A multidisciplinary consensus statement on the optimal pharmacological treatment for metastatic hormone-sensitive prostate cancer

Androgen deprivation therapy (ADT) is the mainstay treatment for metastatic hormone-sensitive prostate cancer (mHSPC). The addition of docetaxel or new hormone therapies (abiraterone, apalutamide, or enzalutamide) improves overall survival and is currently the standard of care. However, the decision on the specific regimen to accompany ADT should be discussed with the patient, considering factors such as possible associated toxicities, duration of treatment, comorbidities, patient preferences, as there is no sufficient evidence to recommend one regimen over the other in most cases. This paper summarizes the evidence on the management of mHSPC and provides consensus recommendations on the optimal treatment in combination with ADT in mHSPC patients, with special attention to the patient's clinical profile.

The impact of psychiatric pathology on the prognosis and survival of men with prostate cancer undergoing radical prostatectomy

INTRODUCTION AND OBJECTIVE

Cancer-specific anxiety is the most frequently reported psychological response after radical prostatectomy (RP). We evaluated the prevalence of pretreatment psychiatric pathology in patients with prostate cancer undergoing RP and identified the effects of psychiatric diagnoses on their survival and prognosis.

MATERIAL AND METHODS

Retrospective multicenter observational study including 1078 men treated with RP for organ-confined prostate cancer. Groups: GP: patients with psychiatric pathology prior to RP; GNP: patients without psychiatric pathology prior to RP. Urological, oncological and psychiatric variables, descriptive statistics and multivariate analysis were included.

RESULTS

37.94% of patients presented a psychiatric diagnosis. Adjuvant radiotherapy was required in 27.83% and hormone therapy in 23.38%; being more frequent in GP. Cancer-specific survival was higher in GNP. Anxiety, depression, insomnia, smoking, psychosis and alcoholism were the most frequent. Low TNM and low presence of LUTS and SUI increased the probability of absence of psychiatric pathology. Fatigue, erectile dysfunction and cognitive impairment after RP with RT and/or HT were higher in GP. Older age and higher PSA at diagnosis increased the relative risk of psychiatric pathology and worse outcome. The most frequently related factors were RP, PSA, age and survival time.

CONCLUSIONS

Psychiatric pathology is present in patients undergoing radical prostatectomy for prostate cancer, with a high impact on survival and prognostic outcomes.

Factors related to early castration resistance in metastatic prostate cancer. Results from the National Prostate Cancer Registry in Spain

INTRODUCTION

The objective of the study was to determine the factors independently related with the development of castration resistance (CR) in prostate cancer (PC) in the medium term.

MATERIAL AND METHODS

155 patients diagnosed with metastatic PC with a follow-up of up to 39 months. Data taken from the National PC Registry. The evaluated variables were age, PSA, nadir PSA, Gleason, perineural invasion, TNM stages, and ADT type (intermittent/continuous).

RESULTS

Mean follow-up 26,2±13,4 months. 47.1% developed early CR, with mean time until onset of 12,2±8,7 months. Univariate analysis the mean PSA was correlated with CR (290±905,1 ng/mL in non CR, 519,1±1437,2 ng/mL in CR, P<.001), mean age (73,3±8,3 years in non CR, 69,1±9,3 in CR P=.01), mean PSA nadir (15,5±57,3ng/mL in non CR, 15,9±23,7 ng/mL in CR, p<0,001), Gleason (in ≥8, HR:2,11. 95% CI: 1.22-3.65, p=0.006), and T stage (in T3-T4, HR: 2.85. 95% CI: 1.57-5.19, P<.001). Multivariate analysis the independent variables associated to CR are age (HR: 0.96. 95% CI: 0.94-0.99, P=.01), PSA nadir (HR: 1.65. 95% CI: 1,43-1,91, P<.001), and T3-T4 stage (HR: 2.11. 95% CI: 1.10-4.04, P=.02).

CONCLUSIONS

PSA nadir and T3-T4 tumor stage at diagnosis are associated to an increased risk of developing CR. In addition, age at diagnosis is shown as a variable that decreases risk. Therefore, an older age would be associated with lower risk probability of CR in the medium term.

Current status of young urologists and residents' activity and academic training in Spain. National survey results

OBJECTIVE

To study the current status of the activity and academic training of residents and young urologists in Spain.

MATERIAL AND METHODS

From the working group of residents and young urologists of the Spanish Association of Urology (AEU), an anonymous survey of 32 questions was designed. Its aim was to evaluate the academic activity of residents, defined by: number of communications to congresses, publications in national and international journals, clinical rotations within Spain and abroad, master's degree, Doctorate (PhD), applications to the European Board of Urology exam and language competences. The survey was sent via email and disseminated through social networks.

RESULTS

Ninety-one respondents were obtained; 66% affirmed not having publications in scientific journals, 67% did not perform rotations abroad. Only 21% claimed to have taken the EBU exam. Only 2% of the respondents had completed a Fellowship. Although most of them (82%) had not done so, they would be interested. However, 67% of respondents believed that the relevance of academic/research activity is from high to very high.

CONCLUSIONS

Our results indicate that academic activity, scientific production and publication of articles of the residents and young urologists in Spain is low. Moreover, participation in the EBU exam, the completion of a master's degree, PhD, rotations and fellowship is low. In contrast, the assessment of scientific activity is considered to be very relevant.

Role of PET-CT with 18F-fluorocholine in biochemical recurrence after treatment of prostate cancer with curative intent

OBJECTIVES

To analyse the ability of the PET-CT with ¹⁸F-fluorocholine (¹⁸F-FCH) to detect disease on biochemical recurrence after treatment with curative intent. To determine the clinical variables that would be able to optimise the test's diagnostic yield.

MATERIAL AND METHODS

A retrospective study of PET-CTs with ¹⁸F-fluorocholine performed on 61 patients with prostate cancer who had undergone treatment with curative intent and met the criteria for biochemical recurrence. The results of the PET-CT were categorised into positive or negative and were validated using pre-established criteria. The relationship between the result of the PET-CT and the initial PSA nadir, PSA trigger, rising PSA velocity (PSAva) and PSA doubling time (PSAdt). The relationship between the metastatic sites on the PET-CT and the remaining variables was analysed.

RESULTS

There was a 34.4% detection rate of the disease. The initial PSA, PSA nadir, PSA trigger and PSAva showed statistically significant differences according to the result of the PET-CT. The best discriminatory cut-off point between a positive or negative PET-CT for PSA trigger and PSAva was 3.5ng/ml and 0.25ng/ml/month respectively. The PSAdt was significantly lower in patients with remote disease compared to patients with localised disease (5.1 vs 16.8 months, P=.01). The probability that the PET-CT would detect remote disease vs localised disease was 3.2 times higher if the PSAdt was under 6 months (80% vs 20%, OR: 3.2, P=.02). In the multivariate analysis, only the initial PSA and not having undergone radical prostatectomy were demonstrated as independent predictive factors of a positive PET-CT result.

CONCLUSIONS

The PET-CT with ¹⁸F-FCH can detect disease in a high percentage of patients with biochemical recurrence and provides information on its anatomical location. PSA kinetics and the patient's previous treatment are key variables in increasing the test's diagnostic.

Influence of demographic and tumour variables on prostate cancer treatment with curative intent in Spain. Results of the 2010 national prostate cancer registry

OBJECTIVE

The aim of this study is to determine which cancer and demographic criteria influence the indication for surgery (radical prostatectomy) or radiation therapy (external or brachytherapy) in the treatment of prostate cancer.

MATERIAL AND METHODS

An analysis of the 2714 patients of the 2010 National Prostate Cancer Registry treated with curative intent. The analysed variables were age, prostate-specific antigen (PSA), prostate volume, the number of biopsy cores, the percentage of positive cores, the stage, Gleason score, the type of pathologist, the presence of perineural invasion and the study centre. We analysed the association among these variables and the type of treatment (surgery vs. radiation therapy/brachytherapy), using a univariate analysis (Student's t test and chi-squared) and a binary multiple logistic regression.

RESULTS

The 48.12% of the patients (1306/2714) were treated with surgery, and 51.88% (1,408/2,714) underwent radiation therapy/brachytherapy. Differences were observed between the patients treated with prostatectomy and those treated with radiation therapy/brachytherapy (p<.05) in age (63.50±6.5 vs. 69.0±6.7), PSA (8.76±16.97 vs. 13.21±15.88), biopsied cores, percentage of positives cores (30.0±22 vs. 38.7±29), Gleason score (G6: 53.9% vs. 46.1%; G7: 45% vs. 55% G8-10: 26.6%, 73.4%), stage (localised: 50% vs. 50%; locally advanced: 14.6% vs. 85.4%), perineural invasion and hospital centre. In the multivariate analysis, the selected independent variables were age, PSA, percentage of positives cores, stage, Gleason score and hospital centre.

CONCLUSION

According to our study, age, tumour aggressiveness and stage and the centre where the patient will be treated affect the selection of curative treatment for prostate cancer.

The assessment of surgical skills as a complement to the training method. Revision

CONTEXT AND OBJECTIVE

The acquisition and improvement of surgical skills constitute a fundamental element in the training of any practitioner. At present, however, the assessment of these skills is a scarcely developed area of research. The aim of this study was to analyse the peculiarities of the various assessment systems and establish the minimum criteria that a skills and knowledge assessment system should meet as a method for assessing surgical skills in urological surgery.

ACQUISITION OF EVIDENCE

Scientific literature review aimed at the various currently available assessment systems for skills and competencies (technical and nontechnical), with a special focus on the systematic reviews and prospective studies.

SUMMARY OF THE EVIDENCE

After conducting the review, we found that the various assessment systems for surgical competence have, in our opinion, a number of shortcomings. There is a certain degree of subjectivity in the assessment of surgeons by the evaluators. The assessment of nontechnical competencies is not formally recorded. There is no description of a follow-up assessment or any basic parameters associated with healthcare quality. There is no registration of associated competencies associated with the various surgical techniques. There is also no ranking of these competencies and the specific peculiarities for their application.

CONCLUSIONS

We believe that the development of a new assessment system for surgical competencies (technical and nontechnical) aimed at assessing urologists in the various surgical techniques is necessary. To this end, our team has worked on developing the Evaluation System for Surgical Competencies on Laparoscopy, which is based on the definition, ranking and assessment of competencies demonstrated by surgeons.

The role of positron emission tomography/computed tomography imaging with radiolabeled choline analogues in prostate cancer

INTRODUCTION

prostate cancer is the most frequent solid malignant tumor in Western Countries. Positron emission tomography/x-ray computed tomography imaging with radiolabeled choline analogues is a useful tool for restaging prostate cancer in patients with rising prostate-specific antigen after radical treatment (in whom conventional imaging techniques have important limitations) as well as in the initial assessment of a selected group of prostate cancer patients. For this reason a literature review is necessary in order to evaluate the usefulness of this imaging test for the diagnosis and treatment of prostate cancer.

EVIDENCE ACQUISITION

a MEDLINE (PubMed way) literature search was performed using the search parameters: «Prostate cancer» and «Choline-PET/CT». Other search terms were «Biochemical failure» and/or «Staging» and/or «PSA kinetics». English and Spanish papers were selected; original articles, reviews, systematic reviews and clinical guidelines were included.

CONCLUSIONS

according to available data, radiolabeled choline analogues plays an important role in the management of prostate cancer, especially in biochemical relapse because technique accuracy is properly correlated with prostate-specific antigen values and kinetics. Although is an emerging diagnostic technique useful in treatment planning of prostate cancer, final recommendations have not been submitted.

Primary treatment of painful varicocoele through percutaneous retrograde embolization with fibred coils

The literature on the treatment of painful varicocoele is limited, likely because of the short period since it was recognized as a clinical entity and the limitations posed by the subjectivity of pain. Our aim was to systematically analyse the results of percutaneous embolization as the chosen treatment for this condition. We conducted a retrospective study of patients undergoing percutaneous embolization as primary treatment for painful varicocoele from January 2007 to November 2013. Radiologic and ultrasonographic successes were evaluated according to the existence or absence of venous reflux on venography after embolization and on Echo Doppler control at 3-6 months. Clinical success was assessed by Visual Analog Scale pain questionnaires before surgery and at 3-6 months; in addition, at the time of the study, telephone interviews were conducted to update the clinical situation and development. A total of 154 patients received operations. The median pain before surgery, at 3-6 months and at the time of interview was 7, 1 and 0 points respectively (p < 0.001). The ultrasonographic success rate at 3-6 months was 68.6%. With a median follow-up of 39 months, the success and relapse/clinical persistence rates were 86.9 and 13.1% respectively. By studying the degree of agreement between clinical success and ultrasonographic success, a kappa index = 0.443 was obtained. Patients with success recounted greater pre-operative pain scores than those who relapsed or persisted (7.5 vs. 5.0; p = 0.004). In patients with painful varicocoele, the ultrasonographic recurrence of venous reflux does not imply the recurrence of pain; hence, the proper assessment of success in these patients should include a systematic assessment of their pain and grade of reflux. Percutaneous retrograde embolization as a primary treatment for painful varicocoele is a clinically effective option with a high success rate that can be maintained in the long term, especially in patients with high pre-operative pain.