanio″ General Hospital of Larisa, Larissa, Greece
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27
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Wolff JM, Abrahamsson PA, Irani J, da Silva FC. Is intermittent androgen-deprivation therapy beneficial for patients with advanced prostate cancer? BJU Int 2014; 114:476-83. [PMID: 24433259 DOI: 10.1111/bju.12626] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Use of intermittent androgen-deprivation therapy (IADT) in patients with prostate cancer has been evaluated in several studies, in an attempt to delay the development of castration resistance and reduce side-effects associated with ADT. However it is still not clear whether survival is adversely affected in patients treated with IADT. In this review, we explore the available data in an attempt to identify the most suitable candidate patients for IADT, and discuss factors that may inform appropriate patient stratification. ADT is first-line treatment for advanced/metastatic prostate cancer and is also recommended for use with definitive radiotherapy for high-risk localised prostate cancer. The changes in hormone levels induced by ADT can lead to short- and long-term side-effects which, although treatable in most cases, can significantly reduce the tolerability of ADT treatment. IADT has been investigated in several phase II and phase III studies in patients with locally advanced or metastatic prostate cancer, in an attempt to delay time to tumour progression and reduce the side-effect burden of ADT. In selected patient groups IADT is no less effective than continuous ADT, ameliorating the impact of ADT-related side-effects, and, to a degree, their impact on patient health-related quality of life (HRQL). Further comparative study is required, particularly in relation to HRQL and long-term complications associated with ADT.
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Intermittent androgen deprivation is a rational standard-of-care treatment for all stages of progressive prostate cancer: results from a systematic review and meta-analysis. Prostate Cancer Prostatic Dis 2014; 17:105-11. [DOI: 10.1038/pcan.2014.10] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 01/13/2014] [Accepted: 02/09/2014] [Indexed: 11/09/2022]
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Salonen AJ, Taari K, Ala-Opas M, Sankila A, Viitanen J, Lundstedt S, Tammela TLJ. Comparison of intermittent and continuous androgen deprivation and quality of life between patients with locally advanced and patients with metastatic prostate cancer: a post hoc analysis of the randomized FinnProstate Study VII. Scand J Urol 2014; 48:513-22. [PMID: 24679247 DOI: 10.3109/21681805.2014.901410] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of the study was to compare intermittent (IAD) and continuous (CAD) androgen deprivation therapy (ADT) between locally advanced (M0) and metastatic (M1) prostate cancer, and the effect of ADT on the quality of life. MATERIAL AND METHODS In total, 852 men with advanced prostate cancer were enrolled to receive goserelin acetate for 24 weeks. Of these, 554 patients whose prostate-specific antigen (PSA) decreased to less than 10 ng/ml or by at least 50% (<20 ng/ml at baseline) were randomized to IAD or CAD. In the IAD arm, ADT was resumed for at least 24 weeks whenever PSA increased to greater than 20 ng/ml or above baseline. RESULTS Median follow-up time was 65 months. Median times from randomization to progression, death, prostate cancer death and treatment failure in M0 and M1 patients were 46.8 and 21.4, 57.6 and 40.3, 59.5 and 40.7, and 41.9 and 20.0 months, respectively (p < 0.001). No significant differences emerged between IAD and CAD. ADT showed a beneficial effect on pain, activity limitation and social functioning in M1 patients, and a deleterious effect on physical capacity in M0 patients and on sexual functioning in both groups. IAD offered extra benefit for activity limitation, social functioning and recovery of sexual functioning. CONCLUSIONS IAD is as efficient as CAD in treatment of locally advanced and metastatic prostate cancer. ADT improves quality of life in M1 patients, with IAD offering extra benefit.
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Affiliation(s)
- Arto J Salonen
- Department of Urology, Kuopio University Hospital , Kuopio , Finland
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Botrel TEA, Clark O, dos Reis RB, Pompeo ACL, Ferreira U, Sadi MV, Bretas FFH. Intermittent versus continuous androgen deprivation for locally advanced, recurrent or metastatic prostate cancer: a systematic review and meta-analysis. BMC Urol 2014; 14:9. [PMID: 24460605 PMCID: PMC3913526 DOI: 10.1186/1471-2490-14-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 01/21/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Prostate cancer is the most common cancer in older men in the United States (USA) and Western Europe. Androgen deprivation (AD) constitutes, in most cases, the first-line of treatment for these cases. The negative impact of CAD in quality of life, secondary to the adverse events of sustained hormone deprivation, plus the costs of this therapy, motivated the intermittent treatment approach. The objective of this study is to to perform a systematic review and meta-analysis of all randomized controlled trials that compared the efficacy and adverse events profile of intermittent versus continuous androgen deprivation for locally advanced, recurrent or metastatic hormone-sensitive prostate cancer. METHODS Several databases were searched, including MEDLINE, EMBASE, LILACS, and CENTRAL. The endpoints were overall survival (OS), cancer-specific survival (CSS), time to progression (TTP) and adverse events. We performed a meta-analysis (MA) of the published data. The results were expressed as Hazard Ratio (HR) or Risk Ratio (RR), with their corresponding 95% Confidence Intervals (CI 95%). RESULTS The final analysis included 13 trials comprising 6,419 patients with hormone-sensitive prostate cancer. TTP was similar in patients who received intermittent androgen deprivation (IAD) or continuous androgen deprivation (CAD) (fixed effect: HR = 1.04; CI 95% = 0.96 to 1.14; p = 0.3). OS and CSS were also similar in patients treated with IAD or CAD (OS: fixed effect: HR = 1.02; CI 95% = 0.95 to 1.09; p = 0.56 and CSS: fixed effect: HR = 1.06; CI 95% = 0.96 to 1.18; p = 0.26). CONCLUSION Overall survival was similar between IAD and CAD in patients with locally advanced, recurrent or metastatic hormone-sensitive prostate cancer. Data on CSS are weak and the benefits of IAD on this outcome remain uncertain. Impact in QoL was similar for both groups, however, sexual activity scores were higher and the incidence of hot flushes was lower in patients treated with IAD.
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Affiliation(s)
- Tobias Engel Ayer Botrel
- Evidencias Scientific Credibility, Campinas, São Paulo, Brazil
- Comitê Brasileiro de Estudos em Uro-Oncologia (CoBEU), São Paulo, Brazil
| | - Otávio Clark
- Evidencias Scientific Credibility, Campinas, São Paulo, Brazil
- Comitê Brasileiro de Estudos em Uro-Oncologia (CoBEU), São Paulo, Brazil
| | | | | | - Ubirajara Ferreira
- Comitê Brasileiro de Estudos em Uro-Oncologia (CoBEU), São Paulo, Brazil
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Intermittent Androgen Deprivation Therapy in Advanced Prostate Cancer. Curr Treat Options Oncol 2014; 15:127-36. [DOI: 10.1007/s11864-013-0272-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Intermittent versus continuous cyproterone acetate in bone metastatic prostate cancer: results of a randomized trial. World J Urol 2013; 32:1287-94. [DOI: 10.1007/s00345-013-1206-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 10/28/2013] [Indexed: 10/26/2022] Open
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Efficacy of intermittent androgen deprivation therapy vs conventional continuous androgen deprivation therapy for advanced prostate cancer: a meta-analysis. Urology 2013; 82:327-33. [PMID: 23896094 DOI: 10.1016/j.urology.2013.01.078] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 01/22/2013] [Accepted: 01/24/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare the efficacy of intermittent androgen deprivation therapy (IADT) vs continuous androgen deprivation therapy (CADT) for the treatment of advanced prostate cancer; we performed a meta-analysis of randomized controlled trials (RCTs), assessing the risks of disease progression, all-cause, and disease-specific mortality. MATERIALS AND METHODS We conducted a systematic search of several bibliographic systems to identify all RCTs of IADT in men with newly diagnosed metastatic or biochemical only prostate cancer. We abstracted outcome data, study characteristics, and participant demographics. We performed heterogeneity tests and calculated the summarized risk differences (RD) and risk ratios at 95% confidence intervals (CI), using inverse variance methods in random-effects approaches. RESULTS We identified 8 RCTs (N = 4664) comparing mortality between IADT and CADT. For all men combined, we observed small but nonsignificant differences in all-cause mortality (RD = 0.02, 95% CI = -0.02, 0.06), disease-specific mortality (RD = 0.04, 95% CI = -0.01, 0.08), and disease progression (RD = -0.03, 95% CI = -0.09, 0.04). Among the prespecified subgroup with histologically confirmed, newly diagnosed metastatic disease, we found no difference in overall survival (RD = 0.00, 95% CI = -0.09, 0.09). CONCLUSION We found no difference in overall survival, but a small increased risk in disease-specific survival for men treated with IADT relative to CADT was observed. IADT could be considered as an alternative to CADT because of better quality of life outcome. Patients should be informed of the possible risks and benefits of both therapies. More research confirming the benefits of IADT vs CADT is needed to inform treatment decisions.
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Calais da Silva F, Calais da Silva FM, Gonçalves F, Santos A, Kliment J, Whelan P, Oliver T, Antoniou N, Pastidis S, Marques Queimadelos A, Robertson C. Locally advanced and metastatic prostate cancer treated with intermittent androgen monotherapy or maximal androgen blockade: results from a randomised phase 3 study by the South European Uroncological Group. Eur Urol 2013; 66:232-9. [PMID: 23582949 DOI: 10.1016/j.eururo.2013.03.055] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/25/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND Few randomised studies have compared antiandrogen intermittent hormonal therapy (IHT) with continuous maximal androgen blockade (MAB) therapy for advanced prostate cancer (PCa). OBJECTIVE To determine whether overall survival (OS) on IHT (cyproterone acetate; CPA) is noninferior to OS on continuous MAB. DESIGN, SETTING, AND PARTICIPANTS This phase 3 randomised trial compared IHT and continuous MAB in patients with locally advanced or metastatic PCa. INTERVENTION During induction, patients received CPA 200 mg/d for 2 wk and then monthly depot injections of a luteinising hormone-releasing hormone (LHRH; triptoreline 11.25 mg) analogue plus CPA 200 mg/d. Patients whose prostate-specific antigen (PSA) was <4 ng/ml after 3 mo of induction treatment were randomised to the IHT arm (stopped treatment and restarted on CPA 300 mg/d monotherapy if PSA rose to ≥20 ng/ml or they were symptomatic) or the continuous arm (CPA 200 mg/d plus monthly LHRH analogue). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcome measurement was OS. Secondary outcomes included cause-specific survival, time to subjective or objective progression, and quality of life. Time off therapy in the intermittent arm was recorded. RESULTS AND LIMITATIONS We recruited 1045 patients, of which 918 responded to induction therapy and were randomised (462 to IHT and 456 to continuous MAB). OS was similar between groups (p=0.25), and noninferiority of IHT was demonstrated (hazard ratio [HR]: 0.90; 95% confidence interval [CI], 0.76-1.07). There was a trend for an interaction between PSA and treatment (p=0.05), favouring IHT over continuous therapy in patients with PSA ≤1 ng/ml (HR: 0.79; 95% CI, 0.61-1.02). Men treated with IHT reported better sexual function. Among the 462 patients on IHT, 50% and 28% of patients were off therapy for ≥2.5 yr or >5 yr, respectively, after randomisation. The main limitation is that the length of time for the trial to mature means that other therapies are now available. A second limitation is that T3 patients may now profit from watchful waiting instead of androgen-deprivation therapy. CONCLUSIONS Noninferiority of IHT in terms of survival and its association with better sexual activity than continuous therapy suggest that IHT should be considered for use in routine clinical practice.
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Affiliation(s)
| | | | | | - Américo Santos
- Department of Urology, Hospital S. Marcos, Braga, Portugal
| | - Jan Kliment
- Department of Urology, Jessenius School of Medicine, Martin, Slovakia
| | - Peter Whelan
- Department of Urology, Saint James University Hospital, Leeds, UK
| | - Tim Oliver
- Department of Urology, Saint Bartholomew's, London, UK
| | - Nicos Antoniou
- Department of Urology, Amalia Fleming Hospital, Melissa, Greece
| | - Spiro Pastidis
- Department of Urology, Amalia Fleming Hospital, Melissa, Greece
| | | | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK; Health Protection Scotland, Glasgow, UK; International Prevention Research Institute, Lyon, France
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Klotz L, Toren P. Androgen deprivation therapy in advanced prostate cancer: is intermittent therapy the new standard of care? ACTA ACUST UNITED AC 2013; 19:S13-21. [PMID: 23355789 DOI: 10.3747/co.19.1298] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Intermittent androgen deprivation is increasingly used as an alternative to continuous life-long androgen deprivation therapy for men with advanced or recurrent prostate cancer. RECENT FINDINGS Two recent phase iii trials have clarified the benefits of intermittent therapy. The Canadian-led pr.7 trial in men with nonmetastatic disease and prostate-specific antigen recurrence after definitive local therapy showed that intermittent therapy resulted in survival equivalent to that with continuous therapy, with significant improvements in quality of life. Patients on intermittent therapy experienced improved bone health, fewer metabolic and hematologic disturbances, fewer hot flashes, and improved sexual function. In men with metastatic disease, the data are less clear. The long-awaited results of the Southwest Oncology Group 9346 trial, comparing intermittent with continuous therapy in metastatic disease, showed no difference in overall survival. Post hoc stratification analysis showed a worse outcome in patients with "minimal" metastatic disease, and no difference in those with widespread bone metastases. The significance of that observation is in dispute. The present review also addresses practical issues in the use of intermittent therapy, including patient selection, follow-up, and therapy cycling. SUMMARY The recent results of randomized clinical trials now establish that intermittent androgen deprivation therapy is an approach that should be considered the standard of care in most patients with nonmetastatic prostate cancer requiring hormonal therapy and in selected patients with metastatic disease. KEY POINTS Level i evidence supports the oncologic equivalence of intermittent compared with continuous androgen blockade in men with biochemical failure.Compared with continuous androgen deprivation, intermittent therapy demonstrates improved quality of life and fewer side effects.Patient selection for intermittent therapy is important to maintain good oncologic results.Monitoring of prostate-specific androgen response and duration of off-treatment intervals allow for stratification of patients by risk of progression.
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Affiliation(s)
- L Klotz
- University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON
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López J, López-Fontana G, López-Fontana R. [Current evidence about intermittent androgenic deprivation in prostate cancer]. Actas Urol Esp 2012; 36:608-12. [PMID: 22728019 DOI: 10.1016/j.acuro.2012.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/06/2012] [Accepted: 02/12/2012] [Indexed: 11/26/2022]
Abstract
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.
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Salonen AJ, Taari K, Ala-Opas M, Viitanen J, Lundstedt S, Tammela TLJ. Advanced prostate cancer treated with intermittent or continuous androgen deprivation in the randomised FinnProstate Study VII: quality of life and adverse effects. Eur Urol 2012; 63:111-20. [PMID: 22857983 DOI: 10.1016/j.eururo.2012.07.040] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 07/18/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intermittent dosing may reduce the adverse events (AEs) of androgen-deprivation therapy (ADT). OBJECTIVE To compare intermittent androgen deprivation (IAD) and continuous androgen deprivation (CAD) with regard to health-related quality of life (QoL). DESIGN, SETTING, AND PARTICIPANTS A total of 852 men with advanced prostate cancer (PCa) were enrolled to receive goserelin acetate 3.6 mg every 28 d for 24 wk. A total of 554 patients whose prostate-specific antigen (PSA) decreased to <10 ng/ml or by ≥50% (<20 ng/ml at baseline) were randomised to IAD or CAD. INTERVENTION In the IAD arm, ADT was resumed for at least 24 wk whenever PSA increased >20 ng/ml or above baseline. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS QoL was monitored with a validated Cleary 30-item questionnaire and analysed by the Mann-Whitney U test, 0.5 standard deviation rule, and repeated measures analysis of variance. AEs and adverse drug reactions (ADRs) were analysed by the chi-square test. RESULTS AND LIMITATIONS Median follow-up was 65 mo. Significant differences in QoL emerged in activity limitation, physical capacity, and sexual functioning, favouring IAD. No significant differences emerged in the prevalence of AEs: 87 patients in the IAD arm (31.8%) and 95 in the CAD arm (33.9%) had cardiovascular (CV) AEs (p=0.59), with 25 (9.1%) and 29 (10.4%) withdrawn (p=0.62), and 21 (7.7%) and 24 (8.6%) dying because of a CV event (p=0.70), respectively; bone fractures occurred in 19 (6.9%) and 15 (5.4%) patients (p=0.44), respectively. Hot flushes or night sweats were the most common ADRs (47.1% vs 50.4%; p=0.44). Erectile dysfunction (15.7% vs 7.9%; p=0.042) and depressed mood (2.2 vs 0%; p=0.032) were more common in the IAD arm. CONCLUSIONS IAD showed benefits in the treatment of advanced PCa with respect to QoL. The prevalence of AEs was not significantly lower with IAD. TRIAL REGISTRATION ClinicalTrials.gov, NCT00293670.
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Affiliation(s)
- Arto J Salonen
- Department of Urology, Kuopio University Hospital, Finland.
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Schulman C, Irani J, Aapro M. Improving the management of patients with prostate cancer receiving long-term androgen deprivation therapy. BJU Int 2012; 109 Suppl 6:13-21. [DOI: 10.1111/j.1464-410x.2012.11216.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rohayem J, Kliesch S. [Androgen deprivation therapy in prostate cancer. Indication and systemic consequences]. Urologe A 2012; 51:557-64; quiz 565-6. [PMID: 22476802 DOI: 10.1007/s00120-012-2808-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Androgen deprivation therapy (ADT) is effective in prolonging the progression free survival of patients with symptomatic/metastatic prostate cancer (PC). The reduction of clinical symptoms of tumour disease and the reduction of tumour growth and metastatic dissemination is accompanied by systemic consequences of testosterone deficiency. These are hot flushes, fatigue due to reduction of muscular strength and muscle mass as well as anaemia. Moreover, patients develop cognitive impairment und depressive mood. Weight gain with insulin resistance, disturbances of lipid metabolism and gynecomastia are other effects of androgen deficiency. A decrease in bone mineral density may lead to an increased susceptibility to bone fractures. There are several options to reduce these side effects of ADT, e.g. physical activity, dietary supplementation, tailored pharmacological therapy and psychotherapy. The knowledge of these adjuvant treatment options, despite their palliative character, is relevant to optimize the quality of life of these patients.
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Affiliation(s)
- J Rohayem
- Centrum für Reproduktionsmedizin und Andrologie, WHO Kooperationszentrum, EAA Ausbildungszentrum, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude D11, 48149, Münster, Deutschland
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