The prognostic significance of prostate specific antigen in metastatic hormone-resistant prostate cancer

A comparison of patients with relapsed and chemo-refractory gestational trophoblastic neoplasia

The majority of women requiring chemotherapy for gestational trophoblastic disease (GTN) are cured with their initial chemotherapy treatment. However, a small percentage either become refractory to treatment, or relapse after the completion of treatment. This study investigates the characteristics and outcome of these patients. Patients were identified from the Charing Cross Hospital GTD database. The outcome of these patients with relapsed disease was compared to those with refractory disease. Between 1980 and 2004, 1708 patients were treated with chemotherapy for GTN. Sixty (3.5%) patents relapsed following completion of initial therapy. The overall 5-year survival for patients with relapsed GTN was 93% (95% CI 86-100%). The overall survival for patients with low-risk and high-risk disease at presentation, who subsequently relapsed was 100% (n=35), and 84% (n=25) (95% CI: 66-96%: P<0.05), respectively. Eleven patients were identified who failed to enter remission and had refractory disease. These patients had a worse outcome compared to patients with relapsed disease (5-year survival 43% (95% CI:12-73% P<0.01)). The outcome of patients with relapsed GTN is good. However, patients with primary chemo-refractory disease do poorly and novel therapies are required for this group of patients.

Is baseline quality of life useful for predicting survival with hormone-refractory prostate cancer? A pooled analysis of three studies of the European Organisation for Research and Treatment of Cancer Genitourinary Group

PURPOSE

Patients with symptomatic metastatic hormone-resistant prostate cancer (HRPC) survive a median of 10 months and are often regarded as a homogeneous group. Few prognostic factors have been identified so far. We examined whether baseline health-related quality of life (HRQOL) parameters assessed by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) were independent prognostic factors of survival and whether they bring extra precision to the predictions achievable with models based on clinical and biochemical factors only.

PATIENTS AND METHODS

Data of 391 symptomatic (bone) metastatic HRPC patients from three randomized EORTC trials were used in multivariate Cox proportional hazards models. The significance level was set at alpha =.05.

RESULTS

Of the 391 patients, 371 died, most of prostate cancer. Bone scan result, performance status, hemoglobin level, and insomnia and appetite loss as measured by the EORTC QLQ-C30 were independent predictors of survival. This model's area under the receiver operating curve was 0.65 compared with 0.63 without the two HRQOL factors.

CONCLUSION

Certain HRQOL sores, at baseline, seem to be predictors for duration of survival in HRPC. However, such measurements do not add to the predictive ability of models based only on clinical and biochemical factors.

Neuroendocrine serum tumour markers in hormone-resistant prostate cancer

OBJECTIVE

The primary aim of the study was to assess the prevalence of elevated serum levels of neuron-specific enolase (NSE) and chromogranin A (CgA) in hormone-resistant prostate cancer (HRPC), and to evaluate these markers' prognostic significance. Secondarily we wanted to assess any change in serum levels of NSE or CgA after palliative radiotherapy.

METHODS

Serum samples from patients with painful bone metastases or symptomatic pelvic tumours due to HRPC were analyzed for prostate specific antigen (PSA), NSE and CgA before and after palliative radiotherapy.

RESULTS

Forty-six of 138 patients (33%) had elevated NSE before radiotherapy, while 80 (58%) had elevated CgA, without correlation between the two markers or with PSA. After radiotherapy the median NSE level was significantly reduced (p=0.004), whereas CgA (p=0.009) and PSA (p=0.019) increased. In the multivariate survival analysis, a reduced performance status, >20 bone metastases on bone scan, low hemoglobin, and pre-radiotherapy elevated NSE levels indicated a short survival.

CONCLUSION

Together with known clinical parameters, NSE predicts survival in patients with HRPC. NSE could become a valuable prognostic marker in patients with this condition.

Nomogram for overall survival of patients with progressive metastatic prostate cancer after castration

PURPOSE

To develop a pretreatment prognostic model for survival of patients with progressive metastatic prostate cancer after castration using parameters that are measured during routine clinical management.

PATIENTS AND METHODS

Pretreatment clinical and biochemical determinants from 409 patients enrolled onto 19 consecutive therapeutic protocols from June 1989 through January 2000 were evaluated. The factors selected were age, Karnofsky performance status (KPS), hemoglobin (HGB), prostate-specific antigen (PSA), lactate dehydrogenase (LDH), alkaline phosphatase (ALK), and albumin. These factors were combined in an accelerated failure time regression model to produce a nomogram to predict median, 1-year, and 2-year survival. The nomogram was validated internally and externally using data from a multicenter randomized trial of suramin plus hydrocortisone versus hydrocortisone alone.

RESULTS

The median survival of the entire group was 15.8 months (range, 0.9 to 77.8 months); 87% have died. In multivariable analysis, KPS, HGB, ALK, albumin, and LDH were significantly associated with survival (P <.05), whereas age and PSA were not. All seven factors were included in the nomogram. When applied to the external validation data set, the nomogram achieved a concordance index of 0.67. Calibration plots suggested that the nomogram was well calibrated for all predictions.

CONCLUSION

A nomogram derived from pretreatment parameters that are measured on a routine basis was constructed. It can be used to predict the median, 1-year, and 2-year survival of patients with progressive castrate metastatic disease with reasonable accuracy. The information is useful to assess prognosis, guide treatment selection, and design clinical trials.

A retrospective analysis of the relationship between changes in serum PSA, palliative response and survival following systemic treatment in a Canadian randomized trial for symptomatic hormone-refractory prostate cancer

BACKGROUND

To investigate the relationship between changes in serum PSA, palliative response and survival following systemic treatment for symptomatic hormone-refractory prostate cancer (HRPC).

PATIENTS AND METHODS

A retrospective review of 161 patients, treated with mitoxantrone and prednisone (M + P) (n = 80), or prednisone alone (P) (n = 81) from a Canadian randomized phase III clinical trial. PSA response was defined by > or =50% decline compared to baseline. Palliative response was defined by the primary and secondary endpoints of the trial. All responses were required to be maintained on two visits at least three weeks apart. The Cox proportional hazards model and a landmark analysis (at nine weeks) were used to evaluate survival differences between PSA responders and non-responders.

RESULTS

Using an intent-to-treat analysis in which patients with missing PSA data are considered non-responders, 34% of M + P and 11% of P patients achieved a PSA response (P = 0.0001). Nineteen of thirty-six (53%) patients with PSA response and twenty-six of ninety (29%) patients without PSA response achieved a palliative response (P = 0.001 Chi-square test, phi coefficient = 0.28). From the landmark analysis. PSA responders had longer survival than non-responders (P = 0.009). In multivariate analysis, better performance status, higher hemoglobin and PSA response (P < 0.001) predicted for survival, but palliative response did not (P = 0.11).

CONCLUSIONS

There is significant but imperfect statistical association between PSA response and palliative response. PSA response was associated with longer survival. Patients treated with M + P were more likely to achieve a PSA response and a palliative response than those treated with P.

The pattern of serum markers in patients with androgen-independent adenocarcinoma of the prostate

In this exploratory study, our objectives were to correlate the serum and bone marrow concentrations of putative markers of prostate cancer progression in patients with advanced androgen-independent prostate cancer (AIPC), to assess the frequency and quantity of relative expression of these markers, and to correlate the expression of the markers with extent of disease (EOD) and overall survival. In a cohort of 50 patients with AIPC with bone metastases, we obtained serum and bone marrow samples and measured prostate specific antigen (PSA), serum interleukin-6 (sIL-6), bone marrow interleukin-6, serum chromogranin A (sCgA), bone marrow chromogranin A, and prostate specific membrane antigen (PSMA) by immunoassays. EOD was determined by quantifying identifiable bone lesions on radionuclide bone scans. Each variable was categorized into two groups (low and high) based on the median found in this cohort or on the cutoff based on normal limits when available. Analyses were performed in two subsets of patients with EOD either <20 or >/=20. Results showed that: (1) PSA is associated with EOD but not with outcome; (2) sIL-6 and sCgA may be intermediate markers of early progression in AIPC, because they are predictive of outcome only in patients with EOD <20; (3) elevated PSMA is associated with elevated sIL-6 but not with PSA, suggesting that PSMA may be a useful marker in AIPC; and (4) the ratio of PSA to putative markers of progression may reflect the complex clonal progression of prostate cancer. We conclude that patients with advanced AIPC exhibit one of two patterns of serologic marker expression: in some patients the disease status is reflected by PSA, and in others it is reflected by other markers. If these data are prospectively confirmed, this would help group patients with advanced AIPC into clinically relevant categories.

Prostate-specific antigen: A surrogate endpoint for screening new agents against prostate cancer?

BACKGROUND

An endpoint for clinical trials of prostate cancer which simplifies traditional endpoints (response of measurable lesions, progression rates, and death) is urgently needed. This is especially true for hormone-unresponsive disease, for which many new drugs are presently in a development phase. This paper presents a rationale for the use of prostate-specific antigen (PSA) in clinical trials of progressive prostate cancer under endocrine treatment.

METHODS

The study is based on 84 patients who progressed after radical prostatectomy or node dissection, of whom 24 showed increasing PSA levels under subsequent endocrine treatment. An average linear relationship between (log-transformed) PSA and time and a subject-specific deviation from this average relationship were assessed. The predictive value of the subject-specific parameters of the linear fit with respect to time to prostate cancer-specific death was determined. The outcomes of the fitting procedure were used to calculate sample sizes for future studies (duration, 6 months) using PSA increase over time in hormone-unresponsive prostate cancer as a marker for treatment efficacy.

RESULTS

The average PSA doubling time in this population was 4 months (corresponding time constant = 0.25). The assessed variance of the time constants equalled 0.04; the overall residual variance equalled 0.265. The subject-specific rate of change of the log-transformed PSA value in hormone-unresponsive prostate cancer was a highly significant predictor of prostate cancer-specific death. This suggests the potential usefulness of PSA as an endpoint in trials of hormone-unresponsive prostate cancer. Depending on conditions chosen (e.g, desired power and changes in log PSA slope), 18-70 participants per arm will be necessary in future phase III studies. A suggestion (algorithm) for the use of PSA in drug development is presented.

CONCLUSIONS

Relatively small PSA-based trials in patients with hormone-unresponsive prostate cancer are possible if a similar patient population is utilized. As long as surrogacy is not established, such studies cannot be considered conclusive with respect to effectiveness of treatment, but are likely to be useful as a screening tool for new drugs. Experimental confirmation in human prostate cancer model systems of synergism between PSA decrease and tumor control by a given test treatment is likely to enhance the level of certainty of PSA-based drug evaluation.

Role for retroperitoneal lymphadenectomy for testis cancer

There continue to be several controversies surrounding the role for retroperitoneal lymphadenectomy (RPL) in the management of patients with germ cell cancer of the testis. The initial treatment options for those with clinical stage I disease are surveillance (orchiectomy only), RPL or chemotherapy. Survival rates are similar with RPL and surveillance. Surgical morbidity has been reduced as techniques for RPL continue to improve. The likelihood of early or late (> 2 years) recurrence in the retroperitoneum is almost eliminated by RPL. Fewer follow-up computerized tomography scans of the abdomen are required and there are opportunities to reduce the duration and methods of follow-up, compared with surveillance. For patients with stage II disease, chemotherapy and RPL are equally effective initial treatment options but many patients require a combined approach. Initial RPL should be reserved for patients with smaller volume disease and possibly with lower preoperative marker levels. With RPL, patients are accurately staged and cured most of the time without double treatment. Approximately 30% of those with larger masses will have residual disease after initial chemotherapy and will require RPL as a second treatment. The third indication for RPL is to excise residual retroperitoneal masses following primary chemotherapy. Models to predict the presence of residual viable tumor, rather than necrosis only, at the time of surgery have been developed. If the orchiectomy specimen contained no teratoma, the tumor markers normalize after three or four courses of chemotherapy, and if the residual mass on computerized tomography scan is less than 2 cm in diameter, the rate of viable tumor may be low enough to omit RPL. In this way, the greater morbidity often associated with post-chemotherapy RPL may be avoided.

Epirubicin combined with estramustine phosphate in hormone-resistant prostate cancer: a phase II study

Twenty-four assessable patients with hormone-resistant prostate cancer (HRPC) were to receive daily doses of oral estramustine phosphate (EMP), 10 mg kg(-1), and intravenous epirubicin (EPR) infusions, 100 mg m(-2), every third week up to a cumulative dose of 500 mg m(-2). Biochemical response [> or = 50% reduction in pretreatment serum prostate-specific antigen (PSA) after three cycles of > or = 3 weeks' duration] was demonstrated in 13 of 24 patients included (54%). No objective response (WHO criteria) was observed, although seven of nine evaluable patients achieved a > or = 50% serum PSA reduction. Subjective improvement (pain score, performance status) occurred in 7 of 24 patients, whereas nine patients progressed subjectively. There was no correlation between subjective and biochemical response. Biochemical progression (> or = 50% increase of nadir PSA) occurred after a median of 12 weeks. All but two patients were alive after a median follow-up time of 8.7 months for surviving patients (range 3.3-13.2). Eight patients experienced grade 3/4 leucopenia, with no indication of cumulative myelosuppression. Cardiovascular toxicity was experienced by four patients. Two patients developed angioedema twice, in one patient requiring hospitalization at the intensive ward. Based on this limited series, the combination of EPR and EMP in patients with HRPC is tolerable and appears to be effective in terms of significant PSA reduction. The results warrant further investigations of the two drugs and, in particular, of the clinical significance of > or = 50% PSA decrease in patients with HRPC.

Increase of serum prostatic specific antigen and clinical progression in pN + MO prostate cancer

OBJECTIVE

To analyse the increase of serum prostatic specific antigen (PSA) as a means of early detection of progression in hormonally untreated or androgen-deprived patients with T1-T4, pN+ and MO prostate cancer.

PATIENTS AND METHODS

From 1986 to 1992 40 patients with T1-T4 pN+ MO prostate cancer were either deprived of androgen at diagnosis (Group 1, 19 patients) or had no immediate hormone manipulation (Group 2, 21 patients) and were followed at 3-6-monthly intervals when determinations of PSA and routine clinical/radiological examinations were performed. A significant increase in PSA was defined as a > or = 50% increase of the baseline PSA value which was the either the lowest PSA value within 6 months from the start of androgen deprivation (Group 1) or the initial PSA value (Group 2).

RESULTS

By June 1993 22 of the 40 patients had clinically progressed. In 12 patients the progression was preceded by a significant increase in PSA (Group 1, three of four progressing patients; Group 2, nine of 18 progressing patients). A PSA increase of > or = 50% was observed simultaneously with clinical progression in six patients, whereas clinical progression occurred in four patients with no previous or simultaneous significant increase in PSA. In four of nine hormonally untreated patients > or = 1 year elapsed between antecedent PSA increase and clinical progression.

CONCLUSION

In routine clinical practice PSA does not significantly increase (> or = 50% of baseline value and > 10 micrograms/L) before disease progression in about one third of patients with pN+ MO prostate cancer managed with or with no hormone manipulation. Future studies should be carried out to determine whether a lower rate of increase in PSA during follow-up has any clinical significance.

DNA ploidy, serum prostate specific antigen, histological grade and immunohistochemistry as predictive parameters of lymph node metastases in T1-T3/M0 prostatic adenocarcinoma

OBJECTIVE

To evaluate whether DNA ploidy and immunohistochemistry performed in primary prostatic carcinoma specimens give predictive information on regional lymph node metastasis in addition to T category, histological grade and serum prostate specific antigen (PSA).

PATIENTS AND METHODS

Pre-treatment TURP specimens from 80 patients with prostatic carcinoma T0-T3/M0 disease were retrospectively evaluated by means of DNA ploidy and histological grade, and immunostaining for PSA, prostatic acid phosphatase (PAP), neuron-specific enolase (NSE) and p53 protein. Pelvic lymph node dissection was performed in all patients. Serum PSA was determined in 76 of the 80 patients before pelvic staging lymphadenectomy. Thirty-two (40%) of the 80 patients had pN+ disease.

RESULTS

Thirty-six patients (46%) had serum PSA values below the upper reference limit (< or = 10 micrograms/L). By univariate analysis the pN category correlated with the serum PSA level (P < 0.001), histological grade (P < 0.001), tissue PSA (P < 0.001), tissue PAP (P < 0.04), T category (P < 0.005) and DNA ploidy (P < 0.02). Multivariate analysis revealed that the serum PSA level was the most powerful independent prognosticator, followed by the T category, tissue PAP and tissue PSA. Histological grade and DNA ploidy did not reach the level of significance in the multivariate analysis.

CONCLUSION

These data suggest that tissue PAP and tissue PSA predict the pN status in patients with T0-T3/M0 prostate carcinoma, in addition to serum PSA and T category. Neuroendocrine differentiation and p53 protein seem to have no predictive ability.

Pretreatment of metastatic disease. Prostate cancer in the older male

Prostate cancer is a disease of older men, with more than 80% of cases being diagnosed in men 65 years of age and older. Broader participation in screening and early detection programs has resulted in many diagnoses being made earlier in the course of the disease. However, an estimated 25-30% of cases among older men will be diagnosed as metastatic disease. These will be men initially diagnosed with metastatic disease as well as men previously treated for localized disease that has progressed to metastatic disease. The treatment of metastatic prostate cancer has been straightforward. Objective prognostic factors are assessed, and recommendations for the most suitable hormonal therapy are made. Androgen withdrawal, androgen blockade, or combination therapy are current first-line treatment modalities. Patients with good prognostic factors will generally do well for a long time, even experiencing a time-limited remission. Patients with a poor prognosis will die of their disease, with median survival being 18 months. Pretreatment assessment of men diagnosed with metastatic prostate cancer should include prognostic factors (tumor volume, histologic grade, DNA ploidy, and prostate specific antigen), health status (comorbidity and performance status), quality of life factors (as a baseline against which to evaluate subjective response and to predict subjective progression), and psychosocial dimensions (sexuality and sexual function, self image, sociability, and social support). Each of these assessment areas will provide important predictors for suitable treatment, response and progression, and survival. The challenge presented is the time and difficulty involved in weighing all these areas and in making an informed physician-patient decision on the most appropriate treatment plan. The physician must direct a health care team to treat metastatic prostate cancer effectively. This team includes oncology nurses, dietitians, social workers, spouses, significant others, and the patient himself.