Early Versus Delayed Androgen Deprivation for Prostate Cancer: New Fuel for an Old Debate

The impact of androgen deprivation therapy on the lipid profile in patients with prostate carcinoma

Background

Dyslipidemia is directly related to morbidity and mortality in elderly prostate carcinoma patients. The purpose of this study was to evaluate the effects of androgen deprivation therapy (ADT) on the lipid profile among Indian patients with locally advanced and metastatic prostate carcinoma.

Methods

The prospective database of prostate carcinoma patients, who received ADT and whose lipid profile data for the first two years of treatment with ADT was available, were divided into two groups for retrospective analysis: Group A patients are those who had undergone bilateral orchidectomy, while group B patients received luteinizing hormone-releasing hormone agonist (LHRHa). The data analyzed include baseline characteristics, prostate-specific antigen (PSA), and lipid profile.

Results

A total of 69 eligible patients were divided into two groups: group A—29 patients and group B—40 patients. Patients of both the groups reported a significant decrease in the mean serum PSA level from the commencement of ADT and remained close to nadir level till 24 months. In the group A patients, lipid profile parameters except high-density lipoprotein cholesterol showed statistically insignificant deterioration with maximum impact at 6 months. Among the group B patients, the total cholesterol (11.9%), triglycerides (22.2%), and low-density lipoprotein cholesterol (21.1%) increased significantly at 6 months and returned to the near baseline at 12 months and thereafter persisted at the similar level. The mean very low-density lipoprotein level (15.5%) also increased significantly at 6 months and then showed a gradual decline till 24 months of follow-up.

Conclusions

LHRH agonist used as ADT for prostate carcinoma leads to a statistically significant but clinically insignificant temporary worsening in the lipid profile.

The Relationships between Survivals and Early Salvage Androgen Deprivation Therapy for Non-Organ Confined Prostate Cancer after Radical Prostatectomy

Androgen deprivation therapy (ADT) is one salvage treatment used when prostate-specific antigen (PSA) recurs after radical prostatectomy (RP), especially in high-risk prostate cancer (PC) patients. However, the optimal timing for salvage ADT (SADT) is still unclear. In this study, we analyzed the efficacy of early SADT for non-organ confined PC. We investigated pathologically confirmed, non-organ confined PC patients who received SADT for PSA recurrence after RP. Patients with distant metastasis, those with lymph node involvement confirmed by lymph node dissection, and those who received neo-adjuvant or adjuvant therapy were excluded. Early SADT was defined as ADT initiated before PSA levels reached 0.5 ng/ml from the nadir PSA level after RP. Univariable and multivariable Cox regression analyses were performed for distant metastasis-free, PC-specific, and overall survival. Data from 345 patients were analyzed. The median follow-up duration was 82 months. The median PSA level was 10.9 ng/ml. Patients with T3b or T4 stage cancers represented 24.9% of the cohort; those with a Gleason score ≥9 represented 15.1%. The 10-year distant metastasis-free survival, PC-specific survival and overall survival were 87.1%, 92.0%, 80.9%, respectively. In univariable and multivariable Cox regression analyses, SADT that was initiated when PSA levels were less than 0.5 ng/mL was significantly associated with improved distant metastasis-free survival, PC-specific survival, and overall survival in non-organ confined PC. Early SADT initiated in patients with PSA levels <0.5 ng/mL was associated with increased distant metastasis-free survival, PC-specific survival, and overall survival in non-organ confined PC after RP.

The current status of hormone treatment for prostate cancer patients in Korean real-world practice: a multi-institutional observational study

We aimed to evaluate the current nationwide trend, efficacy, safety, and quality of life (QoL) profiles of hormone treatment in real-world practice settings for prostate cancer (PCa) patients in Korea. A total of 292 men with any biopsy-proven PCa (TanyNanyMany) from 12 institutions in Korea were included in this multi-institutional, observational study of prospectively collected data. All luteinizing hormone-releasing hormone (LHRH) agonists were allowed to be investigational drugs. Efficacy was defined as (1) the rate of castration (serum testosterone ≤50 ng dl⁻¹) at 4-week visit and (2) breakthrough (serum testosterone >50 ng dl⁻¹ after castration). Safety assessments included routine examinations for potential adverse events, laboratory tests, blood pressure, body weight, and bone mineral density (BMD, at baseline and at the last follow-up visit). QoL was assessed using the Expanded Prostate Cancer Index Composite-26 (EPIC-26). The most common initial therapeutic regimen was LHRH agonist with anti-androgen (78.0%), and the most commonly used LHRH agonist for combination and monotherapy was leuprolide (64.0% for combination and 58.0% for monotherapy). The castration and breakthrough rates were 78.4% and 6.6%, respectively. The laboratory results related to dyslipidemia worsened after 4 weeks of hormone treatment. In addition, the mean BMD T-score was significantly lower at the last follow-up (mean: −1.950) compared to baseline (mean: −0.195). The mean total EPIC-26 score decreased from 84.8 (standard deviation [s.d.]: 12.2) to 78.3 (s.d.: 8.1), with significant deterioration only in the urinary domain (mean: 23.5 at baseline and 21.9 at the 4-week visit). These findings demonstrate the nationwide trend of current practice settings in hormone treatment for PCa in Korea.

Survival and mortality of elderly men with localized prostate cancer managed with primary androgen deprivation therapy or by primary observation

BACKGROUND

Androgen deprivation therapy (ADT) remains a primary treatment for localized prostate cancer (PCa) even though there is no evidence that its use is beneficial in the absence of curative treatment.

METHODS

Men aged ≥70 years (n = 16,534) diagnosed with localized PCa from 1985 to 2014 and managed either with primary observation or ADT in the absence of curative treatment were included. The cases were identified from the population-based Finnish Cancer Registry. We estimated the standardized mortality ratios (SMR) for overall mortality by treatment group. We determined the relative risk (RR) of PCa-specific mortality (PCSM) and other-cause mortality between the two treatment groups. Survival was determined using the life table method. Two age groups (70-79 years and ≥ 80 years) and three calendar time cohorts (1985-1994, 1995-2004, and 2005-2014) were compared following adjustment of propensity score matching between the treatment groups with four covariates (age, year of diagnosis, educational level, and hospital district). Follow-up continued until death or until December 31, 2015.

RESULTS

Patients in the observation group had lower overall SMRs than those in the ADT group in both age cohorts over the entire study period. PCSM was higher in men aged 70-79 years undergoing primary ADT compared to those managed by observation only (RR: 1.70, 95% confidence interval [CI]: 1.29-2.23 [1985-1994]; RR 1.55, 95% CI: 1.35-1.84 [1995-2004]; and RR 2.71, 95% CI: 2.08-3.53 [2005-2014]); p = 0.005 for periodic trend. A similar trend over time was also observed in men aged > 80 years; (p for age-period interaction = 0.237). Overall survival was also higher among men in their 70's managed by observation compared to those undergoing ADT.

CONCLUSIONS

Primary ADT within four months period from diagnosis is not associated with improved long-term overall survival or decreased PCSM compared to primary conservative management for men with localized PCa. However, this observational study's conclusions should be weighted with confounding factors related to cancer aggressiveness and comorbidities.

Impact of Early Salvage Androgen Deprivation Therapy in Localized Prostate Cancer after Radical Prostatectomy: A Propensity Score Matched Analysis

PURPOSE

Androgen deprivation therapy (ADT) is used as a salvage treatment for men with biochemical recurrence (BCR) of prostate cancer (PCa) following initial radical prostatectomy (RP). The optimal time at which to begin salvage ADT (sADT) remains controversial. In this retrospective study, we evaluated the efficacy of initiating sADT in patients before prostate-specific antigen (PSA) values met the clinical definition of BCR.

MATERIALS AND METHODS

We identified 484 PCa patients who received sADT for BCR after RP. Median follow-up was 82 months. Propensity score matching was performed based on preoperative PSA level, pathologic T stage, and Gleason score. Patients were assigned to two groups of 169 patients each, based on PSA levels at the time of sADT: Group A (without meeting of the definition of BCR) and Group B (after BCR). Kaplan-Meier survival analyses and Cox regression analyses were performed.

RESULTS

The median PSA level at sADT initiation was 0.12 ng/mL in group A and 0.42 ng/mL in group B. Kaplan-Meier analyses showed that group A had favorable disease progression-free survival (DPFS) and distant metastasis-free survival (DMFS), but did not have better cancer-specific survival (CSS) than group B. In subgroup analyses, group A showed better CSS rates in the non-organ confined PCa group. In Cox regression analyses, early sADT was associated significantly with DPFS and DMFS rates, however, did not correlate with CSS (p=0.107).

CONCLUSION

Early sADT after RP improved DPFS and DMFS. Furthermore, early sADT patients demonstrated better CSS in non-organ confined PCa.

Androgen-deprivation therapy alone versus combined with radiation therapy or chemotherapy for nonlocalized prostate cancer: a systematic review and meta-analysis

In this paper, we reviewed the long-term survival outcomes, safety, and quality-of-life of androgen-deprivation therapy (ADT) alone versus combined with radiation therapy (RT) or chemotherapy for locally advanced and metastatic prostate cancer (PCa). A literature search was performed using OvidSP. Randomized controlled trials (RCTs) that met the following criteria were included: including locally advanced or metastatic PCa, comparing ADT alone versus combined with any treatment method and reporting quantitative data of disease control or survival outcomes. Finally, eight RCTs met the inclusion criteria. Among these, three compared ADT versus ADT plus RT (n = 2344) and one compared ADT versus ADT plus docetaxel–estramustine (n = 413) in locally advanced PCa; two compared ADT versus ADT plus docetaxel (n = 1175) and two compared ADT versus ADT plus estramustine (n = 114) in metastatic PCa. For locally advanced PCa, the addition of RT to long-term ADT can improve the outcomes of survival and tumor control with fully acceptable adverse effects. Specially, the pooled odds ratio (OR) of overall survival (OS) was 1.43 (95% confidence interval 1.20–1.71) when compared ADT plus RT with ADT alone (P < 0.0001). For metastatic hormonally sensitive PCa, the concurrent use of docetaxel plus ADT was effective and safe (pooled OR of OS: 1.29 [1.01–1.65]: P = 0.04). In all, long-term ADT plus RT and long-term ADT plus docetaxel should be considered as proper treatment option in locally advanced and metastatic hormonally sensitive PCa, respectively. The major limitation for the paper was that only eight RCTs were available.

Limitations of Prostate-specific Antigen Testing After a Prostate Cancer Diagnosis

Prostate-specific antigen (PSA) is frequently used in isolation to guide treatment decisions in men with recurrent prostate cancer, a practice discouraged by prostate cancer working groups and guidelines. Instead, PSA should be used with imaging and other factors to make treatment decisions.

Survival after initiation of androgen deprivation therapy for prostate cancer of Australian men

OBJECTIVE

To examine duration of use and survival rates of Australian males who initiated androgen deprivation therapy for prostate cancer, including survival rates stratified by the type of the initial androgen deprivation therapy and age at initiation.

METHOD

Cohort study using Australian Government Department of Veterans' Affairs (DVA) data. Males aged 50 and over initiating androgen deprivation therapy (2008-2010) were included in the cohort. Time to death or end of study (31 Dec 2012), duration of therapy and 1 to 5-year relative survival rates stratified by type of initial therapy and age were presented.

RESULTS

Of the androgen deprivation therapy initiators (n=3,611, mean age 84), 92% survived 1 year with the relative survival rate decreasing to 79% at 3 years and to 57% at 5 years. Survival outcomes stratified by the type of initial therapy showed slightly higher rates amongst those initiated on gonadotropin releasing hormone analogues or on combined androgen blockage compared to those initiated on anti-androgens. Age specific rates were similar amongst the younger groups (under 80 years old) at each single point of time and were slightly higher than in those aged 80 years and over for some points of time. Fifty percent of patients received androgen deprivation therapy for extended periods (30 months).

CONCLUSIONS

The 1-year relative survival of veterans was high and similar to that of the general Australian population with prostate cancer. Factors such as tumour stage and grade (not available in the data) could explain differences in survival based on the type of the initial therapy.

Risk factors for clinical metastasis in men undergoing radical prostatectomy and immediate adjuvant androgen deprivation therapy

BACKGROUND

Adjuvant androgen deprivation therapy (ADT) is a treatment option for prostate cancer (PC) patients after radical prostatectomy (RP). Although it can achieve a good progression-free survival rate, some patients still develop clinical metastasis. We here investigated risk factors of clinical metastasis in post- prostatectomy patients who received immediate adjuvant ADT.

MATERIALS AND METHODS

We identified 197 patients with non-metastatic PC who underwent RP at our institution between 2000 and 2012, followed by adjuvant ADT. The associations of various clinicopathologic factors with clinical metastasis (primary endpoint) and cancer-specific survival (secondary endpoint) were assessed. Multivariate analysis was conducted using a Cox proportional hazards model. Median follow-up was 87 months after RP.

RESULTS

Nine (4.6%) patients developed clinical metastasis and six (3.0%) died from PC. Eight of nine metastatic patients had a pathologic Gleason score (GS) 9 and developed bone metastasis, while the remaining one had pathologic GS 7 and developed metastasis only to para-aortic lymph nodes. On multivariate analyses, pathologic GS ≥9 and regional lymph node metastasis (pN1) were independent predictors of clinical metastasis and pathologic GS ≥9 was an independent predictor of cancer-specific death.

CONCLUSIONS

Pathologic GS ≥9 and pN1 were independent predictors of clinical metastasis in post-prostatectomy patients who received immediate adjuvant ADT. Furthermore, pathologic GS ≥9 was an indispensable condition for bone metastasis, which may imply that patients with GS ≤8 on adjuvant ADT are unlikely to develop bone metastasis.

Less advanced disease at initiation of salvage androgen deprivation therapy is associated with decreased mortality following biochemical failure post-salvage radiation therapy

BACKGROUND

The optimal clinical context for initiation of salvage androgen deprivation therapy (SADT) following the biochemical recurrence of localized prostate cancer remains controversial. We chose to investigate if disease burden at time of SADT initiation is associated with clinical outcomes following biochemical failure (BF) post-salvage radiation therapy (SRT).

METHODS

Medical records of 575 patients receiving SRT at a single institution from 1986-2010 were retrospectively reviewed. Of 250 patients experiencing BF post-SRT, 172 had a calculable prostate-specific antigen doubling time (PSADT) prior to SADT initiation. These patients comprise the analyzed cohort and were divided into four groups based on characteristics at SADT initiation: those with PSADTs >3 months without distant metastasis (DM) (group 1 [less advanced disease], n=62), those with PSADTs <3 months without DM (group 2 [more advanced disease], n=28), those with DM (group 3 [more advanced disease], n=32), and those not receiving SADT during follow-up (group 4, n=50). Endpoints included prostate cancer-specific mortality (PCSM) and overall mortality (OM). Kaplan-Meier methods were used to estimate survival, and Cox proportional hazards models were used for multivariate analysis.

RESULTS

Median follow-up post-SRT was 7.9 years. Patients starting SADT with more advanced disease were at significantly increased risk for PCSM (hazard ratio [HR]:2.8, 95% confidence interval [CI]: 1.4-5.6, p=0.005) and OM (HR:1.9, 95% CI: 1.0-3.5, p=0.04) compared to those receiving SADT with less advanced disease. PCSM and OM did not significantly differ between groups 1 and 4 or groups 2 and 3. Of note, patients in group 4 had very long PSADTs (median = 27.0 months) that were significantly longer than those of group 1 (median = 6.0 months) (p<0.001). Multivariate analysis including groups 1-3 found a pre-SADT PSADT <3 months to be the most significant predictor of PCSM (HR:4.2, 95% CI: 1.6-11.1, p=0.004) and the only significant predictor of OM (HR:2.9, 95% CI: 1.3-6.7, p=0.01).

CONCLUSIONS

Less advanced disease at initiation of SADT is associated with decreased PCSM and OM following BF post-SRT; however, observation may be reasonable for patients with very long PSADTs. A PSADT <3 months prior to SADT initiation significantly predicts an increased risk of PCSM and OM in this patient demographic.

Ultra-early versus early salvage androgen deprivation therapy for post-prostatectomy biochemical recurrence in pT2-4N0M0 prostate cancer

BACKGROUND

The optimal timing of salvage androgen deprivation therapy (ADT) for biochemical recurrence after radical prostatectomy is controversial. We compared the outcomes of ultra-early versus early salvage ADT.

METHODS

Among 855 patients undergoing radical prostatectomy at our institution between 2000 and 2012, we identified 121 with adjuvant-treatment-naïve pT2-4N0M0 prostate cancer who received salvage ADT for biochemical recurrence. These patients were divided into an ultra-early salvage ADT group (n = 51), who started salvage ADT before meeting the standardized definition of biochemical recurrence in Japan (two consecutive prostate-specific antigen [PSA] values ≥0.2 ng/ml), and an early salvage ADT group (n = 70) who started salvage ADT when they met the definition. The ultra-early ADT group consisted of those who started salvage ADT with a single PSA value ≥0.2 ng/ml (n = 30) or with two consecutive PSA values >0.1 ng/ml and rising (n = 21). The primary endpoint was biochemical recurrence after salvage ADT, defined as a single PSA value ≥0.2 ng/ml after PSA nadir following salvage ADT. Secondary endpoints were clinical metastasis and cancer-specific survival. A Cox proportional hazards model was used for multivariate analysis. The median follow-up was 65.5 months.

RESULTS

Biochemical recurrence occurred in one patient (2.0%) in the ultra-early group and in 12 (17.1%) in the early salvage ADT group. Multivariate analysis identified ultra-early salvage ADT and preoperative Gleason score ≤7 as independent negative predictors of biochemical recurrence after salvage ADT. Only one patient in the early salvage ADT group developed clinical metastasis to a left supraclavicular lymph node, and no patient died from prostate cancer during follow-up. The major limitations of this study were its retrospective design, selection bias, and the possibility that the ultra-early salvage ADT group may have included patients without biochemical recurrence.

CONCLUSIONS

Ultra-early salvage ADT was an independent negative predictor of biochemical recurrence after salvage ADT in post-prostatectomy patients. Further consideration should be given to the use of salvage ADT before meeting the current definition of biochemical recurrence.

Prostate Cancer in the Elderly Patient

Treatment for prostate cancer (PCa) has evolved significantly over the last decade. PCa is the most prevalent non-skin cancer and the second leading cause of cancer death in men, and it has an increased incidence and prevalence in older men. As a result, physicians and patients are faced with the challenge of identifying optimal treatment strategies for localized, biochemical recurrent, and advanced PCa in the older population. When older patients are appropriately selected, treatment for PCa results in survival benefits and toxicity profiles similar to those experienced in younger patients. However, underlying health status and age-related changes can have an impact on tolerance of hormonal therapy and chemotherapy in men with advanced disease. Therefore, the heterogeneity of the elderly population necessitates a multidimensional assessment to maximize the benefit of medical and/or surgical options. Providing clinicians with the requisite health status data on which to base treatment decisions would help ensure that older patients with PCa receive optimal therapy if it will benefit them and/or active surveillance or best supportive care if it will not. We provide a review of the existing evidence to date on the management of PCa in the older population.

Conversion of androgen receptor signaling from a growth suppressor in normal prostate epithelial cells to an oncogene in prostate cancer cells involves a gain of function in c-Myc regulation

In normal prostate, androgen-dependent androgen receptor (AR) signaling within prostate stromal cells induces their secretion of paracrine factors, termed “andromedins” which stimulate growth of the epithelial cells. The present studies demonstrate that androgen-dependent andromedin-driven growth stimulation is counter-balanced by androgen-induced AR signaling within normal adult prostate epithelial cells resulting in terminal G₀ growth arrest coupled with terminal differentiation into ΔNp63-negative, PSA-expressing secretory luminal cells. This cell autonomous AR-driven terminal differentiation requires DNA-binding of the AR protein, is associated with decreases in c-Myc m-RNA and protein, are coupled with increases in p21, p27, and SKP-2 protein expression, and does not require functional p53. These changes result in down-regulation of Cyclin D₁ protein and RB phosphoryation. shRNA knockdown documents that neither RB, p21, p27 alone or in combination are required for such AR-induced G₀ growth arrest. Transgenic expression of a constitutive vector to prevent c-Myc down-regulation overrides AR-mediated growth arrest in normal prostate epithelial cells, which documents that AR-induced c-Myc down-regulation is critical in terminal growth arrest of normal prostate epithelial cells. In contrast, in prostate cancer cells, androgen-induced AR signaling paradoxically up-regulates c-Myc expression and stimulates growth as documented by inhibition of both of these responses following exposure to the AR antagonist, bicalutamide. These data document that AR signaling is converted from a growth suppressor in normal prostate epithelial cells to an oncogene in prostate cancer cells during prostatic carcinogenesis and that this conversion involves a gain of function for regulation of c-Myc expression.

Salvage therapy of small volume prostate cancer nodal failures: a review of the literature

New imaging modalities may be useful to identify prostate cancer patients with small volume, limited nodal relapse ("oligo-recurrent") potentially amenable to local treatments (radiotherapy, surgery) with the aim of long-term control of the disease, even in a condition traditionally considered prognostically unfavorable. This report reviews the new diagnostic tools and the main published data about the role of surgery and radiation therapy in this particular subgroup of patients.

SEOM clinical guidelines for treatment of prostate cancer

Prostate cancer (PC) is the most common cancer in men. Many patients have prolonged survival and die of other diseases, so treatment decisions are often influenced by age and coexisting comorbidities. The main procedure to diagnose PC is an ultrasound-guided core needle biopsy, which is indicated when a digital rectal examination (DRE) finds nodularity or when PSA is >10 ng/ml, but is also recommended with PSA between 4.0 and 10 ng/ml. Depending on age, PSA, Gleason score and characteristics of the tumour, treatment options for localised PC are active surveillance, radical prostatectomy and radiation therapy. Androgen deprivation treatment (ADT) should be added to radiotherapy for men with intermediate- or high-risk PC. ADT is the current standard first-line treatment for metastatic PC. Castration-resistant PC is a heterogeneous entity. Several treatments such as sipuleucel-T, docetaxel-based chemotherapy, radium 223, cabazitaxel or abiraterone plus prednisone, zoledronic and denosumab, are useful for this situation.

Early salvage hormonal therapy for biochemical failure improved survival in prostate cancer patients after neoadjuvant hormonal therapy plus radiation therapy--a secondary analysis of irish clinical oncology research group 97-01

PURPOSE

To assess the survival benefit of early vs late salvage hormonal therapy (HT), we performed a secondary analysis on patients who developed recurrence from Irish Clinical Oncology Research Group 97-01, a randomized trial comparing 4 vs 8 months neoadjuvant HT plus radiation therapy (RT) in intermediate- and high-risk prostate adenocarcinoma.

METHODS AND MATERIALS

A total of 102 patients from the trial who recurred were analyzed at a median follow-up of 8.5 years. The patients were divided into 3 groups based on the timing of salvage HT: 57 patients had prostate-specific antigen (PSA)≤10 ng/mL and absent distant metastases (group 1, early), 21 patients had PSA>10 ng/mL and absent distant metastases (group 2, late), and 24 patients had distant metastases (group 3, late). The endpoint analyzed was overall survival (OS) calculated from 2 different time points: date of enrolment in the trial (OS1) and date of initiation of salvage HT (OS2). Survival was estimated using Kaplan-Meier curves and a Cox regression model.

RESULTS

The OS1 differed significantly between groups (P<.0005): OS1 at 10 years was 78% in group 1, 42% in group 2, and 29% in group 3. The OS2 also differed significantly between groups (P<.0005): OS2 at 6 years was 70% in group 1, 47% in group 2, and 22% in group 3. Group 1 had the longest median time from end of RT to biochemical failure compared with groups 2 and 3 (3.3, 0.9, and 1.7 years, respectively; P<.0005). Group 1 also had the longest median PSA doubling time compared with groups 2 and 3 (9.9, 3.6, and 2.4 months, respectively; P<.0005). On multivariate analysis, timing of salvage HT, time from end of RT to biochemical failure, and PSA nadir on salvage HT were significant predictors of survival.

CONCLUSION

Early salvage HT based on PSA≤10 ng/mL and absent distant metastases improved survival in patients with prostate cancer after failure of initial treatment with neoadjuvant HT plus RT.

Contemporary role of androgen deprivation therapy for prostate cancer

CONTEXT

Androgen deprivation therapy (ADT) for prostate cancer (PCa) represents one of the most effective systemic palliative treatments known for solid tumors. Although clinical trials have assessed the role of ADT in patients with metastatic and advanced locoregional disease, the risk-benefit ratio, especially in earlier stages, remains poorly defined. Given the mounting evidence for potentially life-threatening adverse effects with short- and long-term ADT, it is important to redefine the role of ADT for this disease.

OBJECTIVE

Review the published experience with currently available ADT approaches in various contemporary clinical settings of PCa and reported serious treatment-related adverse events. This review addresses the level of evidence associated with the use of ADT in PCa, focusing upon survival outcome measures. Furthermore, this paper discusses evolving approaches targeting androgen receptor signaling pathways and emerging evidence from clinical trials with newer compounds.

EVIDENCE ACQUISITION

A comprehensive review of the literature was performed, focusing on data from the last 10 yr (January 2000 to July 2011) and using the terms androgen deprivation, hormone treatment, prostate cancer and adverse effects. Abstracts from trials reported at international conferences held in 2010 and 2011 were also evaluated.

EVIDENCE SYNTHESIS

Data from randomized controlled trials and population-based studies were analyzed in different clinical paradigms. Specifically, the role of ADT was evaluated in patients with nonmetastatic disease as the primary and sole treatment, in combination with radiation therapy (RT) or after surgery, and in patients with metastatic disease. The data suggest that in men with nonmetastatic disease, the use of primary ADT as monotherapy has not shown a benefit and is not recommended, while ADT combined with conventional-dose RT (<72Gy) for patients with high-risk disease may delay progression and prolong survival. The postoperative use of ADT remains poorly evaluated in prospective studies. Likewise, there are no trials evaluating the role of ADT in patients with biochemical relapses after surgery or RT. In patients with metastatic disease, there is a clear benefit in terms of quality of life, reduction of disease-associated morbidity, and possibly survival. Treatment with bilateral orchiectomy, luteinizing hormone-releasing hormone agonist therapy, with and without antiandrogens has been associated with various serious adverse events, including cardiovascular disease, diabetes, and skeletal complications that may also affect mortality.

CONCLUSIONS

Although ADT is an effective treatment of PCa, consistent long-term benefits in terms of quality and quantity of life are predominantly evident in patients with advanced/metastatic disease or when ADT is used in combination with RT (<72Gy) in patients with high-risk tumors. Implementation of ADT should be evidence based, with special consideration to adverse events and the risk-benefit ratio.

Androgen receptor rediscovered: the new biology and targeting the androgen receptor therapeutically

Discoveries over the past decade suggest that castration-resistant prostate cancer (CRPC) is sensitive, but not resistant to, further manipulation of the androgen-androgen receptor (AR) axis. Several new therapies that target this axis have demonstrated clinical activity. In this article, preclinical and clinical findings occurring in the field of AR-targeted therapies are reviewed. Reviews of scientific and clinical development are divided into those occurring prereceptor (androgen production and conversion) and at the level of the receptor (AR aberrations and therapies targeting AR directly). Intracrine androgen production and AR amplification, among others, are among the principal aberrancies driving CRPC growth. Phase III data with abiraterone acetate and phase II data with MDV-3100, along with other similar therapies, confirm for the clinician that the scientific findings related to persistent AR signaling in a castrate milieu can be harnessed to produce significant clinical benefit for patients with the disease. Studies aimed at optimizing the timing of their use and exploring the mechanisms of resistance to these therapies are under way. The clinical success of therapies that directly target androgen synthesis as well as the most common aberrancies of the AR confirm that prostate cancer retains dependence on AR signaling, even in the castrate state.

Individualized decision-making for older men with prostate cancer: balancing cancer control with treatment consequences across the clinical spectrum

Prostate cancer (PCa) is the most prevalent non-skin cancer among men and is the second leading cause of cancer death in men. PCa has an increased incidence and prevalence in older men. Age-associated incidence is on the rise due to increased screening in the older population. This has led to a sharp rise in the detection of early stage PCa. Given the indolent nature of many prostatic malignancies, a large proportion of older men with PCa will ultimately die from other causes. As a result, physicians and patients are faced with the challenge of identifying optimal treatment strategies for localized PCa, biochemically recurrent PCa and later-stage PCa. Age-related changes can impact tolerance of hormonal therapy and chemotherapy in men with metastatic disease and shift the risk-benefit ratio of these treatments. Tools such as the Comprehensive Geriatric Assessment (CGA) can help estimate remaining life expectancy and can help predict treatment-related morbidity and mortality in older men. Application of CGA in older men with PCa is important to help individualize and optimize treatment strategies. Research that integrates multidisciplinary and multidimensional assessment of PCa and the patient's overall health status is needed.

Genistein increases epidermal growth factor receptor signaling and promotes tumor progression in advanced human prostate cancer

Genistein is an isoflavone found in soy, and its chemo-preventive and -therapeutic effects have been well established from in vitro studies. Recently, however, its therapeutic actions in vivo have been questioned due to contradictory reports from animal studies, which rely on rodent models or implantation of cell lines into animals. To clarify in vivo effects of genistein in advanced prostate cancer patients, we developed a patient-derived prostate cancer xenograft model, in which a clinical prostatectomy sample was grafted into immune deficient mice. Our results showed an increased lymph node (LN) and secondary organ metastases in genistein-treated mice compared to untreated controls. Interestingly, invasive malignant cells aggregated to form islands/micrometastasis only in the secondary organs of the genistein-treated groups, not in the untreated control group. To understand the underlying mechanism for metastatic progression, we examined cell proliferation and apoptosis on paraffin-sections. Immunohistological data show that tumors of genistein-treated groups have more proliferating and fewer apoptotic cancer cells than those of the untreated group. Our immunoblotting data suggest that increased proliferation and metastasis are linked to enhanced activities of tyrosine kinases, EGFR and its downstream Src, in genistein-treated groups. Despite the chemopreventive effects proposed by earlier in vitro studies, the cancer promoting effect of genistein observed here suggests the need for careful selection of patients and safer planning of clinical trials.

Role of androgen deprivation therapy for node-positive prostate cancer

PURPOSE

To determine the impact of adjuvant androgen deprivation therapy (ADT) for patients who have node-positive prostate cancer in the prostate-specific antigen (PSA) era.

PATIENTS AND METHODS

We used linked Surveillance, Epidemiology and End Results-Medicare data to construct a cohort of men who underwent radical prostatectomy (RP) between 1991 and 1999 and who had positive regional lymph nodes. We classified men as receiving adjuvant ADT if they received ADT within 120 days of RP, and we compared them to the men who had not received adjuvant ADT. We used propensity scores to balance potential confounders of receiving adjuvant ADT (ie, tumor characteristics, extent of nodal disease, demographics, receipt of radiation therapy) and Cox proportional hazard methods to measure the impact of adjuvant ADT on overall survival (OS), stratified by propensity score quintile. We conducted a sensitivity analysis that used 90, 150, 180, and 365 days as the definition for adjuvant ADT.

RESULTS

A total of 731 men were identified, 209 of whom received ADT within 120 days of RP. There was no statistically significant difference in OS between the adjuvant ADT and non-ADT group (HR, 0.97; 95% CI, 0.71 to 1.27). There was no statistically significant survival difference with 90, 150, 180, and 365 days as the adjuvant ADT definition.

CONCLUSION

Deferring immediate ADT in men with positive lymph nodes after RP may not significantly compromise survival. Because observational studies should be considered hypothesis-generating studies, these results should be validated in a prospective fashion in a similar patient population.

Caring for a patient with metastatic prostate cancer

Learn about the latest treatments and what your patient needs to know at this difficult time.

Prospective study of depression and fatigue in men with advanced prostate cancer receiving hormone therapy

PURPOSE

We prospectively examined the development of depressive symptoms and fatigue among men with locally advanced prostate cancer receiving hormone therapy.

METHODS

Fifty-two men with advanced or recurrent prostate cancer were randomly assigned to receive either parenteral leuprolide or oral bicalutamide. Patients completed the Beck Depression Inventory (BDI) and Fatigue Severity Scale (FSS) at pretreatment baseline, 6 months, and 12 months.

RESULTS

Rates of at least mild depression ranged from 10.4 to 16.3% over the 12 months and were not significantly different at each time point. Mean change in BDI scores from baseline to 6 months for the entire sample was 0.91 (SE = 0.73), and from baseline to 12 months was 0.35 (SE = 0.67). Mean FSS scores increased significantly from baseline (M = 24.43, SD = 11.75) to 6 months (M = 27.93, SD = 13.52) and remained steady at 12 months (M = 27.80, SD = 14.44). There were no significant differences in depression between the two types of hormone therapy.

CONCLUSION

Hormone therapy does not appear to cause clinically significant changes in depression among men with locally advanced prostate cancer. However, fatigue increased significantly over the study period.

Current perspectives in the treatment of advanced prostate cancer

Prostate cancer (PC) continues to be an important world health problem for men. Patients with locally confined PC are treated with either radiotherapy or surgery. However, treatment of more advanced stages of the disease is problematic. Initially, androgen deprivation offers a period of clinical stability, which is however invariably followed by progression to non-responsiveness to hormonal manipulation. Current management of patients with androgen-independent prostate cancer (AIPC) displays modest response rates and achieves only short-term benefit. Recently, knowledge in the complex pathophysiology of advanced PC has led to the identification of mechanisms and target molecules permitting the introduction of new therapies. Consequently, many investigational treatments are ongoing for AIPC in Phase-II and Phase-III trials aiming at the combination of chemotherapeutic regimens along with immunotherapy targeting PC-associated antigens. Other attractive options are gene therapy, as well as the targeting of survival signaling, differentiation, and apoptosis of the malignant PC cells. Further treatment modalities are directed against the tumor microenvironment, bone metastasis, or both. Collectively, the aforementioned efforts introduce a new era in the management of advanced PC. Novel pharmaceutical compounds and innovative approaches, integrated into the concept of individualized therapy will hopefully, during the next decade, improve the outcome and survival for hundreds of thousands of men worldwide.

Characteristics of urologists predict the use of androgen deprivation therapy for prostate cancer

PURPOSE

We previously have reported wide variations among urologists in the use of androgen deprivation for prostate cancer. Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we examined how individual urologist characteristics influenced the use of androgen deprivation therapy.

METHODS

Participants included 82,375 men with prostate cancer who were diagnosed from January 1, 1992, through December 31, 2002, and the 2,080 urologists who provided care to them. Multilevel analyses were used to estimate the likelihood of androgen deprivation use within 6 months of diagnosis in the overall cohort, in a subgroup in which use would be of uncertain benefit (primary therapy for localized prostate cancer), and in a subgroup in which use would be evidence-based (adjuvant therapy with radiation for locally advanced disease).

RESULTS

In the overall cohort of patients, a multilevel model adjusted for patient characteristics, tumor characteristics, and urologist characteristics (eg, board certification, academic affiliation, patient panel size, years since medical school graduation) showed that the likelihood of androgen deprivation use was significantly greater for patients who saw urologists without an academic affiliation. This pattern also was noted when the analysis was limited to settings in which androgen deprivation would have been of uncertain benefit. Odds ratios for use in that context were 1.66 (95% CI, 1.27 to 2.16) for urologists with no academic affiliation and 1.45 (95% CI, 1.13 to 1.85) for urologists with minor versus major academic affiliations.

CONCLUSION

Use of androgen deprivation for prostate cancer varies by the characteristics of the urologist. Patients of non-academically affiliated urologists were significantly more likely to receive primary androgen deprivation therapy for localized prostate cancer, a setting in which the benefits are uncertain.

Regulation of global gene expression in the bone marrow microenvironment by androgen: androgen ablation increases insulin-like growth factor binding protein-5 expression

BACKGROUND

Prostate cancer frequently metastasizes to bone. Androgen suppression treatment is initially highly effective, but eventually results in resistant cancer cells. This study evaluates the effects of androgen suppression on the bone and bone marrow (BM). In particular we questioned whether the androgen therapy could adversely facilitate prostate cancer progression through an increase growth factor secretion by the bone microenvironment.

METHODS

Global gene expression is analyzed on mPEDB DNA microarrays. Insulin-like growth factor binding protein-5 (IGFBP5) is detected by immunohistochemistry in mouse tissues and its regulation measured by qPCR and Western blotting in human BM stromal cells. Effects of extracellular matrix-associated IGFBP5 on human prostate epithelial cells are tested in an MTS cell-growth assay.

RESULTS

Castration increases expression of 159 genes (including 4 secreted cytokines) and suppresses expression of 84 genes. IGFBP5 is most consistently increased and the increase in expression is reversed by testosterone administration. IGFBP5 protein is detected in vivo in osteoblasts, BM stromal cells, and endothelial cells. Primary human stromal cell cultures secrete IGFBP5. In vitro, treatment of immortalized human marrow stromal cells with charcoal-stripped serum increases IGFBP5 mRNA expression, which is reversed by androgen supplementation. IGFBP5 is incorporated into the extracellular matrix. Further, IGFBP5 immobilized on extracellular matrices of stromal cells enhances the growth of immortalized prostate epithelial cells.

CONCLUSIONS

Androgen suppressive therapy increases IGFBP5 in the BM microenvironment and thereby may facilitate the progression of prostate cancer.

The spectrum of prostate cancer care: From curative intent to palliation

Prostate cancer is one of the most prevalent malignancies affecting men in the developed world. A spectrum of disease states exists and management is tailored to individual patients. Increasing public awareness and prostate-specific antigen testing have led to earlier detection and the possibility of cure but have increased the risk of overtreatment of indolent disease. Advances in curative modalities have reduced side effects and offer patients a choice of treatments. Nonetheless, many need no intervention and may be safely treated with active monitoring. Choice and timing of therapy for locally advanced and recurrent disease are variable, with potential benefits of early intervention counterbalanced by side effects of treatment. Progress has been made in the management of advanced disease; skeletal-related events have been reduced and survival has been increased. This review examines the evidence and rationale behind the treatment options from curative intent to management of locally advanced disease and palliation of metastatic disease.

Vaccination therapy in prostate cancer

Radical prostatectomy and radiation therapy provide excellent localized prostate cancer (PC) control. Although the majority of prostate carcinoma is nowadays diagnosed at early stages with favourable risk features, in patients up to 30-40% it recurs within 10 years. Furthermore, the lack of effective therapies, once prostate carcinoma becomes refractory to androgen deprivation, mandates the development of alternative therapeutic options. There is a growing interest in harnessing the potency and specificity of anti-tumour immunity through the generation of fully competent dendritic cells and tumour reactive effector lymphocytes. Several strategies to treat or prevent the development of metastatic PC have been explored in clinical trials and are summarized in this review, considering also the feasibility and safety of these approaches. In some cases clinical responses were achieved showing that vaccine-primed T cells induced anti-tumour activity in vivo. The present findings and perspectives of the immunologic interventions in PC patients will be discussed.

Prostate cancer: a practical approach to current management of recurrent disease

Prostate cancer is the leading cause of cancer in men in the United States, with 234,460 men expected to be diagnosed as having the disease in 2006 (33% of cancers in men), and the third leading cause of cancer deaths in men, with 27,350 men expected to die of the disease (9% of cancer deaths). Through early detection and improved local therapies, including surgery or radiation therapy, a large number of men will be cured, but unfortunately, a significant number of men will still experience relapse of disease and require continued surveillance and ongoing therapy. This article discusses approaches to treatment of men who have recurrent disease, including active surveillance, androgen ablation therapy, secondary hormone therapy, chemotherapy, bisphosphonates, radiation therapy, and future directions.