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Grönlund E, Almhagen E, Johansson S, Traneus E, Nyholm T, Thellenberg C, Ahnesjö A. Robust treatment planning of dose painting for prostate cancer based on ADC-to-Gleason score mappings - what is the potential to increase the tumor control probability? Acta Oncol 2021; 60:199-206. [PMID: 32941092 DOI: 10.1080/0284186x.2020.1817547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to evaluate the potential to increase the tumor control probability (TCP) with 'dose painting by numbers' (DPBN) plans optimized in a treatment planning system (TPS) compared to uniform dose plans. The DPBN optimization was based on our earlier published formalism for prostate cancer that is driven by dose-responses of Gleason scores mapped from apparent diffusion coefficients (ADC). MATERIAL AND METHODS For 17 included patients, a set of DPBN plans were optimized in a TPS by maximizing the TCP for an equal average dose to the prostate volume (CTVT) as for a conventional uniform dose treatment. For the plan optimizations we applied different photon energies, different precisions for the ADC-to-Gleason mappings, and different CTVT positioning uncertainties. The TCP increasing potential was evaluated by the DPBN efficiency, defined as the ratio of TCP increases for DPBN plans by TCP increases for ideal DPBN prescriptions (optimized without considering radiation transport phenomena, uncertainties of the CTVT positioning, and uncertainties of the ADC-to-Gleason mapping). RESULTS The median DPBN efficiency for the most conservative planning scenario optimized with a low precision ADC-to-Gleason mapping, and a positioning uncertainty of 0.6 cm was 10%, meaning that more than half of the patients had a TCP gain of at least 10% of the TCP for an ideal DPBN prescription. By increasing the precision of the ADC-to-Gleason mapping, and decreasing the positioning uncertainty the median DPBN efficiency increased by up to 40%. CONCLUSIONS TCP increases with DPBN plans optimized in a TPS were found more likely with a high precision mapping of image data into dose-responses and a high certainty of the tumor positioning. These findings motivate further development to ensure precise mappings of image data into dose-responses and to ensure a high spatial certainty of the tumor positioning when implementing DPBN clinically.
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Affiliation(s)
- Eric Grönlund
- Medical radiation sciences, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Section of Medical Physics, Eskilstuna Hospital, Eskilstuna, Sweden
| | - Erik Almhagen
- Medical radiation sciences, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- The Skandion Clinic, Uppsala, Sweden
| | - Silvia Johansson
- Uppsala University Hospital, Uppsala, Sweden
- Experimental and clinical oncology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Tufve Nyholm
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | | | - Anders Ahnesjö
- Medical radiation sciences, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Uppsala University Hospital, Uppsala, Sweden
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Crippa A, De Laere B, Discacciati A, Larsson B, Connor JT, Gabriel EE, Thellenberg C, Jänes E, Enblad G, Ullen A, Hjälm-Eriksson M, Oldenburg J, Ost P, Lindberg J, Eklund M, Grönberg H. The ProBio trial: molecular biomarkers for advancing personalized treatment decision in patients with metastatic castration-resistant prostate cancer. Trials 2020; 21:579. [PMID: 32586393 PMCID: PMC7318749 DOI: 10.1186/s13063-020-04515-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Multiple therapies exist for patients with metastatic castration-resistant prostate cancer (mCRPC). However, their improvement on progression-free survival (PFS) remains modest, potentially explained by tumor molecular heterogeneity. Several prognostic molecular biomarkers have been identified for mCRPC that may have predictive potential to guide treatment selection and prolong PFS. We designed a platform trial to test this hypothesis. METHODS The Prostate-Biomarker (ProBio) study is a multi-center, outcome-adaptive, multi-arm, biomarker-driven platform trial for tailoring treatment decisions for men with mCRPC. Treatment decisions in the experimental arms are based on biomarker signatures defined as mutations in certain genes/pathways suggested in the scientific literature to be important for treatment response in mCRPC. The biomarker signatures are determined by targeted sequencing of circulating tumor and germline DNA using a panel specifically designed for mCRPC. DISCUSSION Patients are stratified based on the sequencing results and randomized to either current clinical practice (control), where the treating physician decides treatment, or to molecularly driven treatment selection based on the biomarker profile. Outcome-adaptive randomization is implemented to early identify promising treatments for a biomarker signature. Biomarker signature-treatment combinations graduate from the platform when they demonstrate 85% probability of improving PFS compared to the control arm. Graduated combinations are further evaluated in a seamless confirmatory trial with fixed randomization. The platform design allows for new drugs and biomarkers to be introduced in the study. CONCLUSIONS The ProBio design allows promising treatment-biomarker combinations to quickly graduate from the platform and be confirmed for rapid implementation in clinical care. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03903835. Date of registration: April 4, 2019. Status: Recruiting.
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Affiliation(s)
- Alessio Crippa
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Bram De Laere
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Andrea Discacciati
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Berit Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jason T Connor
- University of Central Florida College of Medicine, Orlando, FL, USA
- Confluence Stat LLC, Orlando, FL, USA
| | - Erin E Gabriel
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Camilla Thellenberg
- Department of Radiation Sciences and Oncology, Umeå University, Umeå, Sweden
| | - Elin Jänes
- Länssjukhuset Sundsvall Härnösand, Sundsvall, Sweden
| | - Gunilla Enblad
- Department of Immunology, Genetics and Pathology, Uppsala Universitet, Uppsala, Sweden
| | - Anders Ullen
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | - Jan Oldenburg
- Division of Medicine, University of Oslo, Oslo, Norway
| | - Piet Ost
- Department of Radiotherapy and Experimental Cancer Research, Ghent University, Ghent, Belgium
| | - Johan Lindberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Eklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Grönberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Anand A, Trägårdh E, Edenbrandt L, Beckman L, Svensson JH, Thellenberg C, Widmark A, Kindblom J, Ullén A, Bjartell A. Assessing Radiographic Response to 223Ra with an Automated Bone Scan Index in Metastatic Castration-Resistant Prostate Cancer Patients. J Nucl Med 2019; 61:671-675. [PMID: 31586004 DOI: 10.2967/jnumed.119.231100] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/16/2019] [Indexed: 01/24/2023] Open
Abstract
For effective clinical management of patients being treated with 223Ra, there is a need for radiographic response biomarkers to minimize disease progression and to stratify patients for subsequent treatment options. The objective of this study was to evaluate an automated bone scan index (aBSI) as a quantitative assessment of bone scans for radiographic response in patients with metastatic castration-resistant prostate cancer (mCRPC). Methods: In a multicenter retrospective study, bone scans from patients with mCRPC treated with monthly injections of 223Ra were collected from 7 hospitals in Sweden. Patients with available bone scans before treatment with 223Ra and at treatment discontinuation were eligible for the study. The aBSI was generated at baseline and at treatment discontinuation. The Spearman rank correlation was used to correlate aBSI with the baseline covariates: alkaline phosphatase (ALP) and prostate-specific antigen (PSA). The Cox proportional-hazards model and Kaplan-Meier curve were used to evaluate the association of covariates at baseline and their change at treatment discontinuation with overall survival (OS). The concordance index (C-index) was used to evaluate the discriminating strength of covariates in predicting OS. Results: Bone scan images at baseline were available from 156 patients, and 67 patients had both a baseline and a treatment discontinuation bone scan (median, 5 doses; interquartile range, 3-6 doses). Baseline aBSI (median, 4.5; interquartile range, 2.4-6.5) was moderately correlated with ALP (r = 0.60, P < 0.0001) and with PSA (r = 0.38, P = 0.003). Among baseline covariates, aBSI (P = 0.01) and ALP (P = 0.001) were significantly associated with OS, whereas PSA values were not (P = 0.059). After treatment discontinuation, 36% (24/67), 80% (54/67), and 13% (9/67) of patients demonstrated a decline in aBSI, ALP, and PSA, respectively. As a continuous variable, the relative change in aBSI after treatment, compared with baseline, was significantly associated with OS (P < 0.0001), with a C-index of 0.67. Median OS in patients with both aBSI and ALP decline (median, 134 wk) was significantly longer than in patients with ALP decline only (median, 77 wk; P = 0.029). Conclusion: Both aBSI at baseline and its change at treatment discontinuation were significant parameters associated with OS. The study warrants prospective validation of aBSI as a quantitative imaging response biomarker to predict OS in patients with mCRPC treated with 223Ra.
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Affiliation(s)
- Aseem Anand
- Division of Urological Cancers, Department of Translational Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Elin Trägårdh
- Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Malmö, Sweden
| | - Lars Edenbrandt
- Department of Nuclear Medicine, Gothenburg University, Gothenburg, Sweden
| | - Lars Beckman
- Department of Oncology, Sundsvall-Härnösand County Hospital, Sundsvall, Sweden
| | | | | | - Anders Widmark
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Jon Kindblom
- Department of Oncology, Gothenburg University, Gothenburg, Sweden; and
| | - Anders Ullén
- Department of Oncology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Bjartell
- Division of Urological Cancers, Department of Translational Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
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Stranne J, Brasso K, Brennhovd B, Johansson E, Jäderling F, Kouri M, Lilleby W, Meidahl Petersen P, Mirtti T, Pettersson A, Rannikko A, Thellenberg C, Akre O. SPCG-15: a prospective randomized study comparing primary radical prostatectomy and primary radiotherapy plus androgen deprivation therapy for locally advanced prostate cancer. Scand J Urol 2018; 52:313-320. [PMID: 30585526 DOI: 10.1080/21681805.2018.1520295] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To describe study design and procedures for a prospective randomized trial investigating whether radical prostatectomy (RP) ± radiation improves cause-specific survival in comparison with primary radiation treatment (RT) and androgen deprivation treatment (ADT) in patients with locally advanced prostate cancer (LAPC). MATERIALS AND METHODS SPCG-15 is a prospective, multi-centre, open randomized phase III trial. Patients are randomized to either standard (RT + ADT) or experimental (RP with extended pelvic lymph-node dissection and with addition of adjuvant or salvage RT and/or ADT if deemed necessary) treatment. Each centre follows guidelines regarding the timing and dosing of postoperative RT and adjuvant treatment such as ADT The primary endpoint is cause-specific survival. Secondary endpoints include metastasis-free and overall survival, quality-of-life, functional outcomes and health-services requirements. Each subject will be followed up for a minimum of 10 years. RESULTS Twenty-three centres in Denmark, Finland, Norway and Sweden, well established in performing RP and RT for prostate cancer participated. Each country's sites were coordinated by national coordinating investigators and sub-investigators for urology and oncology. Almost 400 men have been randomized of the stipulated 1200, with an increasing rate of accrual. CONCLUSIONS The SPCG-15 trial aims to compare the two curatively intended techniques supplying new knowledge to support future decisions in treatment strategies for patients with LAPC The Scandinavian healthcare context is well suited for performing multi-centre long-term prospective randomized clinical trials. Similar care protocols and a history of entirely tax-funded healthcare facilitate joint trials.
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Affiliation(s)
- J Stranne
- a Department of Urology , Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - K Brasso
- b Copenhagen Prostate Cancer Center and Department of Urology, Rigshospitalet Copenhagen , Copenhagen , Denmark
| | - B Brennhovd
- c Department of Uro-Oncology, Radiumhospitalet , Oslo University Hospital HF , Oslo , Norway
| | - E Johansson
- d Department Of Urology , Uppsala University Hospital , Uppsala , Sweden
| | - F Jäderling
- e Department of Radiology , Karolinska Institutet/University Hospital , Stockholm , Sweden
| | - M Kouri
- f Department of Oncology , Helsinki University Hospital , Helsinki , Finland
| | - W Lilleby
- c Department of Uro-Oncology, Radiumhospitalet , Oslo University Hospital HF , Oslo , Norway
| | - P Meidahl Petersen
- g Department of Oncology , The Finsen Centre, Copenhagen University Hospital , Copenhagen , Denmark
| | - T Mirtti
- h Institute for Molecular Medicine Finland (FIMM), University of Helsinki , Helsinki , Finland
| | - A Pettersson
- i Department of Medicine Solna , Karolinska Institutet , Clinical Epidemiology Unit , Stockholm , Sweden
| | - A Rannikko
- j Department of Urology , Helsinki University Hospital , Helsinki , Finland
| | - C Thellenberg
- k Cancercentrum , Norrlands University Hospital , Umeå , Sweden
| | - O Akre
- l Department of Molecular Medicine and Surgery , Karolinska Institutet , Stockholm , Sweden
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Grönlund E, Johansson S, Nyholm T, Thellenberg C, Ahnesjö A. Dose painting of prostate cancer based on Gleason score correlations with apparent diffusion coefficients. Acta Oncol 2018; 57:574-581. [PMID: 29260950 DOI: 10.1080/0284186x.2017.1415457] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Gleason scores for prostate cancer correlates with an increased recurrence risk after radiotherapy (RT). Furthermore, higher Gleason scores correlates with decreasing apparent diffusion coefficient (ADC) data from diffusion weighted MRI (DWI-MRI). Based on these observations, we present a formalism for dose painting prescriptions of prostate volumes based on ADC images mapped to Gleason score driven dose-responses. METHODS The Gleason score driven dose-responses were derived from a learning data set consisting of pre-RT biopsy data and post-RT outcomes for 122 patients treated with a homogeneous dose to the prostate. For a test data set of 18 prostate cancer patients with pre-RT ADC images, we mapped the ADC data to the Gleason driven dose-responses by using probability distributions constructed from published Gleason score correlations with ADC data. We used the Gleason driven dose-responses to optimize dose painting prescriptions that maximize the tumor control probability (TCP) with equal average dose as for the learning sets homogeneous treatment dose. RESULTS The dose painting prescriptions increased the estimated TCP compared to the homogeneous dose by 0-51% for the learning set and by 4-30% for the test set. The potential for individual TCP gains with dose painting correlated with increasing Gleason score spread and larger prostate volumes. The TCP gains were also found to be larger for patients with a low expected TCP for the homogeneous dose prescription. CONCLUSIONS We have from retrospective treatment data demonstrated a formalism that yield ADC driven dose painting prescriptions for prostate volumes that potentially can yield significant TCP increases without increasing dose burdens as compared to a homogeneous treatment dose. This motivates further development of the approach to consider more accurate ADC to Gleason mappings, issues with delivery robustness of heterogeneous dose distributions, and patient selection criteria for design of clinical trials.
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Affiliation(s)
- Eric Grönlund
- Department of Immunology, Genetics and Pathology, Medical Radiation Sciences, Uppsala University, Uppsala, Sweden
| | - Silvia Johansson
- Department of Immunology, Genetics and Pathology, Experimental and Clinical Oncology, Uppsala University, Uppsala, Sweden
- Uppsala University Hospital, Uppsala, Sweden
| | - Tufve Nyholm
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | | | - Anders Ahnesjö
- Department of Immunology, Genetics and Pathology, Medical Radiation Sciences, Uppsala University, Uppsala, Sweden
- Uppsala University Hospital, Uppsala, Sweden
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Gronberg H, Eklund M, Lindberg J, Ullén A, Bjartell A, Andren O, Robinson D, Franck Lissbrant I, Enblad G, Stahl O, Thellenberg C. ProBio II: An adaptive and randomized multi-arm biomarker driven phase 2 study in men with castrate resistant prostate cancer (CRPC). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.tps397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS397 Background: Castrate-resistant prostate cancer (CRPC) affects around 3,000 men in Sweden every year. New drugs are available but they have moderate effect, low response rates, are expensive, and lack predictive treatment markers. This will lead to an unsustainable situation for prostate cancer care. Our hypothesis is that treatment decisions based on molecular profiling will significantly increase the response rate at 3 months compared to current clinical care, translating into improved progression free and overall survival. The vast majority of CRPC metastasize to the bone, with low success rate in obtaining sufficient material. Therefore, we will sequence circulating tumor DNA (ctDNA) being present at high levels in plasma. Methods: ProBio-II is an adaptive, multi-arm, open-label, multiple assignment randomized biomarker driven phase 2 trial in men with CRPC . Men (n=750) will be randomized to receive either standard of care (following Swedish national guidelines) or treatment with Enzalutamide, Abiraterone, PARP inhibitors, RA-223, Cabazitaxel, or immune modulators based on molecular subtypes. The molecular subtypes are defined as tumor properties or mutations in certain genes/pathways including: Microsatellite instability; Androgen receptor alterations; DNA-repair deficiency; TP53 inactivation; PTEN inactivation etc. The molecular subtypes will be identified by ctDNA profiling. A specially designed ctDNA profile for CRPC has been developed by our group to detect: mutations, amplifications and genomic rearrangements in the androgen receptor (AR); mutations, genomic rearrangements and amplifications/deletions in 300 key genes involved in prostate cancer; and microsatellite instable and hypermutated cancers. ProBio-II’s design is novel and inspired by successful studies as I-SPY (breast cancer) and the NCI-MATCH trial (metastatic cancer). Novel aspects of the study design includes using prior probability of treatment response; re-randomization of non-responders; and adaptive design. The ProBio II study will start recruiting patients in Sweden in Q1 2018 and recruit patients during a 18 month period. All major oncology departments in Sweden will participate.
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Affiliation(s)
| | | | | | | | | | | | | | - Ingela Franck Lissbrant
- Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gunilla Enblad
- Department of Immunology, Genetics, and Pathology, Uppsala, Sweden
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Friðriksson JÖ, Folkvaljon Y, Nilsson P, Robinson D, Frank Lissbrant IF, Ehdaie B, Eastham JA, Widmark A, Thellenberg C, Stattin P. PD6-10 ADVERSE EVENTS AFTER RADICAL PROSTATECTOMY AND CURATIVE RADIOTHERAPY. POPULATION-BASED NATION-WIDE REGISTER STUDY. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE Evaluation of second primary cancers provides valuable insight about etiology and shared risk factors. Studies of second primary cancers following prostate cancer conclude that overall risk of second primary cancers decreases. However, risk of bladder cancer and kidney cancer increases. We examine the risk of common and rare second primary cancers following prostate cancer in a large population based cohort to identify possible common etiological factors. MATERIALS AND METHODS All prostate cancer cases in the Swedish Cancer Registry (135, 713) from 1958 to the end of 1996 constituted the study base. Risk (standardized incidence ratio) of second primary cancers was calculated as the ratio between observed and expected number of cancers. We used 2-tailed 95% confidence intervals (CI) to test significance. RESULTS An overall increased risk (standardized incidence ratio 1.17, 95% CI 1.15-1.19) of second primary cancers was found but was only seen in the first 6 months of followup (ratio 3.45, 3.32-3.57). The most interesting finding was an increased risk (ratio 2.01, 95% CI 1.44-2.74) of male breast cancer. Other tumor sites with increased risk were the small intestine (standardized incidence ratio 1.39, 95% CI 1.09-1.51), skin melanoma (ratio 1.33, 95% CI 1.16-1.51) and endocrine tumors (ratio 1.41, 95% CI 1.13-1.74). CONCLUSIONS A small but increased risk of second primary cancers following prostate cancer was found, most likely due to increased surveillance during the first 6 months after diagnosis. However, following prostate cancer there is an increased risk of endocrine related second primary cancers such as male breast cancer and carcinoids in the small intestine. To our knowledge these associations have not been reported previously, and they warrant more study.
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