Androgen Deprivation Therapy for Prostate Cancer: Focus on Cognitive Function and Mood

Prostate cancer is the second leading cause of cancer death in men in the United States. Androgen deprivation therapy (ADT) is currently the primary treatment for metastatic prostate cancer, and some studies have shown that the use of anti-androgen drugs is related to a reduction in cognitive function, mood changes, diminished quality of life, dementia, and possibly Alzheimer's disease. ADT has potential physiological effects such as a reduction in white matter integrity and a negative impact on hypothalamic functions due to the lowering of testosterone levels or the blockade of downstream androgen receptor signaling by first- and second-generation anti-androgen drugs. A comparative analysis of prostate cancer patients undergoing ADT and Alzheimer patients identified over 30 shared genes, illustrating common ground for the mechanistic underpinning of the symptomatology. The purpose of this review was to investigate the effects of ADT on cognitive function, mood, and quality of life, as well as to analyze the relationship between ADT and Alzheimer's disease. The evaluation of prostate cancer patient cognitive ability via neurocognitive testing is described. Future studies should further explore the connection among cognitive deficits, mood disturbances, and the physiological changes that occur when hormonal balance is altered.

Primary Whole-gland Ablation for the Treatment of Clinically Localized Prostate Cancer: A Focal Therapy Society Best Practice Statement

CONTEXT

Whole-gland ablation is a feasible and effective minimally invasive treatment for localized prostate cancer (PCa). Previous systematic reviews supported evidence for favorable functional outcomes, but oncological outcomes were inconclusive owing to limited follow-up.

OBJECTIVE

To evaluate the real-world data on the mid- to long-term oncological and functional outcomes of whole-gland cryoablation and high-intensity focused ultrasound (HIFU) in patients with clinically localized PCa, and to provide expert recommendations and commentary on these findings.

EVIDENCE ACQUISITION

We performed a systematic review of PubMed, Embase, and Cochrane Library publications through February 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. As endpoints, baseline clinical characteristics, and oncological and functional outcomes were assessed. To estimate the pooled prevalence of oncological, functional, and toxicity outcomes, and to quantify and explain the heterogeneity, random-effect meta-analyses and meta-regression analyses were performed.

EVIDENCE SYNTHESIS

Twenty-nine studies were identified, including 14 on cryoablation and 15 on HIFU with a median follow-up of 72 mo. Most of the studies were retrospective (n = 23), with IDEAL (idea, development, exploration, assessment, and long-term study) stage 2b (n = 20) being most common. Biochemical recurrence-free survival, cancer-specific survival, overall survival, recurrence-free survival, and metastasis-free survival rates at 10 yr were 58%, 96%, 63%, 71-79%, and 84%, respectively. Erectile function was preserved in 37% of cases, and overall pad-free continence was achieved in 96% of cases, with a 1-yr rate of 97.4-98.8%. The rates of stricture, urinary retention, urinary tract infection, rectourethral fistula, and sepsis were observed to be 11%, 9.5%, 8%, 0.7%, and 0.8%, respectively.

CONCLUSIONS

The mid- to long-term real-world data, and the safety profiles of cryoablation and HIFU are sound to support and be offered as primary treatment for appropriate patients with localized PCa. When compared with other existing treatment modalities for PCa, these ablative therapies provide nearly equivalent intermediate- to long-term oncological and toxicity outcomes, as well as excellent pad-free continence rates in the primary setting. This real-world clinical evidence provides long-term oncological and functional outcomes that enhance shared decision-making when balancing risks and expected outcomes that reflect patient preferences and values.

PATIENT SUMMARY

Cryoablation and high-intensity focused ultrasound are minimally invasive treatments available to selectively treat localized prostate cancer, considering their nearly comparable intermediate- to long term cancer control and preservation of urinary continence to other radical treatments in the primary setting. However, a well-informed decision should be made based on one's values and preferences.

IL-15 Superagonist NAI in BCG-Unresponsive Non-Muscle-Invasive Bladder Cancer

IL-15 Superagonist NAI in BCG-Unresponsive NMIBCIn this trial, patients with BCG-unresponsive bladder CIS with or without Ta/T1 papillary disease or BCG-unresponsive high-grade Ta/T1 papillary NMIBC were treated with intravesical NAI, an IL-15 superagonist, plus BCG. Primary end points were CR at 3 or 6 months for patients with CIS disease and DFS rate at 12 months for those with high-grade Ta/T1 disease. CR rate was 71% (58 of 82 patients), and the DFS rate was 55.4%.

Safety of stereotactic body radiation therapy for localized prostate cancer without treatment planning MRI

Background

The use of treatment planning prostate MRI for Stereotactic Body Radiation Therapy (SBRT) is largely a standard, yet not all patients can receive MRI for a variety of clinical reasons. Thus, we aim to investigate the safety of patients who received CT alone based SBRT planning for the definitive treatment of localized prostate cancer.

Methods

Our study analyzed 3410 patients with localized prostate cancer who were treated with SBRT at a single academic institution between 2006 and 2020. Acute and late toxicity was evaluated using the Common Terminology Criteria for Adverse Events version 5.0. Expanded Prostate Cancer Index Composite (EPIC) questionnaires evaluated QOL and PSA nadir was evaluated to detect biochemical failures.

Results

A total of 162 patients (4.75%) received CT alone for treatment planning. The CT alone group was older relative to the MRI group (69.9 vs 67.2, p < 0.001) and had higher risk and grade disease (p < 0.001). Additionally, the CT group exhibited a trend in larger CTVs (82.56 cc vs 76.90 cc; p = 0.055), lower total radiation doses (p = 0.048), and more frequent pelvic nodal radiation versus the MRI group (p < 0.001). There were only two reported cases of Grade 3 + toxicity within the CT alone group. Quality of life data within the CT alone group revealed declines in urinary and bowel scores at one month with return to baseline at subsequent follow up. Early biochemical failure data at median time of 2.3 years revealed five failures by Phoenix definition.

Conclusions

While clinical differences existed between the MRI and CT alone group, we observed tolerable toxicity profiles in the CT alone cohort, which was further supported by EPIC questionnaire data. The overall clinical outcomes appear comparable in patients unable to receive MRI for their SBRT treatment plan with early clinical follow up.

Prostate cancer treatment and the relationship of androgen deprivation therapy to cognitive function

Prostate cancer is the second most common form of cancer in men. For advanced, high risk prostate cancer, androgen deprivation therapy (ADT) is the preferred treatment and can induce remission, but resistance to ADT brings biochemical recurrence and progression of cancer. ADT brings adverse effects such as erectile dysfunction, decreased libido, and diminished physical strength. It is estimated that between 25 and 50% of men on ADT manifest some form of cognitive dysfunction that may be self-reported or reported by a family member. There is concern that impaired cognitive function with ADT is due to loss of testosterone support. Testosterone and its metabolites are known to possess neuroprotective properties. While a direct causal relationship between ADT and cognitive decline in prostate cancer patients has not been established, this review describes the controversy surrounding the possible connection between ADT and neurocognitive deterioration. The cellular and molecular mechanisms believed to underlie the protection of neuronal integrity by androgens are discussed. Results from animal models and human clinical studies are presented. Finally, we call attention to lifestyle modifications that may minimize cognitive issues in prostate cancer patients.

Utilization of focal therapy for patients discontinuing active surveillance of prostate cancer: Recommendations of an international Delphi consensus

BACKGROUND

With the advancement of imaging technology, focal therapy (FT) has been gaining acceptance for the treatment of select patients with localized prostate cancer (CaP). We aim to provide details of a formal physician consensus on the utilization of FT for patients with CaP who are discontinuing active surveillance (AS).

METHODS

A 3-stage Delphi consensus on CaP and FT was conducted. Consensus was defined as agreement by ≥80% of physicians. An in-person meeting was attended by 17 panelists to formulate the consensus statement.

RESULTS

Fifty-six respondents participated in this interdisciplinary consensus study (82% urologist, 16% radiologist, 2% radiation oncology). The participants confirmed that there is a role for FT in men discontinuing AS (48% strongly agree, 39% agree). The benefit of FT over radical therapy for men coming off AS is: less invasive (91%), has a greater likelihood to preserve erectile function (91%), has a greater likelihood to preserve urinary continence (91%), has fewer side effects (86%), and has early recovery post-treatment (80%). Patients will need to undergo mpMRI of the prostate and/or a saturation biopsy to determine if they are potential candidates for FT. Our limitations include respondent's biases and that the participants of this consensus may not represent the larger medical community.

CONCLUSIONS

FT can be offered to men coming off AS between the age of 60 to 80 with grade group 2 localized cancer. This consensus from a multidisciplinary, multi-institutional, international expert panel provides a contemporary insight utilizing FT for CaP in select patients who are discontinuing AS.

Salvage Therapy Options for Local Prostate Cancer Recurrence After Primary Radiotherapy: a Literature Review

PURPOSE OF REVIEW

While recurrence after primary treatment of prostate cancer (PCa) is not uncommon, there is currently no consensus on the most appropriate management after radiation treatment failure. This article seeks to explore the currently utilized modalities for salvage treatment for radiorecurrent PCa. We focused our review on the oncologic outcomes and reported toxicity rates in the latest studies examining salvage radical prostatectomy (SRP), salvage cryotherapy (SCT), salvage high-intensity focused ultrasound (HIFU) and re-irradiation.

RECENT FINDINGS

There does not appear to be any significant difference in overall survival for more invasive salvage radical prostatectomy compared to the minimally invasive salvage approaches. Additionally, there seems to be a trend towards lower morbidity rates associated with minimally invasive and focal salvage treatment. We are encouraged by the results presented in this review and find that there is clearly a role for emerging minimally invasive and focal therapies as durable options for salvage treatment in patients with radiorecurrent PCa.

Effects of Focal vs Total Cryotherapy and Minimum Tumor Temperature on Patient-reported Quality of Life Compared With Active Surveillance in Patients With Prostate Cancer

OBJECTIVE

To investigate the effects of focal (hemiablation) or total cryotherapy and minimum tumor temperature on patient-reported quality of life (QoL) in patients with prostate cancer.

METHODS

An Institutional Review Board-approved database was reviewed for patients who underwent cryotherapy or active surveillance (AS). QoL questionnaire responses were collected and scores were analyzed for differences between focal and total cryotherapy and between very cold (<-76°C) and moderate-cold (≥-76°C) minimum tumor temperatures.

RESULTS

A total of 197 patients responded to a total of 547 questionnaires. Focal and total cryotherapy patients had initially lower sexual function scores relative to AS (year 1 mean difference focal: -31.7, P <.001; total: -48.1, P <.001). Focal cryotherapy was associated with a more rapid improvement in sexual function. Both focal and total cryotherapy sexual function scores were not statistically significantly different from the AS cohort by postprocedural year 4. Very cold and moderate-cold temperatures led to initially lower sexual function scores relative to AS (year 1 very cold: -38.1, P <.001; moderate-cold: -30.7, P <.001). Moderate-cold temperature scores improved more rapidly than those of very cold temperature. Neither very cold nor moderate-cold temperatures had a statistically significant difference in sexual function scores relative to AS by postprocedural year 4. Urinary function and bowel habits were not significantly different between focal and total cryotherapy and between very cold and moderate-cold temperature groups.

CONCLUSION

Focal cryotherapy and moderate-cold (≥-76°C) temperature were associated with favorable sexual function relative to total cryotherapy and very cold temperature, respectively. No significant differences in urinary function or bowel habits were observed between groups.

Patient-reported quality of life progression in men with prostate cancer following primary cryotherapy, cyberknife, or active holistic surveillance

BACKGROUND

Technological advancements have led to the success of minimally invasive treatment modalities for prostate cancer such as CyberKnife and Cryotherapy. Here, we investigate patient-reported urinary function, bowel habits, and sexual function in patients following CyberKnife (CK) or Cryotherapy treatment, and compare them with active holistic surveillance (AHS) patients.

METHODS

An IRB-approved institutional database was retrospectively reviewed for patients who underwent CK, Cryotherapy, or AHS. Quality of life (QoL) survey responses were collected every three months and the mean function scores were analyzed in yearly intervals over the 4 years post-treatment.

RESULTS

279 patients (767 survey sets) were included in the study. There was no difference among groups in urinary function scores. The CyberKnife group had significantly lower bowel habit scores in the early years following treatment (year 2 mean difference: -5.4, P < 0.01) but returned to AHS level scores by year 4. Cryotherapy patients exhibited initially lower, but not statistically significant, bowel function scores, which then improved and approached those of AHS. Both CyberKnife (year 1 mean difference: -26.7, P < 0.001) and Cryotherapy groups (-35.4, P < 0.001) had early lower sexual function scores relative to AHS, but then gradually improved and were not significantly different from AHS by the third year post-treatment. A history of hormonal therapy was associated with a lower sexual function scores relative to those patients who did not receive hormones in both CyberKnife (-18.45, P < 0.01) and Cryotherapy patients (-14.6, P < 0.05).

CONCLUSIONS

After initial lower bowel habits and sexual function scores, CyberKnife or Cryotherapy-treated patients had no significant difference in QoL relative to AHS patients. These results highlight the benefit of CyberKnife and Cryotherapy in the management of organ-confined prostate cancer.

3-T multiparametric MRI characteristics of prostate cancer patients suspicious for biochemical recurrence after primary focal cryosurgery (hemiablation)

INTRODUCTION

We aimed to report on multiparametric MRI (mpMRI) characteristics of post-primary focal cryosurgery (PFC) patients suspected of biochemical recurrence (BCR) by the Phoenix criteria.

METHODS

We retrospectively reviewed all patients at our institution who had undergone PFC. Prostate-specific antigen nadir was determined using 2 or more post-PFC values. Suspicion of BCR was determined using the Phoenix criteria (nadir + 2 ng/ml). At the discretion of the physician, pre-and post-PFC 3-T mpMRIs were obtained and in a few cases biopsies were performed.

RESULTS

Ninety (58.4%) of 154 consecutive patients who underwent PFC were included in our analysis and had a median (range) age and prostate volume of 66.5 (48-82) years and 40.5 (16-175) ml, respectively. Of those suspected of BCR (37/90, 41.1%), with a median time to BCR of 19.9 (7.0-38.5) months, 27 patients (73.0%) underwent a post-PFC mpMRI. Twenty-two (81.5%) of these mpMRIs were found with 24 suspicious lesions. A considerable number (9/24, 37.5%) of these lesions were located in the central gland of the prostate. Seven of 24 lesions exhibited adverse mpMRI characteristic; 4 (16.7%) had capsular contact, 2 (8.2%) showed frank extracapsular extension, and 1 (4.2%) showed seminal vesicle invasion. Five (45.5%) of 11 patients with positive post-PFC mpMRIs were positive on biopsy (4/5, 80% were clinically significant prostate cancer).

CONCLUSION

Post-PFC mpMRI, at Phoenix suspicion of BCR, may help identify a significant number of patients failing post-PFC.

Perioperative and readmission rates in open and robotic assisted radical cystectomy: A National Cancer Database analysis

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Background: Perioperative mortality and readmission rates are evolving metrics of care being monitored in radical cystectomies (RC). We aim to evaluate these outcomes in open radical cystectomies (ORC) and robotic assisted radical cystectomies (RARC) reported in the National Cancer Database adjusted by surgery type. Methods: Using the National Cancer Database, patients treated with RC from 2003 to 2010 were identified. We evaluated the association between 90-day conditional mortality and readmission with respect to surgery type, adjusted by patient (age, gender, race/ethnicity, Charlson-Deyo score, tumor type, clinical stage, margin status and receipt of neoadjuvant chemo-or radiotherapy) and facility characteristics (overall cystectomy volume and facility type [Academic/Research, Comprehensive Community, or other]). Results: 16,923 RC cases (13,236 ORC, 3,687 RARC) were identified with 480 deaths (3.6%) after ORC and 99 deaths (2.7%) after RARC within 90 days, conditional upon surviving 30 days post-surgery. Comparing <3 ORC/year to >20 ORC/year, 90-day overall conditional mortality rates decreased from 4.0% to 2.5%. In stratified analyses, 90-day conditional mortality rates decreased from 4.2% to 2.7% for ORC and 2.7% to 2.0% for RARC. Center volume was strongly associated with 90-day conditional survival (p=0.002), independent of surgery type. In multivariable analysis of 90-day conditional mortality, age (OR=1.03, 95% CI: 1.02-1.04, p<0.0001), comorbidites (OR=1.4, 95% CI: 1.12-1.6, p=0.0005), margin rates (OR=3.5,95% CI: 2.9-4.3, p<0.0001) as well as facility volume (OR=0.99, 95% CI: 0.98-1.00, p=0.001), were predictive of 90-day conditional mortality. Cystectomy volume did not predict 30 day readmission, but Charlson-Deyo score 1-2 (OR=1.274, 1.112-1.461 95% CI, p=0.0005) and receipt of neoadjuvant chemo- or radiotherapy (OR=1.161, 1.032-1.307 95% CI, p=0.0134) were significantly associated with 30-day readmission. Conclusions: Patients were less likely to incur death following robotic or open cystectomy within 90 days as institutional cystectomy volume increased. 30 day readmission rates were not influenced by institutional cystectomy volume.

Cryosurgery, an alternative treatment option for organ-confined prostate cancer: current beliefs and practice patterns of urologists

PURPOSE

We aim to evaluate the current beliefs and practice patterns of urologists in regard to use of cryosurgery for management of PCa.

METHODS

An anonymous 13-point survey was designed and sent out to members of the Society of Urologic Oncology (SUO), Endourological Society (ES) and American College of Cryosurgery (ACC). Descriptive statistics and univariate analyses were used to determine variables associated with the use of cryosurgery.

RESULTS

Of the 206 responses received [81 (39.2 %) SUO; 106 (51.5 %) ES; 19 (9.2 %) ACC], 83 (40.3 %) performed cryosurgery. The majority of respondents who utilize cryosurgery do so in unilateral (80.3 %) and bilateral (77.6 %) intermediate-risk PCa. Also, users of this technology indicated significant use in primary treatment (>72 %), salvage treatment (>83 %), in patients who prefer cryosurgery (89.9 %) have a life expectancy ≥10 years (65.8 %) and poor erections (74.7 %). The main reason for not utilizing cryosurgery was the lack of technical expertise (56.7 %). A urologist in a non-academic practice setting was 3.2 times more likely to perform cryosurgery compared to a urologist in an academic setting, p = 0.0001.

CONCLUSION

Cryosurgery is increasingly being accepted among urologists. However, the need for large-scale studies as well as randomized clinical trials to further delineate the benefits of cryosurgery and convince the non-users and institutions cannot be overemphasized.

Gross Findings of Widespread Visceral Metastasis of Prostatic Adenocarcinoma With Neuroendocrine Features: A Case Report

Although prostate cancer is common in the western world and is associated with favorable overall survival, neuroendocrine prostate cancer is difficult to detect and is known to aggressively metastasize throughout the body. This subset of disease thus has a poor prognosis, and early detection and treatment of neuroendocrine prostate cancer may increase overall survival. We present a case of a now deceased 63 year old male with extensive epicardial, respiratory, hepato-bilary, adrenal, genitourinary, and osseous tissue metastasis.

The Role of Zyflamend, an Herbal Anti-inflammatory, as a Potential Chemopreventive Agent Against Prostate Cancer: A Case Report

Correlation between dietary intake and occurrence of prostate cancer has gained significant support in recent years. Although a direct correlation has yet to be proven between inflammation and prostate cancer, chronic or recurrent inflammation has been hypothesized to be the major predisposing factor for this disease. The authors have been studying Zyflamend, a novel herbal anti-inflammatory mixture, as a potential chemopreventive agent in a phase 1 trial for patients diagnosed with prostatic intraepithelial neoplasia. They report the results of the first patient who has completed the 18-month study in which 24 patients were assigned to a cohort and placed on successive herbal supplement regimen starting with Zyflamend alone.

Emerging minimally invasive procedures for focal treatment of organ-confined prostate cancer

Prostate cancer is the most common malignancy amongst American men. However, the majority of prostate cancer diagnoses are of low risk, organ-confined disease. Many men elect to undergo definitive treatment, but may benefit from focal therapy to maintain continence and potency. This review reports the mechanism of action and outcomes of emerging focal therapies for prostate cancer. We report the mechanism of action of focal cryotherapy, high intensity focused ultrasound, focal laser ablation, and irreversible electroporation. In addition, we reviewed the largest studies available reporting rates of urinary incontinence, erectile dysfunction, biochemical recurrence-free survival (ASTRO), and post-operative adverse events for each procedure. Each treatment modality stated has a unique mechanism in the ablation of cancerous cells. Genito-urinary symptoms following these studies report incontinence and erectile dysfunction rates ranging from 0-15% and 0-53%, respectively. Biochemical disease-free survival was reported using the ASTRO definition. Some treatment modalities lack the necessary follow-up to determine effectiveness in cancer control. No focal therapy studies reported serious adverse events. These minimally invasive procedures are feasible in a clinical setting and show promising functional and disease control results with short to medium-term follow-up. However, each treatment requires additional robust prospective studies as well as its own unique domain to determine biochemical recurrence free survival to properly determine their role in treatment of organ-confined prostate cancer.

Prostate-specific antigen bounce following stereotactic body radiation therapy for prostate cancer

Introduction: Prostate-specific antigen (PSA) bounce after brachytherapy has been well-documented. This phenomenon has also been identified in patients undergoing stereotactic body radiation therapy (SBRT). While the parameters that predict PSA bounce have been extensively studied in prostate brachytherapy patients, this study is the first to analyze the clinical and pathologic predictors of PSA bounce in prostate SBRT patients.

Materials and Methods: Our institution has maintained a prospective database of patients undergoing SBRT for prostate cancer since 2006. Our study population includes patients between May 2006 and November 2011 who have at least 18 months of follow-up. All patients were treated using the CyberKnife treatment system. The prescription dose was 35–36.25 Gy in five fractions.

Results: One hundred twenty patients were included in our study. Median PSA follow-up was 24 months (range 18–78 months). Thirty-four (28%) patients had a PSA bounce. The median time to PSA bounce was 9 months, and the median bounce size was 0.50 ng/mL. On univariate analysis, only younger age (p = 0.011) was shown to be associated with an increased incidence of PSA bounce. Other patient factors, including race, prostate size, prior treatment by hormones, and family history of prostate cancer, did not predict PSA bounces. None of the tumor characteristics studied, including Gleason score, pre-treatment PSA, T-stage, or risk classification by NCCN guidelines, were associated with increased incidence of PSA bounces. Younger age was the only statistically significant predictor of PSA bounce on multivariate analysis (OR = 0.937, p = 0.009).

Conclusion: PSA bounce, which has been reported after prostate brachytherapy, is also seen in a significant percentage of patients after CyberKnife SBRT. Close observation rather than biopsy can be considered for these patients. Younger age was the only factor that predicted PSA bounce.

A report on major complications and biochemical recurrence after primary and salvage cryosurgery for prostate cancer in patients with prior resection for benign prostatic hyperplasia: a single-center experience

OBJECTIVE

To report on biochemical recurrence (BCR) and major complications in patients with prior prostate resection that underwent cryosurgery (CS) for prostate cancer.

METHODS

The Columbia University Urologic Oncology database identified patients that underwent CS after resection. Patient demographics, surgical details, prostate volume, prostate-specific antigen (PSA) levels, biopsy results, major complications, and BCR were recorded.

RESULTS

Prior resection for benign prostatic hyperplasia was identified in 32 patients who underwent CS. Median age was 70.7 years (range 54.9-83.1 years). Median prostate volume before and after resection was 40 (range 30-90) and 20 cm(3) (range 9-54), respectively. Median time from resection to CS was 50.4 months (range 0-178.1 months). Twenty-one (16 full and 5 focal gland ablations) and 11 patients underwent primary and salvage CS, respectively. Median prostate-specific antigen at CS was 5.9 ng/mL (range 0.1-18.4 ng/mL), with a median nadir post-CS of 0.1 ng/mL (range 0.04-12.2 ng/mL). Median follow-up was 41.2 months (range 8.9-154.2 months). According to Stuttgart and Phoenix definitions, 11 and 10 patients, respectively, experienced BCR. Three patients underwent further CS for disease recurrence. Overall complications were rare and minor. Patients with smaller glands postresection (<20 cc(3)) experienced a similar incidence of BCR as those with larger glands after CS in all the settings.

CONCLUSION

Although no patients experienced major complications after primary CS, 18% (2/11) had grade III or higher complications in the salvage setting. Postresection gland volume was not associated with BCR. Further research is needed to evaluate functional and oncological outcomes in postresection patients after CS because they are considered high-risk for major complications.

Comparison of biochemical failure definitions for predicting local cancer recurrence following cryoablation of the prostate

BACKGROUND

Various definitions of biochemical failure (BF) have been used to predict cancer recurrence following prostate cryoablation. However to date, none of these definitions have been validated for this use. We have reviewed several definitions of BF to determine their accuracy in predicting biopsy-proven local recurrence following prostate cryoablation.

METHODS

The Columbia University Urologic Oncology Database was queried for patients who underwent prostate cryoablation between 1994 and 2010, and who subsequently underwent surveillance biopsy due to clinical suspicion of prostate cancer recurrence. Serial postoperative prostate-specific antigen (PSA) results were used to determine BF according to various definitions of BF. Biopsy results were used to determine local recurrence. Sensitivity, specificity, positive and negative predictive value, and receiver operating characteristic (ROC) curve area were calculated for each of the BF definitions.

RESULTS

A total of 110 patients met inclusion criteria for the study. These patients were treated with primary full-gland (n = 38), primary focal (n = 24), or salvage cryoablation (n = 48). On surveillance biopsy, 66 patients (60%) were found to have locally recurrent prostate cancer. The most accurate BF definition overall was PSA nadir plus 2 ng/ml (Phoenix definition), with sensitivity, specificity, and ROC curve area of 68%, 59%, and 0.64, respectively.

CONCLUSIONS

Overall, the Phoenix definition best predicted local cancer recurrence following prostate cryoablation. These preliminary data may be useful for researchers evaluating the short-term efficacy of cryoablation, and for urologists assessing their patients for potential cancer recurrence.

Transdifferentiation of cultured human prostate cancer cells to a neuroendocrine cell phenotype in a hormone-depleted medium

Neuroendocrine (NE) cells are enigmatically found in association with human prostate cancers and their numbers are reported to increase in advanced and hormoneresistant tumors. The origin of this cell type and the reason for their appearance in prostate tumors remains unresolved. Previously, Bang et al. (Proc Natl Acad Sci USA 1994;91:5330) reported that dibutyryl adenosine 3',5'-cyclic phosphate (db-cAMP), an agent that upregulates intracellular cAMP, was able to induce a NE cell-like phenotype of cultured human prostate cancer cells, including the androgen-sensitive LNCaP line. Here we report that chronic incubation of LNCaP cells in a medium containing 10% charcoal-stripped fetal bovine serum (CSFBS) likewise induces NE differentiation of these cells. Within 5 days of switching low density cultures of LNCaP cells to this modified medium, the cells growth arrest and acquire an altered morphology with numerous cytoplasmic secretory granules and elongated processes that resemble cultured neurons. This morphology predominates at 10 days with complete transformation seen by 20 days of culture. Electron microscopic analysis of sections of CS-FBS maintained cells showed the presence of abundant dense core secretory granules characteristic of NE cells. Immunohistochemical staining identified the upregulation of the expression of NE markers bombesin, neuron-specific enolase, and S-100 in this modified culture medium. Once established, the NE cell-like phenotype was found to be reversible upon replacement with a medium containing unmodified fetal bovine serum, but not by direct supplementation of CS-FBS medium with dihydrotestosterone (DHT) (I nM). DHT supplementation did, however, suppress the development of the NE cell-like phenotype when it was present at the initiation of exposure to CS-FBS medium. In contrast to db-cAMP treatment, which did not affect prostate specific antigen (PSA) or androgen receptor (AR) expression of LNCaP cells, NE-differentiated LNCaP cells derived in this hormone-deficient medium showed marked downregulation of PSA and AR expression. These in vitro results further support the concept that prostate cancer cells can tranform in vivo to cells with a NE phenotype and suggest that this transformation might be accelerated in patients by certain therapies for prostate cancer.

Zyflamend inhibits the expression and function of androgen receptor and acts synergistically with bicalutimide to inhibit prostate cancer cell growth

BACKGROUND

Interference of androgen receptor (AR) signaling is a target for prostate cancer (CaP) chemoprevention and treatment. We hypothesize that Zyflamend (ZYF) assert its anti-cancer effect by disrupting AR signaling. We also hypothesize that it may act synergistically with the anti-androgen bicalutimde to inhibit CaP cell growth.

METHODS

Western blotting, ELISA and reporter assays were done to test ZYF on AR signaling. Semi-quantitative RT-PCR and AR half-life were also examined. Potential synergism between ZYF and bicalutimide were tested via cytotoxicity, colony formation assays, flow cytometry, and Western blotting in the human CAP line, LNCaP and 22RV1.

RESULTS

ZYF reduced AR protein, mRNA and protein stability levels in LNCaPs. ZYF also reduced both full-length AR protein and truncated AR protein in the 22Rv1 cell line. Nkx3.1 and PSA were also reduced at the mRNA level. PSA promoter activity and secretion were lower after treatment of cells with ZYF. DHT induction of cell proliferation and AR responsiveness revealed reduction of AR, Nkx3.1, and PSA protein were demonstrated with ZYF treatment. Co-treatment with bicalutimide reducing cell growth, induced apoptosis, and reduced Bcl-2 and BclxL, caspase-3 and PARP. Co-treatment also reduced Nkx3.1 and PSA protein.

CONCLUSIONS

These data indicate that ZYF suppresses cell growth mediated by AR signaling, and suggests that the co-treatment with the anti-androgen bicalutimide and ZYF may be a promising approach for cancer therapy and may demonstrate the mechanism of action of ZYF.

Diet and prostate cancer - a holistic approach to management

There is now increasing evidence from epidemiologic surveys and from laboratory, intervention, and case-control studies that diet and lifestyle plays a crucial role in prostate cancer biology and tumorigenesis. This applies to both the development and progression of prostate cancer, although in many cases the specific initiating factors in the diet are poorly understood. Conversely, many nutrients and herbs also show significant promise in helping to treat prostate cancer by slowing progression and reducing recurrence, ultimately reducing the risk of morbidity and mortality from the disease. Furthermore for all grades of prostate cancer, nutritional interventions complement conventional treatment to improve response and quality of life. Slowing or even reversing the progression of, high-grade prostate intraepithelial neoplasia [HGPIN]). with chemo-preventative agents could be the best primary defense against prostate cancer, preventing it from occurring in the first place. The information given in this review about prostate cancer chemoprevention summarizes the key evidence for the role of different dietary components and their effect on prostate cancer prevention and progression. Most nutritional chemoprevention agents also have the added benefit of being beneficial for the cardiovascular system, bone health and for the prevention of other cancers.

ProstaCaid Induces G2/M Cell Cycle Arrest and Apoptosis in Human and Mouse Androgen-Dependent and-Independent Prostate Cancer Cells

The anticancer effects of ProstaCaid, a novel integrative blend of vitamins, minerals, multiherb extracts, and derivatives, were tested in human and mouse androgen—dependent (AD) and —independent (AI) prostate cancer cell lines. ProstaCaid shows growth inhibitory effects on both human and mouse AD prostate cancer cells (LNCaP and CASP 2.1) and AI prostate cancer cells (PC3 and CASP 1.1) in a dose-/time-dependent manner. Consistently, long-term treatment with ProstaCaid also reduced colony formation capacities of prostate cancer cells. Flow cytometry assays revealed that ProstaCaid induces G2/M arrest and apoptosis in LNCaP and PC3 cells after 72 hours of treatment. Immunoblotting assay demonstrated that 25 µg/mL of ProstaCaid treatment resulted in (1) the reduction of cyclin D1, cyclin B1, and Cdc2 expression in a time-dependent way; (2) increase in p21WAF1/Cip1 as early as 12 hours after the treatments in PC3 cells and reduction to base line at the 72-hour time point; and (3) repression of Bcl-2, BclxL, and induction of Bim as well as the cleavages of caspase-3 and poly(ADP-ribose) polymerase (PARP) at 72 hours of treatment, suggesting caspase-3-dependent apoptosis. Moreover, ProstaCaid suppressed activation of AKT and MAPK signaling pathways in PC3 and LNCaP cells by reducing phosphorylation levels of AKT, its downstream target S6 ribosomal protein and GSK3β, and ERK1/2, respectively. In summary, these findings strongly suggest that ProstaCaid may be a potential chemopreventive and therapeutic agent for both AD and, more importantly, AI prostate cancer.

Abstract B75: Herbal extract amalgam Zyflamend suppresses prostate cancer cell growth and survival through inducing androgen receptor degradation and inhibiting AR signaling

Background: Prostate cancer is a public health problem due to its high incidence and mortality rates. The intervention of androgen receptor (AR) signaling is one of the methods for prostate cancer chemoprevention [eg. prostate cancer prevention trail (PCPT)] and therapy (androgen deprivation therapy). It is now being increasingly recognized that natural herbal and phytochemical agents can be crucial to decease the morbidity and mortality of prostate cancer for both chemoprevention and therapy. Zyflamend is an amalgam comprised of ten different herbal extracts (rosemary, turmeric, ginger, holy basil, green tea, hu zhang, Chinese goldthread, barberry, oregano, and Scutellaria baicalensis) and preliminary data showed that it reduced serum PSA after 18-month treatment in patients who has a prior biopsy showing HGPIN. We hypothesize that Zyflamend can induce anti-cancer effects through affecting AR signaling and androgen antagonist Casodox can sensitize cells to Zyflamend.

Methods: We performed MTT, colony formation and soft agar assays to test the anti-cancer effects of Zyflamend. The alterations in cell cycle were analyzed by flow cytometry and further confirmed by Western blotting. AR and its downstream targets were analyzed at mRNA and protein level. Half-life of AR protein was tested by cycloheximide assay. The nuclear localization and activation of AR were detected by immunofluorescence and luciferase assays. Finally, the combination of androgen antagonist Casodex with Zyflamend was tested in LNCaP cells.

Results: Zyflamend showed cytotoxicity on AR expressing human prostate cancer cells (LNCaP, VCaP and 22Rv1) and mouse prostate cancer cells (CASP1.1 and CASP2.1) in a dose and time dependent manner. Long term exposure to Zyflamend also reduced colony formation capacities of prostate cancer cells in both anchorage dependent and independent assays. Flow cytometry assay revealed that Zyflamend induced G1 phase arrest and apoptosis, manifested by the induction of p21waf1 and p27kip1 protein levels and cleavage of PARP and caspase-3. Of note, Zyflamend reduced AR expression in human and mouse prostate cancer cells, regardless of their androgen responsiveness, indicating that it is not restricted to specific cell line. We found that Zyflamend can reduce AR expression level at mRNA level by semi-quantitative RT-PCR and at protein stability level by cycloheximide assay. Zyflamend reduced AR protein level, induced by DHT treatment and inhibited DHT-induced cell proliferation. Consistently, AR downstream targets genes (PSA and NKX3.1) were reduced and luciferase assay revealed that PSA and probasin promoter activities were reduced by Zyflamend in dose dependent manner. Interestingly, co-treatment with 25 uM casodex sensitized LNCaP cells to the cytotoxicity of Zyflamend.

Conclusions: These data indicate that Zyflamend suppressed cell growth through AR signaling, and suggested that the co-treatment of androgen antagonist casodex with Zyflamend may be a promising approach for chemoprevention and therapy.

Citation Information: Cancer Prev Res 2010;3(1 Suppl):B75.

A pretreatment nomogram predicting biochemical failure after salvage cryotherapy for locally recurrent prostate cancer

OBJECTIVE

To gather a pooled database from six tertiary-care referral centres using salvage cryotherapy (SC) for locally recurrent prostate cancer, and develop a pretreatment nomogram allowing a prediction of the probability of biochemical failure after SC, based on pretreatment clinical variables.

PATIENTS AND METHODS

We retrospectively analysed 797 men treated at six tertiary-care referral centres with SC for locally recurrent disease after primary radiotherapy with curative intent. The median duration of follow-up from the time of SC to the date of last contact was 3.4 years. The primary study endpoint was biochemical failure, defined as a serum prostate-specific antigen (PSA) level after SC of >0.5 ng/mL.

RESULTS

Overall, the rate of biochemical failure was 66% with a median of 3.4 years of follow-up. A logistic regression model was used to predict biochemical failure. Covariates included serum PSA level at diagnosis, initial clinical T stage, and initial biopsy Gleason score. On the basis of these results, a pretreatment nomogram was developed which can be used to help select patients best suited for SC. Our pretreatment nomogram was internally validated using 500 bootstrap samples, with the concordance index of the model being 0.70.

CONCLUSION

A pretreatment nomogram based on several diagnostic variables (serum PSA level at diagnosis, biopsy Gleason grade, and initial clinical T stage) was developed and might allow the selection of ideal candidates for SC.

Update on cryotherapy for localized prostate cancer

Stage migration has led to an increased incidence of localized and low-risk prostate cancer. Intermediate-term data are emerging on the efficacy of cryotherapy, but direct comparison to other therapeutic modalities is difficult as the parameters for recurrence are not well defined. Studies using the American Society for Therapeutic Radiation and Oncology and the Phoenix (nadir plus 2) criteria for biochemical recurrence show that primary cryotherapy appears to be comparable for low-risk prostate cancer as other treatment modalities. In addition, health-related quality-of-life measures have improved with the most recent third-generation systems demonstrating low incontinence and urethrorectal fistula rates. Erectile dysfunction is high with whole gland ablation, but focal therapy may reduce these rates while still ablating unilateral cancerous tissue. Prostate cryotherapy for localized prostate cancer is an evolving but viable therapeutic option. Long-term data are still needed to establish a definitive role for cryosurgery in prostate cancer treatment.

Zyflamend in men with high-grade prostatic intraepithelial neoplasia: results of a phase I clinical trial

Subjects diagnosed with high-grade prostatic intraepithelial neoplasia (HGPIN) at biopsy are at increased risk for developing prostate cancer (CaP). A prospective clinical trial was done to determine the safety and tolerability of a novel herbal amalgam, Zyflamend (New Chapter, Inc., Brattleboro, VT), with various dietary supplements in subjects with HGPIN. Men ages 40 to 75 years with HGPIN were eligible. Subjects were evaluated for 18 months. Every 3 months, standard blood chemistries and prostate-specific antigen (PSA) were monitored. Rebiopsy was done every 6 months. Tissue was evaluated for HGPIN or CaP and stained for cyclooxygenase-2, nuclear factor kappaB (NF-kappaB), interleukin-6, and thromboxane. Twenty-three subjects were evaluable. The median age was 64.1 years (range 46-75 years), and the mean (+/- SD) PSA level was 6.13 +/- 3.56 ng/mL. Side effects, when present, were mild and gastrointestinal in nature. There were no reported serious adverse events or toxicities. No significant changes in blood chemistries, testosterone, or cardiac function were noted. Forty-eight percent of subjects demonstrated a 25 to 50% decrease in PSA after 18 months. Of subjects who had the 18-month biopsy, 60% (9 of 15) had benign tissue, 26.7% (4 of 15) had HGPIN in one core, and 13.3% (2 of 15) had CaP at 18 months. A reduction in serum C-reactive protein was observed (95% confidence interval [CI] 0.7-1.7, p = .045). Immunoreactive staining demonstrated a reduction in NF-kappaB in the 18-month samples (95% CI 0.8-3.0, p = .017). Zyflamend alone and in combination with various dietary supplements is associated with minimal toxicity and no serious adverse events when administered orally for 18 months. Further studies are warranted to evaluate these agents in patients who are at risk for CaP.

beta-carboline alkaloid-enriched extract from the amazonian rain forest tree pao pereira suppresses prostate cancer cells

Bark extracts from the Amazonian rain forest tree Geissospermum vellosii (pao pereira), enriched in alpha-carboline alkaloids have significant anticancer activities in certain preclinical models. Because of the predominance of prostate cancer as a cause of cancer-related morbidity and mortality for men of Western countries, we preclinically tested the in vitro and in vivo effects of a pao pereira extract against a prototypical human prostate cancer cell line, LNCaP. When added to cultured LNCaP cells, pao pereira extract significantly suppressed cell growth in a dose-dependent fashion and induced apoptosis. Immunodeficient mice heterotopically xenografted with LNCaP cells were gavaged daily with pao pereira extract or vehicle control over 6 weeks. Tumor growth was suppressed by up to 80% in some groups compared with tumors in vehicle-treated mice. However, we observed a striking U-shaped dose-response curve in which the highest dose tested (50 mg/kg/d) was much less effective in inducing tumor cell apoptosis and in reducing tumor cell proliferation and xenograft growth compared with lower doses (10 or 20 mg/kg/d). Although this study supports the idea that a pao pereira bark extract has activity against human prostate cancer, our in vivo results suggest that its potential effectiveness in prostate cancer treatment may be limited to a narrow dose range.

High-grade prostatic intraepithelial neoplasia is an independent predictor of outcome after radical prostatectomy

OBJECTIVE

To examine the relationship between the presence of high-grade prostatic intraepithelial neoplasia (HGPIN) in retropubic radical prostatectomy (RP) specimens and cancer-specific outcomes, including pathological variables and biochemical disease-free survival (bDFS), as HGPIN shares many histopathological characteristics with prostate carcinoma and has been considered a precursor lesion to prostate cancer.

PATIENTS AND METHODS

The Columbia University Urologic Oncology Database was reviewed; 3460 patients were identified who underwent RP between 1988-2006, and 2133 with or without HGPIN and >12 months of follow-up were included in the analysis. Analysis of variance methods were used to evaluate the relationship between HGPIN and pathological stage, Gleason sum, perineural invasion, multifocality, extraprostatic extension, margin and nodal status. Kaplan-Meier analysis with the log-rank test and a multivariate Cox proportional hazard model fitted for preoperative prostate-specific antigen (PSA) level, Gleason sum and pathological stage were used to assess differences in bDFS.

RESULTS

In all, 1885 (88.4%) patients had HGPIN in the RRP specimen and 248 (11.6%) had no HGPIN. There was no significant difference in the distribution of PSA level (P = 0.27), pathological stage (P = 0.18) or Gleason sum (P = 0.84) between patients with and with no HGPIN. The HGPIN-positive group had higher rates of perineural invasion (69.9 vs 57.5%; P = 0.003) and multifocality (63.0 vs 38.4%; P < 0.001). Patients with no HGPIN had a better bDFS, at 87.3% vs 81.0% at a median follow-up of 50 months, and 73.6% vs 67.0% at 9 years (P = 0.045). The risk of biochemical failure was 1.9 times greater in the HGPIN-positive group than the negative group (P = 0.006) when controlling for PSA level, pathological stage and Gleason sum.

CONCLUSIONS

In addition to traditional pathological prognostic variables, the absence of HGPIN in RRP specimens, although found in a minority of patients, denotes a significantly lower rate of tumour multifocality, perineural invasion and ultimately biochemical recurrence.

Focal cryosurgery: encouraging health outcomes for unifocal prostate cancer

OBJECTIVES

Owing to the ability to better detect small-volume tumors, we have seen an increasing population of men with low-risk unifocal prostate cancer. We report our safety and efficacy experience of focal cryoablation of the prostate to maintain potency and preserve genitourinary function in men with localized, unifocal disease.

METHODS

From June 2002 to December 2005, 25 patients with primary unifocal prostate cancer were treated with focal cryoablation of the prostate. The patients were followed up with physical examinations, morbidity questionnaires, and prostate-specific antigen (PSA) determinations every 3 months for the first year and every 6 to 12 months thereafter. Patients with a PSA nadir greater than 1.0 ng/mL or a nadir plus 2 ng/mL underwent repeat biopsy to assess for cancer recurrence.

RESULTS

The median age was 68 years (range 48 to 78). The median preoperative PSA level was 6.0 ng/mL, and the postoperative PSA nadir was 2.4 ng/mL. The median follow-up was 28 months. Seventeen patients remained potent. No patients reported worsened lower urinary tract symptoms, incontinence, rectal pain, perineal discomfort, or fistula formation. The median PSA nadir was 2.4 ng/mL, and 40% of patients had a PSA nadir of less than 1.0 ng/mL. Of the 25 patients, 21 (84%) had not experienced biochemical failure, defined as a greater than 50% PSA nadir reduction. Seven patients underwent repeat biopsy, and prostate cancer was detected in the contralateral gland in 2 patients and in the area of previous cryosurgery in 1 patient.

CONCLUSIONS

Focal cryoablation of the prostate has exhibited minimal morbidity and promising efficacy in our 3-year observation. Longer follow-up is necessary to determine its role in the treatment of patients with low-risk unifocal prostate cancer.

The use of herbal and over-the-counter dietary supplements for the prevention of prostate cancer

Having a high probability of experiencing prostate cancer during their lifetime, men are increasingly seeking protection against this disease with the use of over-the-counter dietary supplements containing herbs, vitamins, or plant-derived biochemical agents. The use of these agents for prostate cancer prevention is driven by epidemiology supporting the idea that regional diets and consumption of specific dietary components (certain herbs, vitamins, isoflavones, and polyphenols) are associated with a lower risk for prostate cancer, in conjunction with basic research that is defining molecules within food substances that kill or suppress growth of cultured human prostate cancer cells. Moreover, there is a sense that these dietary agents lack side effects, although this assumption often is faulty. Unfortunately, at this time, there is insufficient clinical evidence to support the widespread use of these dietary supplements for chemoprevention of prostate cancer, although ongoing clinical trials of the most promising vitamins and minerals are approaching conclusion.