Unexpected response of hormone-refractory prostate cancer to treatment with an antileukemic chemotherapy regimen

Our patient was a 61-year-old man with hormone-refractory prostate cancer and a rapidly rising serum prostate-specific antigen level. During the course of therapy for prostate cancer, abnormal blood counts and subsequent bone marrow biopsy led to a diagnosis of acute lymphoblastic leukemia. He was treated with a chemotherapeutic regimen in standard use for lymphoblastic leukemia, which resulted in an unusual response of his prostate cancer, with declining serum prostate-specific antigen levels that had reached undetectable levels at the time of the patient's death from acute sepsis and leukemic relapse. Autopsy showed minimal evidence of prostate cancer, localized to the prostate.

Monotherapy in advanced prostate cancer: an overview

Prostate cancer is the second leading malignancy in men associated with an enormous research interest in all aspects of the disease. It is well recognized that the regulation of prostatic growth is a complicated biological process. Further more the androgenic dependence of the advanced prostate cancer is well know and in the last 50 years significant progresses regarding the principle of deprivation of androgens for the treatment of the disease occured. Prostate cancer is now diagnosed in earlier stages and treatment results in increased potential for cure or extension of overall survival. Unfortunately, every treatment for prostate cancer has adverse effects with negative impact in health-related quality of life. Surgical or pharmacological castration has a significant negative impact on quality of life in patients with prostate cancer (loss of sexuality, osteoporosis, and loss of muscle mass, e.g.). Antiandrogen monotherapy is considered to be a treatment in well-informed patients who wish to remain sexually active, can be administered orally, and is well tolerated by patients with prostate cancer. This review is focused on antiandrogen monotherapy in the treatment of advanced prostate cancer.

Osteoporosis and spinal fractures in men with prostate cancer: risk factors and effects of androgen deprivation therapy

PURPOSE

We determined the risk factors for osteoporosis and spinal fractures in men with prostate cancer receiving androgen deprivation therapy.

MATERIALS AND METHODS

We performed a retrospective analysis of 87 consecutive men with prostate cancer receiving androgen deprivation therapy referred for evaluation of osteoporosis. Data were comprised of lateral thoracolumbar radiographs, bone densitometry, serum biochemistry and a detailed assessment of osteoporotic risk factors. Multivariate regression analysis was used to determine the major risk factors for osteoporosis and spinal fractures.

RESULTS

There were 38 (44%) men who were 74.5 years old with radiographic evidence of spinal fractures. They had an initial mean prostate specific antigen of 52.8 ng/ml and had received androgen deprivation therapy for a mean of 39.6 months (95% confidence interval 28.7 to 50.4). Mean spinal (quantitative computerized tomography t-score -4.2) and femoral neck bone mineral densities (dual energy x-ray absorptiometry t-score -2.1) were significantly lower than in men without spinal fractures (p < 0.001 for all measurements). In the regression analysis the duration of androgen deprivation therapy (p = 0.002), serum 25-hydroxyvitamin D levels (p = 0.003) and a history of alcohol excess (defined as more than 4 standard drinks daily, p = 0.04) were the main determinants of spinal fractures.

CONCLUSIONS

Prolonged androgen deprivation therapy, low serum 25-hydroxyvitamin D levels and a history of alcohol excess are important risk factors for osteoporosis and spinal fractures in men with prostate cancer.

Antiandrogen monotherapy: recommendations for the treatment of prostate cancer

OBJECTIVE

The concept of antiandrogens as monotherapy for the treatment of prostate cancer is discussed.

METHODS

Both Medline and Current Contents were used to identify studies on antiandrogen monotherapy in prostate cancer. We tried to analyze this database critically to establish whether or not there is evidence for using this monotherapy.

RESULTS

In particular, bicalutamide in monotherapy has been compared with castration in large international trials. Results show that antiandrogen monotherapy is inferior to castration in patients with metastatic tumour but the difference in median survival is limited. In locally advanced M0 prostate cancer bicalutamide 150 mg monotherapy seems equivalent to castration in terms of overall survival and time to progression. Analysis of quality of life showed that there is evidence of some benefits from bicalutamide when compared to castration in both sexual interest and physical capacity.

CONCLUSION

Antiandrogens in monotherapy can be effective and well tolerated. However, more research is needed because none of the available compounds have definitively been proven to be equivalent to castration.

Bicalutamide (Casodex) in the treatment of prostate cancer

Prostate cancer is an important healthcare issue in men worldwide. With the advent of prostate-specific antigen screening and improved diagnostic techniques, prostate cancer is now being diagnosed in younger men and at earlier disease stages. As a result, patients often live with their disease for many years after diagnosis. This shift in the patient profile has focused attention to the impact of treatment on quality of life. Medical/surgical castration has traditionally been the mainstay of hormonal therapy but is associated with side effects including loss of libido and impotence. Nonsteroidal antiandrogens such as bicalutamide (Casodex) offer an effective alternative to castration with potential quality-of-life benefits. This paper reviews the evidence concerning the use of bicalutamide at all stages of the disease.

The 3rd Conference on Asian Trends in Prostate Cancer Hormone Therapy

From its inception in 2001, the Conference on Asian Trends in Prostate Cancer Hormone Therapy has served as an annual forum for Asian urologists to compare data on prostate cancer and to discuss issues regarding the use of hormone therapy. The 3rd conference, held in Tokyo in December 2003, began with participants from China, Indonesia, Japan, Korea, Singapore, and Taiwan presenting QOL data deriving from a survey of patients with prostate cancer. For this purpose, each country translated the Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire into its own language. Although the surveys conducted in each country included a heterogeneous cohort of patients and gave very mixed results, the trial of FACT-P in Asian countries seemed propitious and in future may provide insights that could prove beneficial to patients. Day 2 of the conference included 2 discussions, focusing on the most appropriate number of biopsy cores and the implementation of prospective trials involving the collaboration of Asian countries, respectively. In the latter discussion, although a varied assortment of proposals were put forth, the participants generally agreed that any collaborative study must be a prospective outcome study conducted in a relatively short time not exceeding 2-3 years, and that patient registration should be done using the Internet.

Cost-effectiveness analysis of bicalutamide (Casodex) for adjuvant treatment of early prostate cancer

OBJECTIVES

To assess the cost-effectiveness of bicalutamide (Casodex) as adjuvant treatment in early prostate cancer (EPC).

METHODS

A Markov state transition model was developed, using disease progression rates from a large (N = 8113) clinical trial program comparing bicalutamide in addition to standard care with standard care alone. Utility scores for different disease stages were obtained from published reports. Costs of disease progression were obtained from a retrospective patient chart analysis in six Belgian centers (n = 60). The time horizon was 15 years and the analysis was conducted from the public payer perspective.

RESULTS

The model showed good validity in predicting clinical outcomes. At a time horizon of 15 years, an incremental cost-effectiveness of 27,059 euros/QALY was obtained. The main factors influencing conclusions included the time horizon, the duration of bicalutamide treatment, which was set at a maximum (5 years) in the base case, and possible differences in prognosis of metastatic cancer between comparators. Also the discounting of health effects significantly altered cost-effectiveness ratios. Many of these influences are inherently associated with any cost-effectiveness analysis related to treatment of early, slowly progressing malignancies because such an analysis requires a sufficient time horizon to include not only the treatment costs but its benefits as well.

CONCLUSION

Based on the current data, bicalutamide appears to be a cost-effective option for adjuvant treatment of EPC.

An evaluation of bicalutamide in the treatment of prostate cancer

Although prostate cancer is traditionally considered a disease of old age, improved diagnostic techniques have resulted in early diagnosis, and many men are now treated while still physically and sexually active. Current therapies for prostate cancer often include medical or surgical castration, which cause adverse effects on physical and sexual function; therefore, greater attention has been focused on quality of life. The nonsteroidal antiandrogen bicalutamide is an effective agent with a favorable tolerability profile and, in some settings, represents an alternative to castration. Mature survival data reveal that bicalutamide monotherapy provides survival benefits for untreated locally advanced disease that do not differ significantly from those of castration and maintains better physical capacity and sexual interest. Recent data from a prospective randomized trial demonstrate that bicalutamide given as immediate therapy, either alone or as adjuvant to therapy of curative intent, significantly reduces the risk of objective disease progression in patients with localized or locally advanced prostate cancer. Antiandrogens are also used in combination with castration, a treatment known as combined androgen blockade (CAB), for advanced disease. A randomized trial demonstrated that CAB with bicalutamide is associated with similar survival outcome to CAB with flutamide and is better tolerated. Current evidence demonstrates that bicalutamide currently has a favorable risk-benefit ratio in several stages of prostate cancer and that the role of bicalutamide will be further defined by ongoing studies.

The biological basis for the use of an anti-androgen and a 5-alpha-reductase inhibitor in the treatment of recurrent prostate cancer: Case report and review

Although many prostate cancer cases relapse to a hormone-insensitive state, endocrine therapy involving androgen depletion by orchiectomy or by treatment with LHRH-analogue as well as blockade of the androgen receptor (AR) with anti-androgens remains a primary treatment option. Quality of life (QOL) however, is a prime consideration of men choosing such an approach. In this report we discuss a synergistic combination of 150-mg bicaltumide (Casodex) and 5 mg finasteride (Proscar) in the treatment of a 69-year-old patient with a relapsed (biochemical failure) Gleason score 7 prostate cancer, initially treated with external beam radiation therapy. A successful clinical outcome as evidenced by undetectable serum PSA, bone scan density and overall general well-being was accomplished with minimal side effects. Experiments using an established hormone-dependent prostate cancer cell line (LNCaP) showed that the combination of bicaltumide-finasteride at the same ratio as used clinically, produced synergistic effects on the inhibition of cell proliferation and AR expression/phosphorylation. A more complete inactivation of the AR on this regimen may have had the effect of constraining the ability of the AR to mutate, and/or diminishing the ability of androgen independent clones to evolve. Thus, passage to androgen independence may have been slowed or arrested.

Is the efficacy of hormonal therapy affected by lymph node status? data from the bicalutamide (Casodex) Early Prostate Cancer program

OBJECTIVES

To report an exploratory subgroup analysis assessing the extent to which the overall benefit found in the Early Prostate Cancer program is dependent on lymph node status at randomization. The program is ongoing, and the overall survival data are immature. The first combined analysis of the bicalutamide (Casodex) Early Prostate Cancer program at 3 years' median follow-up showed that bicalutamide, 150 mg once daily, plus standard care (radical prostatectomy, radiotherapy, or watchful waiting), significantly reduced the risk of objective progression and prostate-specific antigen (PSA) doubling in patients with localized/locally advanced prostate cancer.

METHODS

Men (n = 8113) with localized/locally advanced disease received bicalutamide 150 mg or placebo once daily, plus standard care. The time to event data (objective progression, PSA doubling) was analyzed by lymph node status at randomization.

RESULTS

Compared with standard care alone, bicalutamide significantly reduced the risk of objective progression, irrespective of lymph node status, with the most pronounced reduction in patients with N+ (hazard ratio [HR] 0.29; 95% confidence interval [CI] 0.15 to 0.56) compared with those with N0 (HR 0.59; 95% CI 0.48 to 0.73) and Nx (HR 0.60; 95% CI 0.50 to 0.72) disease. The largest decrease in risk of PSA doubling with bicalutamide was observed in N+ disease (HR 0.16; 95% CI 0.09 to 0.29), with significantly reduced risks seen in N0 (HR 0.45; 95% CI 0.40 to 0.51) and Nx (HR 0.38; 95% CI 0.33 to 0.44) disease.

CONCLUSIONS

The greatest reduction in the risk of objective progression and PSA doubling with bicalutamide was seen in patients with N+ disease. However, bicalutamide also provided a statistically significant benefit in those with N0 and Nx disease.

Effect of nonsteroidal antiandrogen monotherapy versus castration therapy on neuroendocrine differentiation in prostate carcinoma

OBJECTIVES

To determine whether the administration of the nonsteroidal antiandrogen bicalutamide reduces the risk of an increase in chromogranin A (CgA) levels in patients with prostate cancer who experienced biochemical failure after radical retropubic prostatectomy (RRP) compared with pharmacologic castration therapy. It has been hypothesized that continuous androgen suppression for the treatment of prostate cancer results in hyperactivation of neuroendocrine cells and an increase in CgA levels.

METHODS

Forty-eight patients with pT3pN0M0 prostate cancer and biochemical (prostate-specific antigen) progression after RRP were randomized to bicalutamide monotherapy or pharmacologic castration. The serum levels of CgA and prostate-specific antigen were measured at 1, 3, 6, 12, 18, and 24 months of therapy. The changes in serum CgA levels were compared for patients who successfully responded to the first 24 months of therapy.

RESULTS

In both treatment groups, a statistically significant trend was noted for CgA levels to increase from baseline to 24 months. This trend was lower in the bicalutamide group (slope = 0.60, 95% confidence interval 0.28 to 0.92; P = 0.004) than in the castration group (slope = 0.29, 95% confidence interval 0.08 to 0.50; P = 0.01).

CONCLUSIONS

The results of this study provide the first evidence to show that in patients with prostate cancer undergoing hormonal therapy, nonsteroidal antiandrogen monotherapy produces a significantly lower increase in serum CgA compared with castration.

Alternative Antiandrogens to Treat Prostate Cancer Relapse After Initial Hormone Therapy

PURPOSE

We studied the efficiency of second or third line hormonal therapy for prostate cancer relapse after hormone therapy.

MATERIALS AND METHODS

The study included 70 patients with advanced prostate cancer treated with hormonal therapy, androgen deprivation monotherapy or maximum androgen blockade including surgical or medical castration combined with steroidal antiandrogen, 100 mg chlormadinone acetate daily or nonsteroidal antiandrogens, 375 mg flutamide (FLT) daily or 80 mg bicalutamide (BCL) daily. When the disease relapsed, we discontinued the antiandrogen and evaluated the patient for the antiandrogen withdrawal syndrome (AWS). Thereafter we administrated an alternative antiandrogen and evaluated its effect.

RESULTS

The incidence of the AWS after first, second and third line hormonal therapy was 35.8%, 8.0% and 0%, respectively. The efficiency of subsequent hormonal therapy was not related to the occurrence of the AWS. Nonsteroidal antiandrogens as alternative therapies for disease relapse from primary therapy were effective in second line (FLT 38.1%, BCL 44.4%) or in third line (FLT 30.0%, BCL 28.6%) hormonal therapy. Of 5 (80%) patients who responded to second line therapy 4 (80%) had effective third line therapy, while only 1 of 12 (8.3%) second line nonresponders had effective third line therapy (p = 0.003). The survival of second line responders was significantly better than that of nonresponders (5-year survival rate 92.3% vs 23.9%, p <0.001), indicating a potential predictive value for second line responsiveness. No significant clinical factor identified second line responsiveness.

CONCLUSIONS

Subsequent nonsteroidal antiandrogen therapies were effective against prostate cancer relapse after hormonal therapy. The response to third line therapy was more effective and survival was improved from the time of first line therapy relapse among second line responders than that in nonresponders. Our data support the notion that second line responders are androgen independent but still hormonally sensitive.

Androgen ablation therapy for prostate carcinoma suppresses the immunoreactive telomerase subunit hTERT

BACKGROUND

Telomerase is a ribonucleoprotein complex that protects the ends of chromosomes from degradation. Its catalytic subunit, hTERT, controls its activity. Prior data in prostate carcinoma cases indicated that immunohistochemical hTERT reactivity increases with tumor grade and may be absent in lower grade cases. The effect of complete androgen ablation (CAA) on tumor hTERT expression was uncertain.

METHODS

hTERT immunostaining was performed on the cancerous pretreatment biopsy tissue of 30 men who consecutively underwent CAA with bicalutamide and goserelin acetate for 30 days prior to undergoing radical prostatectomy, and on their tumor tissue from radical prostatectomy. As controls, biopsy and prostatectomy samples from 30 untreated men were studied. Nuclear staining was evaluated by two observers, and the change in staining between biopsy and prostatectomy samples was evaluated using the Student t test in both groups.

RESULTS

The percent of reactive tumor nuclei in treated men declined from 36.7% to 13.2% (P = 0.0001), and declined from 19.8% to 16.1% in untreated men (P = 0.4). The greater mean hTERT reactivity in the treated men's biopsy specimens was attributed to an increased proportion of higher (Gleason score > or = 7) grade tumors. The decline in hTERT immunostaining remained significant after normalizing it to that of the untreated group (P = 0.002). The original Gleason scores, corresponding declines in the percentage of reactive tumor nuclei, and significance were: Gleason score < or = 6: 11% (P = 0.03); Gleason score of 7: 23% (P < 0.006); and Gleason score > or = 8: 46% (P < 0.005) (from a mean 63% to 17%).

CONCLUSIONS

CAA for prostate carcinoma can be considered an antitelomerase therapy. The steepest reduction in telomerase activity was noted in the highest grade tumors.

Bicalutamide monotherapy for early stage prostate cancer: an update

PURPOSE

The current evidence is considered to support 150 mg of the nonsteroidal antiandrogen bicalutamide for early stage prostate cancer.

MATERIALS AND METHODS

Data from phase III trials of 150 mg bicalutamide monotherapy for locally advanced disease are discussed. In addition, the first overall results are examined from the bicalutamide early prostate cancer program conducted at a median followup of 3 years, in which patients with localized or locally advanced disease were randomized to receive 150 mg bicalutamide or placebo as well as standard care.

RESULTS

Mature data from phase III studies have shown that 150 mg bicalutamide monotherapy provide similar survival outcome to that observed with castration in patients with locally advanced (M0) disease. Moreover, 150 mg bicalutamide have benefits over castration in terms of quality of life, particularly sexual interest and physical capacity, and preservation of bone mineral density. In the bicalutamide early prostate cancer program 150 mg significantly reduced the risk of objective progression in patients with localized or locally advanced disease at 3 years of median followup, with the greatest benefit seen in patients with poorer prognosis. Followup is ongoing to further determine the benefit of 150 mg bicalutamide in early prostate cancer.

CONCLUSIONS

Bicalutamide is emerging as a useful treatment option for early prostate cancer.

Hormonal therapy options for patients with a rising prostate-specific antigen level after primary treatment for prostate cancer

At this time, many treatment options exist for primary androgen-deprivation therapy. "Standard" options with long-term results on outcome include orchiectomy, monotherapy with a luteinizing hormone-releasing hormone (LHRH) agonist, and combined androgen blockade using an LHRH agonist and antiandrogen. All treatments are associated with some morbidity related to the reduction of circulating testosterone. For this reason, "alternative" regimens are under active study to determine whether equal outcomes can be achieved with lesser toxicity.

[Comparative study of the effect of complete prolonged neoadjuvant hormonal blockade versus standard hormonal blockade]

INTRODUCTION

Radical prostatectomy is considered as a curative treatment option in clinically localised prostate cancer patients. Therapy failure is related to positive surgical margins and/or extracapsular extension. The use of neoadjuvant combined androgen blockade (CAB) withdrawal therapy, mainly in cT2 disease, has been shown to decrease positive margin rates. However, CAB therapy remains controversial since there is no proof that this approach confers any benefit in relation to biochemical and clinical disease-free survival. Increasing negatives surgical margins and lower tumour volume (TV) with prolonged CAB therapy has been recently reported.

AIM

To analyse the effect of 6 months neoadjuvant CAB therapy in front of 3 months in clinically localised prostate cancer patients submitted to radical prostatectomy.

PATIENTS AND METHODS

The pathological stage and TV in forty-two patients treated by 6 months in front of thirty-four patients treated by 3 months were studied. The relationship of clinical stage and initial PSA concentration were analysed.

RESULTS

TV was significantly lower in 6 months treated patients (0.97 cc vs. 0.48 cc, p = 0.05). The lowest TV was observed in cT1 patients, but significant differences only were observed in cT2 (1.5 cc vs. 0.86 cc, p = 0.04). No relationship between TV and PSA was obtained. No differences in the incidence of organ-confined disease were seen depending of the CAB length (47% vs. 43%, p = NS). However, increasing incidence of specimen-confined disease was observed in 6 months treated patients (56% vs. 74%, p = 0.05).

CONCLUSION

The duration of neoadjuvant CAB can affect both TV and surgical margin status. Lower TV and increasing incidence of specimen-confined disease with 6 months CAB treatment were observed. Patients with palpable disease may be more benefited by this treatment option.

Immediate Treatment with Bicalutamide 150mg as Adjuvant Therapy Significantly Reduces the Risk of PSA Progression in Early Prostate Cancer

OBJECTIVE

To evaluate the effect of bicalutamide ('Casodex') 150mg (in addition to standard care), on the risk of prostate-specific antigen (PSA) progression, in patients with early prostate cancer.

METHODS

The bicalutamide 150mg Early Prostate Cancer (EPC) programme is the largest clinical trial programme in the treatment of prostate cancer to date. This paper reports the PSA progression data from the EPC programme at a median of 3years' follow-up, for the overall study population, and across the radical prostatectomy and radiotherapy primary therapy strategies. PSA progression was predefined as the earliest occurrence of PSA doubling from baseline, objective progression, or death from any cause.

RESULT

Overall, bicalutamide 150 mg in addition to standard care significantly reduced the risk of PSA progression by 59% compared with standard care alone (HR 0.41; 95% CI 0.38, 0.45; p<<0.0001). Significant reductions were observed following radical prostatectomy (51%; HR 0.49; 95% CI 0.43, 0.56; p<<0.0001) and radiotherapy (58%; HR 0.42; 95% CI 0.33, 0.53; p<<0.0001). Further exploration of the data by disease stage, nodal status, Gleason score and pre-treatment PSA level revealed significant reductions in the risk of PSA progression across most prognostic risk factor subgroups.

CONCLUSIONS

Bicalutamide 150mg significantly reduces the risk of PSA progression, irrespective of whether patients received radical prostatectomy or radiotherapy as standard care. The EPC programme is ongoing and further progression and survival data are awaited.

Adjuvant hormonal treatment for prostate cancer: the bicalutamide early prostate cancer program

Adjuvant hormonal therapy has been demonstrated to be able to delay disease progression in nonmetastatic prostate cancer. To date, however, a favorable impact on survival has only been demonstrated in lymph-node-positive disease and in external-beam radiotherapy series with locally advanced and probably mainly micrometastatic tumors. The Bicalutamide Early Prostate Cancer Program is the largest study under way to define the role of adjuvant treatment in early prostate cancer and identify subgroups of patients likely to benefit from immediate hormonal therapy. At the time of the most recently published analysis, the risk of objective clinical progression was significantly reduced in the bicalutamide arm (hazards ratio 0.58, 95% confidence interval 0.51-0.66, p < 0.0001). However, further maturation of data is needed to see whether this difference will lead to a survival advantage.