Degarelix for treating advanced hormone-sensitive prostate cancer

BACKGROUND

Degarelix is a gonadotropin-releasing hormone antagonist that leads to medical castration used to treat men with advanced or metastatic prostate cancer, or both. It is unclear how its effects compare to standard androgen suppression therapy.

OBJECTIVES

To assess the effects of degree compared with standard androgen suppression therapy for men with advanced hormone-sensitive prostate cancer.

SEARCH METHODS

We searched multiple databases (CENTRAL, MEDLINE, Embase, Scopus, Web of Science, LILACS until September 2020), trial registries (until October 2020), and conference proceedings (until December 2020). We identified other potentially eligible trials by reference checking, citation searching, and contacting study authors.

SELECTION CRITERIA

We included randomized controlled trials comparing degarelix with standard androgen suppression therapy for men with advanced prostate cancer.

DATA COLLECTION AND ANALYSIS

Three review authors independently classified studies and abstracted data from the included studies. The primary outcomes were overall survival and serious adverse events. Secondary outcomes were quality of life, cancer-specific survival, clinical progression, other adverse events, and biochemical progression. We used a random-effects model for meta-analyses and assessed the certainty of evidence for the main outcomes according to GRADE.

MAIN RESULTS

We included 11 studies with a follow-up of between three and 14 months. We also identified five ongoing trials. Primary outcomes Data to evaluate overall survival were not available.  Degarelix may result in little to no difference in serious adverse events compared to standard androgen suppression therapy (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.62 to 1.05; low-certainty evidence; 2750 participants). Based on 114 serious adverse events in the standard androgen suppression group, this corresponds to 23 fewer serious adverse events per 1000 participants (43 fewer to 6 more). We downgraded the certainty of evidence for study limitations and imprecision. Secondary outcomes Degarelix likely results in little to no difference in quality of life assessed with a variety of validated questionnaires (standardized mean difference 0.06 higher, 95% CI 0.05 lower to 0.18 higher; moderate-certainty evidence; 2887 participants), with higher scores reflecting better quality of life. We downgraded the certainty of evidence for study limitations. Data to evaluate cancer-specific survival were not available. The effects of degarelix on cardiovascular events are very uncertain (RR 0.15, 95% CI 0.04 to 0.61; very low-certainty evidence; 80 participants). We downgraded the certainty of evidence for study limitations, imprecision, and indirectness as this trial was conducted in a unique group of high-risk participants with pre-existing cardiovascular morbidities. Degarelix likely results in an increase in injection site pain (RR 15.68, 95% CI 7.41 to 33.17; moderate-certainty evidence; 2670 participants). Based on 30 participants per 1000 with injection site pain with standard androgen suppression therapy, this corresponds to 440 more injection site pains per 1000 participants (192 more to 965 more). We downgraded the certainty of evidence for study limitations. We did not identify any relevant subgroup differences for different degarelix maintenance doses.

AUTHORS' CONCLUSIONS

We did not find trial evidence for overall survival or cancer-specific survival comparing degarelix to standard androgen suppression, but serious adverse events and quality of life may be similar between groups. The effects of degarelix on cardiovascular events are very uncertain as the only eligible study had limitations, was small with few events, and was conducted in a high-risk population. Degarelix likely results in an increase in injection site pain compared to standard androgen suppression therapy. Maximum follow-up of included studies was 14 months, which is short. There is a need for methodologically better designed and executed studies with long-term follow-up evaluating men with metastatic prostate cancer.

Hormonal prostate cancer therapies and cardiovascular disease: a systematic review

Therapeutic intervention for prostate cancer mostly relies on eliminating circulating androgen or antagonizing its effect at the cellular level. As the use of endocrine therapies grows, an under-reported incidence of cardiovascular toxicities occurs in prostate cancer patients. In this review, we summarize data of clinical studies, investigating the cardiovascular and metabolic alterations associated with the use of old and new endocrine drugs (gonadotropin-releasing hormone [GnRH] agonists and antagonists, androgen receptor inhibitors, 17α-hydroxylase/c-17,20-lyase [CYP17] inhibitor) in prostate cancer. To date, studies looking for links between cardiovascular complications and hormone-mediated therapies in prostate cancer have reached conflicting results. Several confounding factors, such as age of patients and related cardiovascular liability, other comorbidities, and use of concomitant drugs, have to be carefully evaluated in future clinical trials. Further research is needed given the continuous advancements being made in prostate cancer treatment.

[Docetaxel or abiraterone in combination with androgen deprivation therapy for metastatic prostate cancer]

BACKGROUND

Androgen deprivation therapy (ADT) alone has long been the standard of care in the treatment of metastatic prostate cancer (mCSPC). A paradigm shift in the treatment of patients with mCSPC has now been initiated by the results of three major phase 3 clinical trials (CHAARTED, STAMPEDE, LATITUDE): They demonstrated a significant advantage of ADT in combination with docetaxel or abiraterone/prednisone over ADT alone.

OBJECTIVES

This review presents the current evidence for the use of docetaxel or abiraterone/prednisone in combination with ADT and discusses-in the absence of directly comparing studies-which patients may have an advantage of ADT plus abiraterone/prednisone over ADT plus docetaxel or vice versa.

METHODS

A systematic review based on bibliographic literature search was conducted.

RESULTS

Both the combinations of ADT with docetaxel and with abiraterone/prednisone represent a major advance in the treatment of patients with mCSPC, in particular of patients with multiple metastases. Compared to chemotherapy, the use of abiraterone in addition to ADT avoids (rare) neutropenic complications and treatment-associated deaths. Long-term oral treatment with abiraterone/prednisone as a complementary therapy to ADT replaces short-term intravenous treatment (docetaxel).

CONCLUSION

In patients with mCSPC, ADT plus docetaxel or ADT plus abiraterone/prednisone is recommended. In particular in patients with pre-existing cardiovascular disease, ADT should be considered with a GnRH (gonadotropin-releasing hormone) antagonist to reduce the risk of cardiotoxic side effects.

Cardiovascular and Metabolic Effects of Androgen-Deprivation Therapy for Prostate Cancer

Androgen-deprivation therapy (ADT) entails lowering serum testosterone levels to castrate levels and forms a cornerstone of the management of hormone-sensitive advanced prostate cancer; however, the benefit of ADT is partially offset by its detrimental metabolic and cardiovascular adverse effects. ADT decreases insulin sensitivity while promoting dyslipidemia and sarcopenic obesity, which leads to an increased risk of cardiovascular morbidity and potentially mortality. The risk seems to be highest in elderly patients who have had recent cardiovascular events before starting ADT. It is prudent to engage in an individualized risk-benefit discussion and develop a cohesive multidisciplinary management plan to medically optimize and closely observe these patients before and during treatment with ADT.