Oral Relugolix for Androgen-Deprivation Therapy in Advanced Prostate Cancer

New endocrine method of oral male contraception

Essential for hormonal male contraception (HMC) is the inhibition of follicle-stimulating hormone (FSH), the hormone responsible for spermatogenesis. No drugs exist that can selectively suppress FSH without also inhibiting luteinizing hormone (LH), the hormone responsible for the biosynthesis of testosterone (T) and estradiol (E2) in men. The consequences are a loss of T and E2, with the accompanying symptoms and signs of T deficiency and E2 deficiency, respectively. The loss of T causes sexual function problems, including reduced libido and problems with erection and ejaculation. Moreover, T is not orally bioavailable, and there is a lack of suitable, orally bioavailable androgens to replace the loss of T. This has led to the use of nonoral T replacements, such as patches, gels, or parenteral administration of T or other androgens in current methods for HMC under development. In case these new HMC methods do not contain a testosterone preparation that is metabolized into E2, the suppression of LH will cause loss of E2 and symptoms of estrogen deficiency. We propose to investigate a new oral endocrine approach for HMC using a triple hormone drug called MANTE (Male oral contraception by a GnRH ANtagonist, Testosterone and an Estrogen). This method combines three novelties: (1) the use of an oral gonadotrophin-releasing hormone antagonist to suppress FSH and spermatogenesis, (2) a high dose of the natural adrenal androgen dehydroepiandrosterone to replace T, and (3) a low dose of an orally bioavailable estrogen, preferably estetrol (E4), to prevent signs and symptoms of estrogen deficiency.

Urolithins: Emerging natural compound targeting castration-resistant prostate cancer (CRPC)

Castration-resistant prostate cancer (CRPC) presents a significant challenge due to its resistance to conventional androgen deprivation therapies. Urolithins, bioactive metabolites derived from ellagitannins, have recently emerged as promising therapeutic agents for CRPC. Urolithins not only inhibit androgen receptor (AR) signaling, a crucial factor in the progression of CRPC, but also play a key role in regulating oxidative stress by their antioxidant properties, thereby inhibiting increased reactive oxygen species, a common feature of the aggressive nature of CRPC. Research has shown that urolithins induce apoptosis and diminish pro-survival signaling, leading to tumor inhibition. This review delves into the intricate mechanisms through which urolithins exert their therapeutic effects, focusing on both AR-dependent and AR-independent pathways. It also explores the exciting potential of combining urolithins with androgen ablation therapy, opening new avenues for CRPC treatment.

Real-world analyses of major adverse cardiovascular events and mortality risk after androgen deprivation therapy initiation in black vs. white prostate cancer patients

BACKGROUND

Prostate cancer(PCa) patients treated with androgen deprivation therapy(ADT) may experience major adverse cardiovascular events(MACE) [1]. Racial disparities in PCa incidence and outcomes have been noted. In contrast to older studies, three recent studies found significantly longer overall survival in Black vs. White patients: 2019 meta-analysis of nine phase III trials in men with metastatic castration-resistant PCa(CRPC) (n = 8820) [2]; 2020 registry study in men with metastatic CRPC (n = 1902) [3]; and 2023 study in men with non-metastatic CRPC (n = 12,992) [4]. Our "real-world" data study compared MACE and all-cause mortality risk for Black vs. White PCa patients. Compared to prior studies [1-4], our study encompassed a broader scope and was not exclusive to CRPC patients.

METHODS

Historical, longitudinal patient-level were collected from the Decision Resources Group (DRG, now Clarivate) Real World Evidence repository. The analysis included PCa patients receiving ≥1 ADT 1991-2020. Multivariable regression model accounted for baseline metastasis, BMI (<18.5 vs. ≥18.5 kg/m2), oncology vs. urology setting, antagonist vs. agonist, personal MACE history, tobacco history, baseline prostate-specific antigen (>4 vs. ≤4 ng/mL), race (White vs. Black), statin use, increasing age per year, ethnicity (non-Hispanic vs. Hispanic), increasing ADT exposure per year, diabetes, hypertension, and family MACE history.

RESULTS

MACE risk was higher for White patients than Black (4.0% vs. 2.4% at one year after ADT initiation; 21.0% vs. 13.3% at four years). Mortality risk after ADT initiation was 1.6% and 2.6% at 1 year and 11.7% and 18.1% at 4 years for Black and White patients, respectively.

CONCLUSIONS

Our analysis reveals a unique finding that MACE and all-cause mortality incidence were higher in White vs. Black patients. Black race is associated with lower MACE rates and improved survival for men undergoing ADT treatment. Whether selection bias, underlying biology or other factors are responsible for these differences remains unknown.

Exploration of cardiac adverse events associated with relugolix and degarelix: a multi-center pharmacovigilance study based on the FAERS database

BACKGROUND

Relugolix and degarelix are gonadotropin-releasing hormone antagonist. However, the cardiac safety of relugolix and degarelix in the real world remains uncertain. The purpose of this study was to explore the potential association of relugolix and degarelix with cardiac adverse events (AEs).

METHODS

We queried the FAERS database and selected AE reports with relugolix or degarelix as the first suspected drug for analysis. Reporting odds ratio (ROR) and empirical Bayes geometric mean (EBGM) were used to quantify the association between relugolix and degarelix and cardiac AEs.

RESULTS

A total of 5,598 and 372 AEs were reported for relugolix and degarelix, respectively, with 235 and 56 being cardiac AEs. The cardiac AEs associated with relugolix and degarelix predominantly occurred in elderly patients (>65 years). Disproportionality analysis showed that relugolix was significantly associated with electrocardiogram/heart rate abnormality and palpitations, with the strongest signal for electrocardiogram abnormality (ROR = 77.54, EBGM = 68.64). While degarelix was significantly associated with cardiac failure, myocardial Infarction, and arrhythmia, with cardiac failure showing the strongest signal (ROR = 8.62, EBGM = 97.71).

CONCLUSIONS

There are differences in the types of cardiac adverse events induced by relugolix and degarelix. Clinicians should consider their differences and enhanced electrocardiogram monitoring when prescribing GnRH antagonists to their patients.

The impact of concomitant therapies on the efficacy and safety of relugolix in advanced prostate cancer

Relugolix is a once-daily oral gonadotropin-releasing hormone antagonist that was approved by the U.S. Food and Drug Administration in 2020 for the treatment of advanced prostate cancer. Relugolix is commonly co-prescribed with complementary oncologic therapies or agents targeting associated comorbidities (e.g. cardiovascular disease). In this podcast, we review studies which evaluate relugolix with concomitant next-generation hormonal therapies (abiraterone, apalutamide, and enzalutamide), chemotherapy (docetaxel), radiotherapy, and common cardiovascular medications (antihypertensives, antithrombotics, and lipid‑lowering agents). Based on these studies, these therapies do not appear to affect relugolix efficacy and no new safety concerns were reported.

Study of persistence and adherence to ADT in prostate cancer: relugolix, degarelix, and GnRH agonists in the US

AIMS

Androgen deprivation therapy (ADT) is standard for advanced prostate cancer. Relugolix, a gonadotropin-releasing hormone (GnRH) receptor antagonist, is the only oral ADT, with limited real-world data on therapy persistence and adherence. This retrospective study evaluates persistence and adherence of relugolix, degarelix, and GnRH agonists (leuprolide, goserelin, triptorelin, histrelin) using data from the IBM MarketScan Research Database (Jan 2017 - Dec 2022).

METHODS

The IBM MarketScan Research Database (1 January 2017 - 31 December 2022) was used for enrollment history and claims. ADT adherence was measured by the proportion of days covered (PDC) at 3, 6, and 12 months, calculated as days on ADT divided by period duration. Kaplan-Meier analysis assessed treatment persistence by measuring time to treatment discontinuation.

RESULTS

Relugolix had higher adherence (PDC ≥ 80%) at 12 months (60.8%) compared to degarelix (13.0%) and GnRH agonists (46.3%). Median time to discontinuation was also longer for relugolix (13.5 months) than degarelix (3.1 months) and GnRH agonists (8.8 months). Persistence and adherence rates were higher in metastatic prostate cancer.

CONCLUSIONS

Findings support relugolix use as an oral treatment due to its favorable persistence and long-term adherence profiles.

Comparative Cardiovascular Safety of Gonadotropin-releasing Hormone Antagonists and Agonists Among Patients Diagnosed with Prostate Cancer: A Systematic Review and Meta-analysis of Real-world Evidence Studies

BACKGROUND AND OBJECTIVE

Gonadotropin-releasing hormone (GnRH) antagonists and agonists are cornerstone treatments in prostate cancer. However, evidence regarding the comparative cardiovascular safety of these drugs from clinical trials is inconclusive. The objective of this study was to systematically assess the risk of adverse cardiovascular events of GnRH antagonists compared with GnRH agonists across real-world evidence studies.

METHODS

We conducted a systematic search of PubMed, Embase, Cochrane Library, Scopus, and Web of Science (2008-2023). We included real-world evidence studies comparing the risk of cardiovascular outcomes of GnRH antagonists with those of GnRH agonists among patients with prostate cancer. We conducted a meta-analysis of effect estimates across studies at a low or moderate risk of bias, assessed via the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool, using random-effect models.

KEY FINDINGS AND LIMITATIONS

Among ten included studies, four were classified as having a moderate and six as having a serious risk of bias. Across three studies at a moderate risk of bias in the primary analysis, degarelix was associated with an increased risk (pooled relative risk [RR]: 1.31, 95% confidence interval [CI]: 1.14-1.51) of major adverse cardiovascular events (MACEs). An augmented risk was observed in two studies among patients with a history of cardiovascular disease (pooled RR: 1.31, 95% CI: 1.11-1.56) compared with one study among patients without a history of cardiovascular disease (RR: 1.15, 95% CI: 0.83-1.59).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Real-world evidence studies indicate that degarelix, compared with GnRH agonists, is associated with a modest increased risk of MACEs, particularly among patients with a history of cardiovascular disease. However, residual confounding due to the treatment of high-risk patients with degarelix may account for these findings. Additional large studies with detailed data on tumor characteristics and cardiovascular risk factors are needed to confirm these findings.

PATIENT SUMMARY

In this systematic evaluation of evidence among patients diagnosed with prostate cancer in routine care, degarelix was associated with higher cardiovascular adverse outcomes than gonadotropin-releasing hormone agonists.

Development and validation of a kinase-related gene signature as a novel diagnostic and prognostic model for prostate cancer

BACKGROUND

Prostate cancer (PCa) is a prevalent malignant tumor in men worldwide. Kinases play a key role in the development of multiple tumors. Nevertheless, the role of kinases in PCa remains largely unclear.

METHODS

A kinase-related gene signature was constructed by LASSO Cox regression analysis using the TCGA_PRAD cohort. The diagnostic and prognostic values of the signature were then evaulated. Furthermore, a loss-of-function assay was carried out to explore the function of NEK5 in PCa.

RESULTS

A signature of 13 kinase-related genes (NEK5, FRK, STK39, STYK1, IGF1R, RPS6KC1, TTK, CDK1, NEK2, PTK6, DAPK1, MELK and EPHA10) was constructed. The PCa patients presenting a high-risk score according to the signature demonstrated poorer disease-free survival compared to those with a low score. Additionally, TMB was found to be remarkably increased in patients categorized as high-risk relative to low-risk patients. Moreover, the 13-gene signature may also have good predictive value for PCa diagnosis. Furthermore, NEK5 expression was remarkably elevated in PCa tissues relative to benign tissues. NEK5 deficiency significantly inhibited PCa cell growth and suppressed mitochondrial OXPHOS.

CONCLUSION

The 13-gene signature constructed in this study may exhibit good performance in PCa diagnosis and prognosis evaluation. We identified the oncogenic role of NEK5 in PCa. NEK5 may serve as a therapeutic target for treatting PCa.

Addressing cardiovascular risks with a goal to prevent cardiovascular complications in patients undergoing antihormonal therapy for prostate cancer

Over 1 million cases of prostate cancer are reported every year, and it is the second most common cancer in men. Androgen deprivation therapy (ADT) is a hallmark treatment for prostate cancer but is associated with the development or exacerbation of cardiovascular disease. The most common cause of non-cancer death in patients with prostate cancer is cardiovascular disease. Thus, a better understanding of the prevalence of cardiovascular toxicity across all therapies, management of potential cardiovascular complications, and prevention of cardiovascular events is essential as treatments continue to evolve. In this article, the first in a 2-part series, we provide a review of the current landscape of ADT therapy and its association with cardiovascular disease, summarize recent clinical trial data evaluating cardiovascular outcomes, and provide insights on the management of cardiovascular risk factors and adverse events for clinicians managing this high-risk population of men undergoing potentially cardiotoxic treatment for prostate cancer.

Management and mitigation of metabolic bone disease and cardiac adverse events throughout the prostate cancer pathway: clinical review and practical recommendations

Some current prostate cancer (PCa) treatment regimens are known to have adverse effects on bone, for example androgen deprivation therapy (ADT), and on cardiovascular health, for example ADT and antiandrogen therapy. Strengthened recommendations for the practical assessment and management of bone and cardiovascular health in men with PCa are needed. This review aims to provide practical guidance for healthcare providers along the continuum of patient care on the management of bone and cardiovascular health in men with PCa undergoing ADT and antiandrogen therapy based on real-world evidence. Evidence was identified by searching PubMed for publications that reported the effects of PCa treatment on bone or cardiovascular health in a real-world setting and were published between January 2017 and August 2023. Review articles were excluded. The evidence identified indicates that ADT decreases bone mineral density (BMD) and increases the risk of osteoporosis and fractures. Bone-protecting agents (BPAs) are effective at improving bone health in patients undergoing ADT and antiandrogen therapy at all stages of the PCa pathway. Despite this, the use and timing of initiation of BPAs are variable. Furthermore, real-world studies have confirmed an association between ADT and cardiovascular risk. As survival outcomes improve, maintenance of bone and cardiovascular health is increasingly important in men with PCa. Risk is a continuous variable that must be assessed throughout the continuum of PCa treatment. Therefore, all men starting ADT should be assessed for bone and cardiovascular risk. Lifestyle adjustments, dietary supplementation and pharmacological intervention may be advised.

Assessing the effects of prostate cancer therapies on cardiovascular health

Contemporary advances in prostate cancer treatments have markedly improved patient outcomes, yet concerns persist regarding the increased cardiovascular toxicity of prostate cancer treatments, which is multifaceted. Local therapies entail non-negligible cardiovascular risks. The effects of androgen deprivation therapy, which is pivotal in disease management, on cardiovascular health remains contentious, with gonadotropin-releasing hormone agonists and antagonists showing varying cardiovascular outcomes. Despite the ongoing controversy over the cardiovascular risks of gonadotropin-releasing hormone antagonists versus agonists, current evidence does not support favouring one over the other based solely on cardiovascular risk. Combination therapy with androgen receptor pathway inhibitors and androgen deprivation therapy shows additive cardiovascular risks, but robust comparative data are lacking. Chemotherapies such as docetaxel and cabazitaxel, along with emerging targeted therapies and radiopharmaceuticals, are associated with varied cardiovascular risks, necessitating personalized patient assessment. Clinicians should adhere to cardio-oncology guidelines when prescribing therapeutic agents, especially for patients with pre-existing cardiovascular conditions. Optimal monitoring and management strategies are essential to mitigate cardiovascular morbidity and mortality.

Major adverse cardiovascular events among Black and White Veterans receiving androgen deprivation therapy for prostate cancer: a retrospective cohort study

BACKGROUND

Androgen deprivation therapy (ADT) is the cornerstone treatment strategy for men diagnosed with high-risk prostate cancer (PC) but may increase risk for major adverse cardiovascular events (MACE). We examined whether men treated with ADT and radiation therapy (ADT + RT) developed MACE at a higher rate than men receiving RT alone. Secondly, we sought to determine if Black men receiving RT + ADT developed MACE at a higher rate than White men.

METHODS

This retrospective cohort study examined time to diagnosis of MACE among Veterans with PC. We used a 1:1 propensity score matching process to determine whether treatment type (ADT + RT vs. RT alone), race (Black vs. White men) or having a previous diagnosis of a cardiometabolic disease (CMD) were associated with differences in the rate at which men develop MACE.

RESULTS

Veterans with PC were White (68%) and Black (32%). At PC diagnosis, the mean age was 65.9 years. The majority had stage 2 disease (83.0%) classified as intermediate risk (43.1%). Treatment-matched models showed men receiving ADT + RT were less likely to develop MACE when they no pre-existing CMD. Men treated with ADT + RT or RT alone had significantly increased risks of MACE is they had pre-existing CMD. Black men had the same risk of MACE as non-Hispanic Whites.

CONCLUSIONS

Preexisting CMD and multimorbidity are significant risks for MACE among men treated for PC within the VA healthcare system whether treated with ADT + RT or with RT alone, highlighting the importance pretreatment optimization of comorbidities.

Management of Patients with Advanced Prostate Cancer. Report from the 2024 Advanced Prostate Cancer Consensus Conference (APCCC)

BACKGROUND AND OBJECTIVE

Innovations have improved outcomes in advanced prostate cancer (PC). Nonetheless, we continue to lack high-level evidence on a variety of topics that greatly impact daily practice. The 2024 Advanced Prostate Cancer Consensus Conference (APCCC) surveyed experts on key questions in clinical management in order to supplement evidence-based guidelines. Here we present voting results for questions from APCCC 2024.

METHODS

Before the conference, a panel of 120 international PC experts used a modified Delphi process to develop 183 multiple-choice consensus questions on eight different topics. Before the conference, these questions were administered via a web-based survey to the voting panel members ("panellists").

KEY FINDINGS AND LIMITATIONS

Consensus was a priori defined as ≥75% agreement, with strong consensus defined as ≥90% agreement. The voting results show varying degrees of consensus, as discussed in this article and detailed in the Supplementary material. These findings do not include a formal literature review or meta-analysis.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The voting results can help physicians and patients navigate controversial areas of clinical management for which high-level evidence is scant or conflicting. The findings can also help funders and policymakers in prioritising areas for future research. Diagnostic and treatment decisions should always be individualised on the basis of patient and cancer characteristics, and should incorporate current and emerging clinical evidence, guidelines, and logistic and economic factors. Enrolment in clinical trials is always strongly encouraged. Importantly, APCCC 2024 once again identified important gaps (areas of nonconsensus) that merit evaluation in specifically designed trials.

Navigating management of localized prostate cancer in the geriatric population

Prostate cancer (PCa) is highly prevalent among aging men and a significant contributor to global mortality. Balancing early detection and treatment of "clinically significant" disease with avoiding over-detection and overtreatment of slow-growing tumors is challenging, especially for elderly patients with competing health risks and potentially aggressive disease phenotypes. This review emphasizes the importance of individualized approaches for diagnosing and treating PCa in geriatric patients. Active surveillance and watchful waiting are common strategies, while surgical interventions are less frequent but considered based on comorbidities, disease risk, and patient preferences. Radiotherapy, often combined with androgen deprivation therapy, is typical for higher-risk cases, and focal therapy is emerging to reduce morbidity. An inclusive approach combining advanced diagnostics, life expectancy considerations, and minimally invasive interventions can improve decision-making. Integrating multidisciplinary strategies with better risk stratification and less invasive options can significantly enhance care and outcomes for elderly patients with significant PCa.

Cardiovascular Risk in Prostate Cancer

Cardiovascular disease is common in patients with prostate cancer and is an important cause of death. Cardiovascular risk factors are frequent in this population and are often not addressed to thresholds recommended by cardiovascular practice guidelines. Androgen deprivation therapy (ADT) reduces muscle strength and increases adiposity, thereby increasing the risk of diabetes and hypertension, although its relationship with adverse cardiovascular events requires confirmation. Androgen receptor signaling inhibitors and CYP17A1 inhibitors may confer incremental risks of hypertension and cardiovascular events to ADT. Lower cardiovascular risk with gonadotropin-releasing hormone antagonists as compared with agonists requires prespecified randomized clinical trial confirmation.

Utilization of patient-reported outcomes to assess adherence to relugolix when combined with stereotactic body radiation therapy for intermediate to high-risk prostate cancer

Introduction

Injectable GnRH receptor agonists have been shown to improve cancer control when combined with radiotherapy (RT). Relugolix is an oral GnRH receptor antagonist that achieves rapid testosterone suppression. Non-adherence to oral medications due to poor social support or bothersome side effects may increase the risk of cancer recurrence. This prospective study sought to evaluate early testosterone suppression and relugolix drug adherence when combined with prostate stereotactic body radiation therapy (SBRT). Utilization of patient-reported outcomes (PROs) to assess oral medication adherence and guide intervention may improve the appropriate utilization of oral medications. This study focuses on the use of the Simplified Medication Adherence Questionnaire (SMAQ) as a tool to assess relugolix adherence.

Methods

Relugolix was initiated at least 2 months prior to questionnaire administration. Adherence was assessed using the SMAQ. Total testosterone levels were obtained at the time of SMAQ administration. Castration was defined as serum testosterone ≤ 50 ng/dL. Poor drug adherence was delineated as failure to reach castration or non-adherence per the SMAQ (any non-adherence answer, missed > 2 doses in last week or since last visit). To compare the demographic and clinical characteristics of patients who adhered to treatment versus who did not, t-test, Wilcoxon rank sum test, Chi-square test, and Fisher's exact test were used. A p-value < 0.05 determined statistical significance.

Results

Between August 2021 and December 2023, 78 men were treated at Georgetown with relugolix and prostate SBRT per an institutional protocol. The median age was 72, and 41% of patients were non-white. Patients initiated relugolix at a median of 4 months prior to the SMAQ (2-19 months). 96% of patients achieved castration (≤ 50 ng/dL) at the time of the SMAQ. 96% of men reported always taking relugolix at the appropriate time. 1% discontinued medication due to bothersome side effects, 17% reported forgetting to take the medication, and 4% reported missing a dose during the weekend. 98% and 93% did not miss a dose more than 2 times in the last week and since the last visit, respectively. Overall patient-reported drug adherence was 75%. No patient demographic or clinical characteristic predicted non-adherence.

Discussion

Relugolix allows for high rates of castration and drug adherence when combined with prostate SBRT. Monitoring drug adherence during treatment allows for prompt detection of non-adherence and timely intervention. Future studies should focus on how to optimally incorporate this questionnaire into patient management.

Maintenance of patient-reported health-related quality of life post neoadjuvant relugolix prior to the initiation of prostate radiation therapy

Introduction

Studies have demonstrated that injectable GnRH receptor agonists further suppress cancer progression when paired with radiotherapy (RT) in patients with intermediate- to high-risk prostate adenocarcinoma. Relugolix is a newly available oral GnRH receptor antagonist that achieves swift and profound castration (total testosterone <20 ng/dl) at high rates, which may shape patients' health-related quality of life. The main objective of this prospective study was to explore the effects of neoadjuvant relugolix on health-related quality of life in prostate cancer patients immediately prior to stereotactic body radiation therapy (SBRT).

Methods

Patients treated at Georgetown between January 2021 and September 2023 with neoadjuvant relugolix per an institutional protocol were included in the study (IRB 12-1775). The five-item EQ-5D-3L, a well-established tool for quantifying patient-reported health status, was administered to each patient at baseline (prior to relugolix treatment) and again 1 h before the start of SBRT. Higher EQ Visual Analog Scale (VAS) overall scores reflected better quality of life (range 0 to 100). In line with the questionnaire framework, individual elements (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) were rated on a three-point scale from 1 (no problems) to 3 (severe problems). McNemar's test and paired-sample t-test were performed to analyze changes pre- and post-relugolix treatment. Our investigation determined clinical significance based on minimally important difference (MID) calculated as 0.5 times the baseline standard deviation.

Results

Among the 87 patients, average age was 71 years, 42% were non-white, and 24% were considered obese (BMI ≥30 kg/m²). Relugolix was initiated a median of 4 months before SBRT initiation (IQR: 3.9-5.4), with 87% of patients reaching profound castration (<20 ng/dl). The VAS overall score was notably higher at baseline (mean ± SD: 82 ± 10) compared to the paired score before RT (79 ± 14, p = 0.02), although this difference was not clinically significant. No statistically or clinically significant changes were observed in any of the five individual items.

Conclusion

The use of neoadjuvant relugolix prior to prostate radiation therapy had no clinically significant impact on patient-reported health-related quality of life. Moreover, no statistically significant reductions were observed in any of the five individual health-related quality of life measures. As a key direction for future research, relugolix-associated changes to healthy-related quality of life should be contrasted to those brought about by injectable GnRH agonists.

Adaptive Treatment of Metastatic Prostate Cancer Using Generative Artificial Intelligence

Despite the expanding therapeutic options available to cancer patients, therapeutic resistance, disease recurrence, and metastasis persist as hallmark challenges in the treatment of cancer. The rise to prominence of generative artificial intelligence (GenAI) in many realms of human activities is compelling the consideration of its capabilities as a potential lever to advance the development of effective cancer treatments. This article presents a hypothetical case study on the application of generative pre-trained transformers (GPTs) to the treatment of metastatic prostate cancer (mPC). The case explores the design of GPT-supported adaptive intermittent therapy for mPC. Testosterone and prostate-specific antigen (PSA) are assumed to be repeatedly monitored while treatment may involve a combination of androgen deprivation therapy (ADT), androgen receptor-signalling inhibitors (ARSI), chemotherapy, and radiotherapy. The analysis covers various questions relevant to the configuration, training, and inferencing of GPTs for the case of mPC treatment with a particular attention to risk mitigation regarding the hallucination problem and its implications to clinical integration of GenAI technologies. The case study provides elements of an actionable pathway to the realization of GenAI-assisted adaptive treatment of metastatic prostate cancer. As such, the study is expected to help facilitate the design of clinical trials of GenAI-supported cancer treatments.

Testosterone Recovery Following Androgen Suppression and Prostate Radiotherapy (TRANSPORT): A Pooled Analysis of Five Randomized Trials from the Meta-Analysis of Randomized Trials in Cancer of the Prostate (MARCAP) Consortium

BACKGROUND AND OBJECTIVE

Time to testosterone recovery (TR) following androgen deprivation therapy (ADT) with gonadotropin-releasing hormone agonists varies widely. We evaluate TR kinetics and the oncological impact of an effective castration period in patients receiving definitive radiotherapy and ADT for prostate cancer.

METHODS

We obtained individual patient data from randomized controlled trials of radiotherapy with ADT and prospectively collected serial testosterone data from the MARCAP Consortium. We estimated the times to noncastrate TR (>1.7 nmol/l) and nonhypogonadal TR (>8.0 nmol/l) were estimated for each prescribed ADT duration, and developed corresponding nomograms. The association between effective castration period and metastasis-free survival (MFS) for any given ADT duration was evaluated via multivariable Cox regression. We conducted cubic spline analyses to assess nonlinear associations.

KEY FINDINGS AND LIMITATIONS

We included 1444 men from five trials in the analysis, of whom 115 received 4 mo, 880 received 6 mo, 353 received 18 mo, 36 received 28 mo, and 60 received 36 mo of ADT. Times to noncastrate TR and to nonhypogonadal TR varied considerably by ADT duration. Higher baseline testosterone and lower age were associated with a higher likelihood of TR (p < 0.001 for both). Effective castration period was not linearly associated with MFS for any ADT duration on Cox regression. Cubic spline analysis revealed that the optimal effective castration period for an MFS benefit was 10.6 mo for men who received 6 mo of ADT and 18 mo for men who received 18 mo of ADT.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Time to TR varies according to the ADT duration, baseline testosterone, and age. The relationship between effective castration period and MFS may be nonlinear, with a longer effective castration period being helpful for men receiving 6 mo of ADT.

Implementing evidence-based strategies for men with biochemically recurrent and advanced prostate cancer: Consensus recommendations from the US Prostate Cancer Conference 2024

Current US clinical practice guidelines for advanced prostate cancer management contain recommendations based on high-level evidence from randomized controlled trials; however, these guidelines do not address the nuanced clinical questions that are unanswered by prospective trials but nonetheless encountered in day-to-day practice. To address these practical questions, the 2024 US Prostate Cancer Conference (USPCC 2024) was created to generate US-focused expert clinical decision-making guidance for circumstances in which level 1 evidence is lacking. At the second annual USPCC meeting (USPCC 2024), a multidisciplinary panel of experts convened to discuss ongoing clinical challenges related to 5 topic areas: biochemical recurrence; metastatic, castration-sensitive prostate cancer; poly [ADP-ribose] polymerase inhibitors; prostate-specific membrane antigen radioligand therapy; and metastatic, castration-resistant prostate cancer. Through a modified Delphi process, 34 consensus recommendations were developed and are intended to provide clinicians who manage prostate cancer with guidance related to the implementation of novel treatments and technologies. In this report, the authors review the areas of consensus identified by the USPCC 2024 experts and evaluate ongoing unmet needs regarding translational application of the current clinical evidence.

Testosterone recovery after androgen deprivation therapy

PURPOSE

Finite courses of androgen deprivation therapy (ADT) are often utilized in men undergoing treatment for prostate cancer. Previous evidence suggests that timing of testosterone (T) recovery can be variable after ADT. Recently, an oral gonadotropin releasing-hormone (GnRH) antagonist, relugolix, has demonstrated more rapid T recovery than injectable GnRH agonists such as leuprolide. In this study, we sought to evaluate patient characteristics associated with T recovery in patients undergoing ADT of defined duration.

MATERIALS AND METHODS

The Northwestern Enterprise Data Warehouse was queried for men with prostate cancer who completed a course of ADT and subsequently had a testosterone lab performed. Testosterone recovery was evaluated for levels that reached above castrate (T > 50 ng/dl), partial recovery (T > 150 ng/dl), and full recovery (T ≥ 300 ng/dl).

RESULTS

388 men who received finite courses of ADT were identified (348 receiving leuprolide, 36 receiving relugolix, and 4 receiving degarelix). In multivariable Cox regression analysis, men who were prescribed GnRH antagonists (HR = 3.74, CI = 2.53-5.53, P ≤ 0.001) and who were younger (HR for 1 year increase in age = 0.96, CI = 0.95-0.98, P < 0.001) were more likely to achieve partial recovery. In a subgroup analysis, men who received extended ADT courses (>12 months) with a GnRH agonist had lower rates of partial T recovery (HR = 0.58, CI = 0.41-0.81, P = 0.001).

CONCLUSION

T recovery after ADT is variable with roughly one sixth of men remaining castrate. GnRH antagonist use and younger age are associated with higher rates of T recovery after ADT. Longer ADT courses were associated with worse T recovery rates.

Use of Relugolix for the Prevention of Impending Oliguria and Progressive Renal Failure in a Suspected Case of Prostate Carcinoma

Androgen deprivation therapy for advanced prostate cancer has traditionally relied on luteinizing hormone-releasing hormone antagonists (LHRH). However, newer oral gonadotropin hormone-releasing hormone antagonists (GnRH) offer faster responses and fewer adverse effects. A 65-year-old male diabetic patient with a history of lower urinary tract symptoms and an indwelling Foley catheter for two weeks presented with respiratory difficulty, bilateral lower limb swelling, and decreased urine output. The investigation was suggestive of locally advanced prostate cancer with obstructive uropathy along with acute or chronic kidney disease. The patient was admitted to the ICU and stabilized. An urgent bedside prostate biopsy was performed. Relugolix 360 mg orally was given on the first day followed by 120 mg daily before histopathological confirmation due to impending oliguria and progressive kidney injury. Subsequent follow-up demonstrated clinical improvements, including reduced PSA and testosterone levels, confirming the efficacy of relugolix in managing advanced prostate cancer. Timely intervention and therapeutic adherence are crucial for optimal outcomes. Additionally, it highlights the preference for LHRH agonists in emergencies and the potential of oral GnRH antagonists like relugolix in prostate cancer management.

Cardiovascular Considerations After Cancer Therapy: Gaps in Evidence and JACC: CardioOncology Expert Panel Recommendations

Cancer survivors, particularly those treated with anthracyclines and chest radiation, face an elevated risk of cancer therapy-related cardiovascular toxicity. These complications affect not only physical health, but also life expectancy. Risk factors for cancer therapy-related cardiovascular toxicity include age at which cancer treatment was received, the use of (potentially) cardiotoxic cancer therapies, and the presence of concomitant cardiovascular risk factors. Current guidelines provide recommendations for cardiovascular surveillance after cancer therapy, including type and frequency. All cancer survivors are advised to undergo annual clinical screenings and optimization of cardiovascular risk factors. Those at higher risk should undergo additional cardiovascular testing. This document aims to summarize the available evidence, present practical recommendations, and outline existent gaps in the current literature regarding cardiovascular care after cancer therapies.

Effectiveness, pharmacokinetics, and safety of triptorelin acetate microspheres in patients with locally advanced and metastatic prostate cancer

Background

A newly generic microspheres, sustained-release formulation of triptorelin acetate 3.75 mg has been developed.

Objectives

To evaluate the efficacy, pharmacokinetics, and safety of triptorelin 1-month formulation in Chinese patients with prostate cancer.

Design

An open-label, multicenter clinical trial with one arm testing a 1-month sustained-release triptorelin formulation in prostate cancer patients.

Methods

Patients with prostate cancer received three consecutive 28-day injections of triptorelin acetate. The primary endpoint was the proportion of successful patients over the total number of evaluable patients. Treatment success was defined as testosterone suppression below the clinical castration level (i.e., <0.5 ng/mL) at day 28 and maintenance of clinical castration until study completion (day 84). The frequency of patients with testosterone concentrations <0.2 ng/mL was also studied.

Results

The study included 125 patients. All 125 patients received at least one dose of the study drug and 122 completed the study. The successful patient proportion among the evaluable patients was 97.6% (122/125; 95% CI, 92.7-99.2). 95.1% (116/122) achieved testosterone concentrations <0.2 ng/mL. The pharmacokinetic profile of triptorelin during the first 3 months of treatment, evaluated in a subset of the study population (n = 11), showed sustained release of triptorelin from the formulation. Values for AUC0-τ calculated from day 0 to 28, and day 56 to 84 were 134.42 (28.76), and 154.72 (21.86) h*ng/mL, respectively. The most common treatment-related adverse events were increased alanine aminotransferase (18.4%), increased aspartate aminotransferase (16.0%), and hot flashes (9.6%). Prolonged QT interval on electrocardiogram, erectile dysfunction, and decreased libido each occurred in ⩽4% of the patients. The frequently reported local adverse reaction was pain at the injection site, experienced by 2.4% (3/125) of the patients.

Conclusion

3.75-mg Triptorelin acetate microspheres for injection were effective in achieving and maintaining testosterone suppression and were well tolerated in patients with prostate cancer.

Trial registration

chictr.org.cn (ChiCTR2000033188).

Thrombo-inflammation linking androgen suppression with cardiovascular risk in patients with prostate cancer

Androgen deprivation therapy (ADT), a key element of prostate cancer treatment, is associated with increased risk for cardiovascular morbidity and mortality. The underlying mechanisms include adverse metabolic alterations, but further mechanisms are likely. Animal studies suggest increased progression of atherosclerosis in androgen deprived conditions. Based on in vitro studies, lack of androgens may modulate immune cells including monocytes, macrophages, and T-cells towards a pro-inflammatory phenotype and pro-atherogenic function. As a novel aspect, this review summarizes existing data on the effect of androgens and androgen deprivation on platelet activity, which play a major role in inflammation and in the initiation and progression of atherosclerotic lesions. Testosterone modulates platelet aggregation responses which are affected by dose level, source of androgen, and age. Data on the effects of ADT on platelet activity and aggregation are limited and conflicting, as both increased and decreased aggregation responses during ADT have been reported. Gaps in knowledge about the mechanisms leading to increased cardiovascular risk during ADT remain and further research is warranted. Improved understanding of pathogenic pathways linking ADT to cardiovascular risk may help identify clinically useful diagnostic and prognostic biomarkers, and accelerate finding novel therapeutic targets, and thus optimize prostate cancer treatment outcomes.

Risk of cardiovascular events following intermittent and continuous androgen deprivation therapy in patients with nonmetastatic prostate cancer

BACKGROUND

Intermittent androgen deprivation therapy (iADT) alleviates some side effects of continuous (c) ADT in patients with prostate cancer (PC), but its relative impact on ADT-associated comorbidities is uncertain. We assessed real-world use of iADT and cADT and associated risk of cardiovascular and endocrine/metabolic events in patients with nonmetastatic (nm) PC.

METHODS

This retrospective longitudinal cohort study included patients with nmPC initiating systemic ADT with gonadotropin-releasing hormone agonists (goserelin, histrelin, leuprolide, and triptorelin) or antagonists (degarelix) in the US Surveillance, Epidemiology and End Results-Medicare database (2010-2017), who had ≥ 36 months of continuous insurance coverage, unless death occurred, and did not receive chemotherapy or next-generation hormonal therapies during follow-up (through 2019). Risk of major adverse cardiovascular events (MACE [myocardial infarction, stroke, cardiomyopathy/heart failure, pulmonary embolism, ischemic heart disease, all-cause mortality]) and endocrine/metabolic events (diabetes, hypercholesterolemia, bone fractures, and osteoporosis) were examined between cohorts. Inverse probability of treatment-weighted Cox regression models estimated adjusted hazard ratios (HRs) of the outcomes.

RESULTS

Of 10,655 eligible patients, 2,095 (19.7%) received iADT and 8,560 (80.3%) cADT. Median follow-up was 43.9 and 48.4 months and median ADT duration (excluding iADT gaps) was 22.0 and 13.5 months for the iADT and cADT cohorts, respectively. Patients receiving cADT had a lower risk of MACE vs. iADT (HR 0.90; 95% confidence interval [CI] 0.83-0.96). No difference in risk of endocrine/metabolic events was observed (HR 0.97; 95% CI 0.92-1.03). Subgroup analysis found that the difference in MACE was maintained in patients with a history of cardiovascular disease (HR 0.90; 95% CI 0.83-0.98) and eliminated in patients without (HR 0.94; 95% CI 0.82-1.08).

CONCLUSIONS

Patients with nmPC who received cADT had a lower risk of MACE and similar risk of endocrine/metabolic events vs. those who received iADT. Further research assessing both regimens is needed to inform treatment decisions.

Testosterone recovery post discontinuation of androgen deprivation for the treatment of advanced prostate cancer

While suppressing testosterone to castration levels is the aim of androgen deprivation therapy for the treatment of advanced prostate cancer, studies have shown that prolonged low testosterone levels can have negative effects on patients' overall health and quality of life. This podcast covers two recently published papers that examined testosterone recovery in different ways. One real-world study assessed the impact of delayed testosterone recovery on clinical outcomes in patients with prostate cancer. A second subgroup analysis of the HERO trial assessed rates of testosterone recovery in patients receiving the long-acting, injectable gonadotropin-releasing hormone receptor agonist, leuprolide or the oral, once-daily gonadotropin-releasing hormone receptor antagonist, relugolix.

The landscape of androgen deprivation therapies for the treatment of advanced prostate cancer

In this podcast discussion, we review the landscape of androgen deprivation therapies (ADT) for the treatment of advanced prostate cancer. Prior to 2020, available ADT options to achieve chemical castration included gonadotropin-releasing hormone receptor agonists (e.g., leuprolide) and antagonists (e.g., degarelix) administered via muscular or subcutaneous injection. In 2020, the once-daily oral gonadotropin-releasing hormone antagonist, relugolix, received US regulatory approval for the treatment of advanced prostate cancer based on results from the Phase III HERO trial. In this podcast, we also discuss the primary efficacy and safety results of this trial, and key points for providers and patients to consider as they discuss the different ADT options.

Relugolix for the treatment of prostate cancer

INTRODUCTION

Androgen deprivation therapy consists of the cornerstone of prostate cancer medical treatment. Until recently, castration of hypothalamus-hypophysis-gonadal axial was based on injectable medical agents. A few years ago, a novel per os administered GnRH antagonist was approved leading testosterone to castration level. Relugolix was approved by FDA in 2020, and it is the first per os administered GnRH antagonist. The present study is a literature review of the efficacy, safety and clinical perspectives of relugolix.

AREAS COVERED

A literature narrative review was conducted using PubMed/MEDLINE, Scopus, and the Cochrane library. Studies written in English language, considering efficacy, safety and cost-effectiveness of relugolix compared with other androgen deprivation therapies were included in the review.

EXPERT OPINION

Recent studies have examined efficacy of relugolix revealing a testosterone suppression percentage of 78.4% after 48 weeks from treatment initiation. Moreover, relugolix has been associated with less major cardiovascular events as well as better rate of testosterone recovery after treatment completion compared with the GnRH agonists. However, there is no head-to-head trial comparing relugolix with injectable GnRH antagonists, so far. As a result, a trial comparing the methods of antagonists' administration should be performed in the future.

Pharmacological treatment landscape of non-metastatic hormone-sensitive prostate cancer: A narrative review on behalf of the meet-URO Group

The definition of "non-metastatic hormone-sensitive prostate cancer" (nmHSPC) can be applied to patients with prostate cancer (PC) who are androgen-deprivation therapy-naïve and without evidence of metastatic disease. This definition includes heterogeneous situations; however, PC patients at high risk of metastatic spread - and who have not started a hormonal treatment - constitute a unique category with unmet clinical needs. This narrative review critically discusses the advances that characterize the rapidly evolving diagnostic and therapeutic scenario in the nmHSPC setting. We found that nmHSPC represents a grey zone in the context of PC. New clinical trials are trying to redefine the therapeutic algorithm of these patients, but escalating treatment seems not to be the right choice for the overall population. Biomarkers able to stratify patients - including molecular ones - are urgently needed, and biomarker-based clinical trials could clarify their prognostic and predictive role in the nmHSPC scenario.

Testosterone and male contraception

PURPOSE OF REVIEW

Rates of unintended pregnancy have remained relatively stagnant for many years, despite a broad array of female contraceptive options. Recent restrictions on access to abortion in some countries have increased the urgency for expanding contraceptive options. Increasing data suggest men are keen to utilize novel reversible male contraceptives.

RECENT FINDINGS

Despite decades of clinical research in male contraception, no reversible hormonal product currently exists. Nestorone/testosterone, among other novel androgens, shows promise to finally move to pivotal Phase 3 studies and introduction to the marketplace.

SUMMARY

Hormonal male contraception utilizes androgens or androgen-progestin combinations to exploit negative feedback that regulates the hypothalamic-pituitary-testicular axis. By suppressing release of gonadotropins, these agents markedly decrease endogenous testosterone production, lower intratesticular testosterone and suppress spermatogenesis. The addition of a progestin enhances the degree and speed of sperm suppression. The androgen component preserves a state of symptomatic eugonadism in the male. There is growing demand and acceptance of male contraceptive options in various forms. As these formulations progress through stages of drug development, regulatory oversight and communication with developers around safety and efficacy standards and garnering industry support for advancing the production of male contraceptives will be imperative.

Cardiovascular Risk in Prostate Cancer: JACC: CardioOncology State-of-the-Art Review

Cardiovascular disease is common in patients with prostate cancer and is a significant cause of death. Cardiovascular risk factors are frequent in this population and are often not addressed to thresholds recommended by cardiovascular practice guidelines. Androgen deprivation therapy reduces muscle strength and increases adiposity, increasing the risk for diabetes and hypertension, although its relationship with adverse cardiovascular events requires confirmation. Androgen receptor pathway inhibitors, including androgen receptor antagonists and cytochrome P450 17A1 inhibitors confer incremental risks for hypertension and cardiovascular events to androgen deprivation therapy. Lower cardiovascular risk with gonadotropin-releasing hormone antagonists compared with agonists requires confirmation in well-designed randomized trials.

French AFU Cancer Committee Guidelines - Update 2024-2026: Prostate cancer - Management of metastatic disease and castration resistance

PURPOSE OF THIS DOCUMENT

The Oncology Committee of the French Urology Association is proposing updated recommendations for the management of recurrent and/or metastatic prostate cancer (PCa).

METHODS

A systematic review of the literature from 2022 to 2024 was conducted by the CCAFU on the therapeutic management of recurrent PCa following local or metastatic treatment, assessing the references based on their level of evidence.

RESULTS

Molecular imaging is the standard approach for assessing recurrence after local treatment and should not delay early salvage treatment. Androgen deprivation therapy (ADT) is the primary treatment option for metastatic PCa. Intensification of ADT, now cononsidered standard care for metastatic PCa, involves incorporating at least one new-generation hormone therapy (ARPI). For patients with high-volume metastatic disease at diagnosis, adding docetaxel to ADT+ARPI may be considered for eligible patients. In castration-resistant PCa (CRPC) patients, poly(ADP) ribose polymerase (PARP) inhibitors and PSMA radioligand therapy are new treatment options. The combination and sequencing of treatmentsare influenced by several factors, including patient and disease characteristics, prior therapies, genomic status, and molecular imaging findings.

CONCLUSION

This update of French recommendations should help to improve the management recurrent or metastatic PCa patients.

Adverse events analysis of Relugolix (Orgovyx®) for prostate cancer based on the FDA Adverse Event Reporting System (FAERS)

BACKGROUND

Due to the limitations of clinical trials, some delayed and rare adverse events (AEs) may remain undetected, and safety information can be supplemented through post-market data analysis. This study aims to comprehensively analyze the AEs associated with Relugolix (Orgovyx®) using data from the FAERS database, and gain a better understanding of the potential risks and side effects of Relugolix (Orgovyx®) therapy.

METHODS

Data of Relugolix (Orgovyx®) were collected from the FAERS database covering the period from the fourth quarter of 2020 to the third quarter of 2023. Disproportionality analysis was performed by calculating the reporting odds ratios (ROR), proportional reporting ratio (PRR), Bayesian analysis confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) to detect positive signals.

RESULTS

Totally, 5,382,189 reports were collected from the FAERS database, 4,397 reports of Relugolix (Orgovyx®) were identified as the 'primary suspected (PS)' AEs. Relugolix (Orgovyx®) induced AEs occurred in 26 organ systems. 58 significant disproportionality preferred terms (PTs) satisfying with the four algorithms were retained at the same time. Unexpected significant AEs such as Pollakiuria, and Prostatic specific antigen increased also occur. The median time of onset was 60 days. The majority of the AEs occurred within the first 30 days after Relugolix (Orgovyx®) initiation.

CONCLUSION

Common AEs included Hot flush, Fatigue, Asthenia, Constipation, and Myalgia. These AEs should be focused on when using the drug to avoid serious consequences. In addition, the study results also suggested that the drug may exist Pollakiuria, Prostatic specific antigen increased and other AEs not mentioned in the manual, to supplement the AEs in the manual. This study is helpful for clinicians and pharmacists to improve their understanding of Relugolix (Orgovyx®) related AEs, and take timely prevention and treatment measures to ensure drug safety for patients.

The Effect of Androgen Deprivation Therapy on the Cardiovascular System in Advanced Prostate Cancer

Androgen deprivation therapy (ADT) is a mainstay treatment for metastatic prostate cancer, improving progression-free survival. ADT suppresses the production of testosterone and reduces circulating levels of the hormone. Luteinizing hormone-releasing hormone (LH-RH) agonists are the most commonly used ADT modality. They can be given alone or in combination with androgen synthesis inhibitors or androgen receptor antagonists. An estimated 40% of prostate cancer patients will receive ADT as part of their therapy during their lifetime. However, ADT has numerous adverse effects, including an increased cardiovascular risk that impacts quality of life. Relugolix is an alternative form of ADT. It is the only oral gonadotropin-releasing hormone antagonist, circumventing injection site reactions, making it easier for patients to take, and thus increasing compliance. Testosterone suppression with relugolix is excellent and testosterone recovery after discontinuation is rapid. This paper reviews the ADT and anti-androgen treatment options for men with prostate cancer and the cardiovascular effects of these therapies. There is accumulating evidence that cardiovascular risk with relugolix is lower than with other ADT medications and also lower than with androgen synthesis inhibitors and androgen receptor antagonists. This paper provides insight into the use of different ADT regimens based on the cardiovascular status and circumstances. It explores strategies to mitigate negative cardiovascular consequences and highlights the need for further study.

Relugolix Plus Enzalutamide For Metastatic Hormone-Sensitive Prostate Cancer: A Case Report

Background

In the UK, relugolix, an oral gonadotropin-releasing hormone receptor antagonist, is indicated for advanced hormone-sensitive prostate cancer, and as neo-adjuvant and adjuvant treatment in combination with radiotherapy in patients with high-risk localised or locally advanced hormone-dependent prostate cancer. Experience with the combination of oral relugolix plus oral enzalutamide is limited.

Case Presentation

A white British male (66 years old) with a history of myelodysplastic syndrome, chronic neutropenia and indeterminate colitis presented with metastatic adenocarcinoma of the prostate gland. The patient started subcutaneous leuprorelin acetate and oral enzalutamide. After 8 weeks, the oral enzalutamide dose was reduced because of fatigue. Following the second leuprorelin injection, the patient developed a subcutaneous abscess that required surgical incision and drainage. The patient switched to oral relugolix and continued with oral enzalutamide. Within 3 months of commencing leuprorelin and enzalutamide the prostate specific antigen (PSA) concentration fell from a peak of 269.00 ng/mL to 2.55 ng/mL. Following the switch to oral relugolix plus enzalutamide, the PSA remained stable until the most recent assessment 11 months later. Relugolix plus enzalutamide was well tolerated.

Conclusion

Relugolix plus enzalutamide produced a sustained reduction in PSA and the combination was well tolerated. Further research including real world data should assess relugolix in doublet and triplet combinations for prostate cancer.

Hormonal male contraception

INTRODUCTION

Male contraception with exogenously administered hormones suppresses both luteinizing hormone and follicle stimulating hormone leading to low intratesticular testosterone concentration. This results in reversible suppression of spermatogenesis and marked decrease in sperm output in the ejaculate and preventing pregnancy in the female partner.

PRIOR STUDIES

Studies of testosterone administered alone or in combination of another gonadotropin suppressive agent such as a progestin or gonadotropin releasing hormone (GnRH) analog showed decisively that the exogenous hormone administrations are effective in suppressing sperm output with few adverse events that are not anticipated. In contraceptive efficacy studies, testosterone alone or combined with a progestin are as effective in preventing pregnancies as female contraceptive methods.

CONCLUSION

Hormone combinations for male contraception are in late-phase clinical trials and hold the promise of being the new, reversible contraception method for men in over half a century. Lessons learned from the male hormonal contraceptive development pave the way for new targeted approached to regulate male fertility.

Post-marketing safety concerns with relugolix: a disproportionality analysis of the FDA adverse event reporting system

BACKGROUND

Relugolix has been used to treat advanced prostate cancer. This study assessed adverse events (AEs) associated with relugolix from the US Food and Drug Administration Adverse Event Reporting System (FAERS).

METHODS

Disproportionality analysis, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) algorithms, were employed to quantify the signals of relugolix-associated AEs.

RESULTS

A total of 5,059,213 reports of AEs were collected from the FAERS database, of which 5,662 reports were identified with relugolix as the "primary suspect (PS)". A total of 70 significant disproportionality PTs conforming to the four algorithms were simultaneously retained. Unexpected new AEs, such as erectile dysfunction, gynaecomastia, testicular atrophy, male genital atrophy, libido decreased might also occur.

CONCLUSION

This study found potential new AEs signals and might provide important support for clinical monitoring and risk identification of relugolix.

Patient Preferences for Attributes of Androgen Deprivation Therapies in Prostate Cancer: A Discrete Choice Experiment with Latent Class Analysis

INTRODUCTION

Medical androgen deprivation therapy (ADT) options have expanded for patients with advanced prostate cancer (PC). Historically, ADT was primarily available in long-acting injectable formulations. In 2020, the first oral formulation was US Food and Drug Administration-approved for adults with advanced PC. This study's aim was to assess patient preferences for attributes of medical ADT, including mode of administration, side effects, impact on sexual interest, and out-of-pocket (OOP) costs, and to segment respondents into distinct groups based on their treatment choice patterns.

METHODS

A cross-sectional survey was conducted among US residents aged > 40 years with PC, employing a discrete choice experiment to assess preferences for ADT attributes. For each choice task, respondents were asked to select the hypothetical treatment profile that they preferred out of two presented. Latent class analysis (LCA) was conducted to estimate attribute-level preference weights and calculate attribute relative importance for groups of respondents with similar treatment preferences.

RESULTS

A total of 304 respondents completed the survey (mean age 64.4 years). LCA identified four preference groups, named according to the attribute each group considered most important: Sexual interest, Cost-sensitive, Favors daily pill, and Favors injection. Most respondents in the Sexual interest group were < 65 years, while the Cost-sensitive group was mostly ≥ 65 years. Favors daily pill had the highest proportion of ADT-naïve individuals. On average, respondents in these groups preferred an oral medication. Favors injection, which had the highest proportion of ADT-experienced individuals, preferred infrequent intramuscular injections, lower chance of post-ADT testosterone recovery, and lower OOP cost.

CONCLUSION

Respondents differed in their preferences regarding ADT attributes, highlighting the need for patient involvement in their treatment decisions. Effective communication between healthcare providers and patients about the benefits and risks of available therapies should be encouraged to ensure that patients receive the PC treatment that best meets their needs.

Patient Demographics and Major Adverse Cardiovascular Events after Androgen Deprivation Therapy for Prostate Cancer

Background

The association between patient demographics and CV events after ADT using real-world data was evaluated. In addition to encompassing >30 times more patients than all previous MACE studies, this is the first study, to the best of our knowledge, to include a comprehensive listing of many demographic factors from one large, recent US dataset over a long period of time.

Materials and Methods

The retrospective analysis of data in the Decision Resources Group (now Clarivate) Real World Evidence repository, representing >300M US patients from 1991 to 2020 across all US regions, was performed. Patients with PCa receiving ≥1 ADT injection were included. MACE risk after ADT initiation was evaluated for demographic and potential PCa-related risk factors. Kaplan-Meier survival curves were constructed, and Cox regression was used to evaluate the association between MACE risk and demographic/PCa-related risk factors.

Results

Overall, MACE risk was slightly lower in the first year after ADT initiation (3.9%) vs. years 2-4 (∼5.2%). In a multivariate Cox model, MACE risk after ADT initiation was significantly higher for older vs. younger patients (adjusted HR per increasing year = 1.08, 95% CI: 1.07-1.09), men with a history of MACE vs. without (HR = 2.22, 95% CI: 1.72-2.88), men with very low BMI vs. normal or high BMI (HR for decreasing BMI per kg/m2 = 1.02, 95% CI: 1.01-1.03), White vs. Black patients (HR = 1.30, 95% CI: 1.08-1.55), and patients who did not use statins vs. those who did (HR = 1.13, 95% CI: 1.00-1.27). Of the PCa-related risk factors, MACE risk after ADT initiation was significantly higher for oncology vs. urology treatment setting (HR = 2.47, 95% CI: 2.12-2.88), patients with baseline metastasis vs. those without (HR = 2.30, 95% CI: 1.72-3.07), and patients treated with antagonists vs. agonists (HR = 1.62, 95% CI: 1.25-2.10).

Conclusions

Demographic factors are important contributors to increased MACE risk for men with PCa on ADT. Clinicians should monitor risk factors and modify if possible.

Strategic Advances in Combination Therapy for Metastatic Castration-Sensitive Prostate Cancer: Current Insights and Future Perspectives

The contemporary treatment for metastatic castration-sensitive prostate cancer (mCSPC) has evolved significantly, building on successes in managing metastatic castration-resistant prostate cancer (mCRPC). Although androgen deprivation therapy (ADT) alone has long been the cornerstone of mCSPC treatment, combination therapies have emerged as the new standard of care based on recent advances, offering improved survival outcomes. Landmark phase 3 trials demonstrated that adding chemotherapy (docetaxel) and androgen receptor pathway inhibitors to ADT significantly enhances overall survival, particularly for patients with high-volume, high-risk, or de novo metastatic disease. Despite these advancements, a concerning gap between evidence-based guidelines and real-world practice remains, with many patients not receiving recommended combination therapies. The challenge in optimizing therapy sequences, considering both disease control and treatment burdens, and identifying clinical and biological subgroups that could benefit from personalized treatment strategies persists. The advent of triplet therapy has shown promise in extending survival, but the uro-oncology community must narrow the gap between evidence and practice to deliver the most effective care. Current research is focused on refining treatment approaches and utilizing biomarkers to guide therapy selection, aiming to offer more personalized and adaptive strategies for mCSPC management. Thus, aligning clinical practices with the evolving evidence is urgently needed to improve outcomes for patients facing this incurable disease.

Metastasis-Free Survival Versus Treatment-Free Survival in Biochemically Recurrent Prostate Cancer: The EMBARK Trial

What is most important to patients with BCR prostate cancer? Metastasis-free versus treatment-free survival.

The impact of neoadjuvant relugolix on multi-dimensional patient-reported fatigue

Introduction

Androgen deprivation therapy has been shown to improve cancer control when combined with radiotherapy. Relugolix is an oral GnRH receptor antagonist that achieves rapid profound testosterone suppression, which may increase the perception and/or impact of fatigue. This study sought to evaluate neoadjuvant relugolix-induced fatigue in prostate cancer patients prior to the start of stereotactic body radiation therapy (SBRT).

Methods

Relugolix was initiated at least two months before SBRT. The 13-item Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire was collected at baseline and one hour prior to SBRT initiation. A five-point scale was used to score individual items. Overall scores range from 0-52 and individual item scores were converted to 0-100, with higher scores reflecting less fatigue. Five "experience" items explored self-perceptions of fatigue, and eight "impact" items sought to evaluate the effect of fatigue on daily activities. Items were evaluated for statistical significance (paired t-test, p < 0.05) and clinical significance (minimally important difference (MID); 0.5 standard deviation from baseline).

Results

Between March 2021 to December 2023, 89 men were treated at Georgetown with neoadjuvant relugolix and SBRT. Mean age was 71 years (range: 49-87). Median initiation of relugolix was 4.5 months prior to SBRT (range: 2-14.2 months). 93% patients achieved castration (testosterone levels ≤ 50 ng/dL) and 85% patients achieved profound castration (testosterone levels ≤ 20 ng/dL). 87 patients completed the FACIT-F questionnaire, with an average overall score of 45.6 at baseline and 41.0 at SBRT initiation. This difference was statistically and clinically significant (p < 0.01, MID = 3.55). Patients experienced an increase in fatigue for 12 of 13 items, with statistically significant changes for 11 items. Three of five experience items showed a clinically significant increase in fatigue. Only two of eight impact items were clinically significant.

Discussion

Our study shows that relugolix significantly increases fatigue, affecting multiple areas of life. While the fatigue does not appear to generally impact a patient's ability to carry out normal activities, patients demonstrate frustration with being too tired for these activities. It is essential for clinicians to counsel prostate cancer patients on the impact of neoadjuvant relugolix on quality-of-life issues like fatigue.

Testosterone Recovery for Relugolix Versus Leuprolide in Men with Advanced Prostate Cancer: Results from the Phase 3 HERO Study

BACKGROUND

In the HERO study, relugolix demonstrated sustained testosterone suppression superior to that of leuprolide acetate (97% vs 89%; difference 7.9% [95% confidence interval, 4.1-12%; p < 0.001]).

OBJECTIVE

To analyze testosterone recovery in a prespecified subset of men from the HERO study not indicated to continue androgen deprivation therapy.

DESIGN, SETTING, AND PARTICIPANTS

Men (N = 934) were randomized (2:1) to receive relugolix 120 mg orally daily or leuprolide acetate injections every 12 wk for 48 wk.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Testosterone recovery was assessed in 184 men who completed 48 wk of treatment. During the 90-d recovery period, assessments included time to testosterone recovery (>280 ng/dl; ≥80% of baseline testosterone), serum levels of prostate-specific antigen and pituitary hormones, and adverse events.

RESULTS AND LIMITATIONS

The cumulative incidence rate of testosterone recovery to >280 ng/dl at 90 d following drug discontinuation was significantly higher in the relugolix cohort (n = 137) than in the leuprolide acetate cohort (n = 47; 54% vs 3.2%; nominal p = 0.002). The median time to testosterone recovery was faster following relugolix treatment than with leuprolide acetate treatment (86.0 d vs 112.0 d). Compared with leuprolide acetate, more men treated with relugolix achieved ≥80% of baseline testosterone levels (39% vs 2.1%). Men ≤65 yr and those with baseline testosterone greater than the median had a higher incident rate of testosterone recovery. Adverse events were generally similar between treatment groups. One limitation is the short testosterone recovery follow-up period.

CONCLUSIONS

Oral relugolix had faster and more complete recovery of testosterone to normal levels after treatment discontinuation than leuprolide acetate in a subset of men from the HERO study. The clinical implications of a faster testosterone recovery with relugolix may be significant for men being treated with androgen deprivation therapy and influence treatment decisions.

PATIENT SUMMARY

The male hormone testosterone is reduced during androgen deprivation therapy for prostate cancer. Reduced testosterone levels cause side effects, impacting patient quality of life. When treatment is stopped, the side effects lessen over time as the levels of testosterone come back to pretreatment range (testosterone recovery). In this study, we found that the time to testosterone recovery was faster with relugolix than with leuprolide acetate.

A Model-Informed Drug Development Approach to Design a Phase 3 Trial of Teverelix Drug Product in Advanced Prostate Cancer Patients with Increased Cardiovascular Risk

Teverelix drug product (DP) is a parenteral gonadotropin-releasing hormone (GnRH) antagonist that has been successfully tested in phase 2 trials for hormone-sensitive advanced prostate cancer (APC) and benign prostatic hyperplasia (BPH). In previous APC trials, teverelix DP was administered as intramuscular (IM) and subcutaneous (SC) injections, using a loading dose and (in a single trial) a maintenance dose. Our objective was to derive an optimal dosing regimen for phase 3 clinical development, using a pharmacometrics modeling approach. Data from 9 phase 2 studies (229 patients) was utilized to develop a population pharmacokinetic (PK) model that described the concentration profile accommodating both IM and SC routes of administration. A 2-compartment model with sequential first-order absorption (slow and fast) and lag times best described the PK profiles of teverelix following SC and IM administration. An indirect response model with inhibition of production rate was fit to describe testosterone (T) concentrations based on physiological relevance. The final population PK-pharmacodynamic model was used to conduct simulations of various candidate dosing regimens to select the optimal dosing regimen to achieve clinical castration (T < 0.5 ng/mL by day 28) and to sustain clinical castration for 26 weeks. Model simulation showed that a loading dose of 360 mg SC and 180 mg IM with a maintenance dose of 360 mg SC 6-weekly (Q6W) starting at day 28 can achieve a ≥95% castration rate up to 52 weeks. This dose regimen was selected for phase 3 clinical development, which includes cardiovascular safety assessment in comparison to a GnRH agonist.

EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer. Part II-2024 Update: Treatment of Relapsing and Metastatic Prostate Cancer

BACKGROUND AND OBJECTIVE

The European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Urological Pathology (ISUP)-International Society of Geriatric Oncology (SIOG) guidelines on the treatment of relapsing, metastatic, and castration-resistant prostate cancer (PCa) have been updated. Here we provide a summary of the 2024 guidelines.

METHODS

The panel performed a literature review of new data, covering the time frame between 2020 and 2023. The guidelines were updated and a strength rating for each recommendation was added on the basis of a systematic review of the evidence.

KEY FINDINGS AND LIMITATIONS

Risk stratification for relapsing PCa after primary therapy may guide salvage therapy decisions. New treatment options, such as androgen receptor-targeted agents (ARTAs), ARTA + chemotherapy combinations, PARP inhibitors and their combinations, and prostate-specific membrane antigen-based therapy have become available for men with metastatic PCa.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Evidence for relapsing, metastatic, and castration-resistant PCa is evolving rapidly. These guidelines reflect the multidisciplinary nature of PCa management. The full version is available online (http://uroweb.org/guideline/ prostate-cancer/).

PATIENT SUMMARY

This article summarises the 2024 guidelines for the treatment of relapsing, metastatic, and castration-resistant prostate cancer. These guidelines are based on evidence and guide doctors in discussing treatment decisions with their patients. The guidelines are updated every year.