Impact of hormone therapy when combined with external beam radiotherapy for early-stage, intermediate-, or high-risk prostate cancer

The purpose of this investigation was to explore the potential benefit of hormone therapy in addition to external beam radiotherapy for patients with early-stage (T1-2), intermediate-(prostate-specific antigen [PSA] > 10 or Gleason score >or= 7) or high-risk (PSA > 10 and Gleason score >or= 7) prostate cancer. The charts of 412 patients with early-stage intermediate- and high-risk prostate cancer treated with external beam radiotherapy with or without a 4-month total androgen blockade were reviewed. The groups were balanced with respect to age, pretreatment PSA, and stage, but differed with respect to Gleason score and radiation dose. Biochemical failure rates, as defined by the ASTRO consensus panel, were compared between those receiving and those not receiving hormones. With a median follow-up of 2.0 years, the biochemical failure rate was 12.1 versus 23.1% (p = 0.02) in favor of those receiving hormones. This difference was seen for the subgroups followed for more than 6 months (12.5 vs. 25.0%), more than 9 months (14.5 vs. 26.3%), and more than 12 months (17.3 vs. 27.0%). Thus, biochemical failure decreased with the administration of hormone therapy in this group of patients with early stage, intermediate- or high-risk prostate cancer. This finding requires validation by ongoing randomized trials.

Neoadjuvant doxil chemotherapy prior to androgen ablation plus radiotherapy for high-risk localized prostate cancer: feasibility and toxicity

Patients with clinical T3 or T4 prostate cancer or with elevated serum prostate-specific antigen (PSA) levels greater than 40 ng/ml are at high risk of failure with primary treatment. Chemotherapy administered at the time of diagnosis may decrease the risk of recurrence. Patients with high risk localized prostate cancer were treated with two cycles of liposomal doxorubicin (Doxil) at 50 mg/m2 every 28 days. Patients were assessed for response by digital rectal examination (DRE), PSA, and endorectal magnetic resonance imaging (MRI) (erMRI). Patients were then treated with androgen ablative therapy and prostate radiotherapy. Seven patients were treated. Three patients had T3 disease, and 4 patients had T2b disease with either PSA greater than 40 ng/ml or erMRI evidence of seminal vesicle involvement or extracapsular disease. Median PSA was 29.4 ng/ml. None of the seven patients experienced a significant response, as measured by changes in DRE, PSA, or erMRI. Toxicity was significant, with 4 of 7 patients developing skin toxicity. All seven patients responded to androgen ablative therapy and prostate irradiation. Neoadjuvant liposomal doxorubicin demonstrates no apparent activity and significant toxicity. New strategies are needed to improve outcomes in high-risk prostate cancer.

The non-steroidal antiandrogen, bicalutamide ('Casodex'), may preserve bone mineral density as compared with castration: results of a preliminary study

The impact of bicalutamide (Casodex) monotherapy on bone mineral density (BMD) was investigated in patients with locally advanced prostate cancer. BMD was assessed after treatment with bicalutamide 150 mg daily ( n=21) or by medical castration (goserelin acetate 3.6 mg every 28 days) ( n=8) for a median of 287 weeks. In 38% of castration compared with 17% of bicalutamide patients, femoral neck Z-scores were < or =-1 SD of the reference value (accepted as a two to three times increased risk of fracture) and T-scores were < or =-2.5 SD (World Health Organization definition of osteoporosis in white females). Total hip Z-scores were < or =-1 in 43% of castration patients and 13% of bicalutamide patients. In 38% of patients, lumbar spine BMD was affected by degenerative disease. These preliminary data suggest that there may be an advantage in terms of BMD in using bicalutamide monotherapy compared with castration; a benefit confirmed in a recent prospective randomised study.

Androgen deprivation in men with prostate cancer is associated with an increased rate of bone loss

The objective of this work was to determine the effect of androgen deprivation therapy (ADT) on rates of bone mineral density (BMD) loss in men with prostate cancer. It was a prospective study comparing men receiving ADT to age matched controls for 2 y. Subjects received a history, physical exam, bone mineral density measurement, and laboratory evaluation every 6 months. Thirty-nine subjects receiving continuous ADT for prostate cancer (subjects) were compared to 39 age-matched controls not receiving ADT (controls). Twenty-three subjects and 30 controls completed the study through 24 months. Men in the ADT group demonstrated greater rates of bone mineral density loss than men in the control group at every site except the lumbar spine. Twenty-four month per cent of bone mineral density loss is presented as mean+/-standard error (s.e.). At the distal forearm, the ADT group value was -9.4%+/-1.0% and -4.4%+/-0.3% for controls (P<0.0005). The ADT group femoral neck values were -1.9%+/-0.7% and 0.6%+/-0.5% in the control group (P=0.0016). The ADT group total hip value was -1.5%+/-1.0% and 0.8%+/-0.5% in the control group (P=0.0018). The ADT group trochanter value was -2.0%+/-1.3% and -0.1%+/-0.5% in the control group (P=0.0019). The ADT group lumbar spine value was -0.2%+/-0.8 % and 1.1%+/-0.6% in the control group (P=0.079). Our data demonstrate greater rates of bone mineral density loss in men receiving androgen deprivation therapy for prostate cancer.

Bicalutamide: in early-stage prostate cancer

Bicalutamide is an oral, once-daily nonsteroidal antiandrogen. Its efficacy in localised or locally advanced prostate cancer is currently being investigated as part of the Early Prostate Cancer (EPC) programme. In the EPC programme, bicalutamide 150 mg/day, as an adjunct to radiotherapy, radical prostatectomy or watchful waiting, significantly reduced the risk of objective disease progression, the incidence of bone metastases and the risk of prostate specific antigen progression compared with placebo (p < 0.0001 for all three parameters) after a median follow-up of 3 years. Survival data are currently immature, with an overall mortality rate of 6% in both treatment arms. On two nonblind, randomised trials, bicalutamide 150 mg/day monotherapy was as effective as medical or surgical castration in terms of overall survival in patients with locally advanced nonmetastatic prostate cancer. After a median follow-up of 6.3 years, median survival was 63.5 and 69.9 months for bicalutamide and castration, respectively; time to disease progression was also similar between treatment groups. Bicalutamide recipients reported a significantly smaller loss in sexual interest and a better physical capacity than recipients of castration (p <or= 0.05 for both parameters). Bicalutamide is well tolerated in studies of up to 6.3 years' duration.

Impact of a novel neoadjuvant and adjuvant hormone-deprivation approach on quality of life, voiding function, and sexual function after prostate brachytherapy

BACKGROUND

Data demonstrate a benefit from neoadjuvant and adjuvant hormone-deprivation therapy with luteinizing hormone-releasing hormone agonists in patients who are treated with radiotherapy for localized prostate carcinoma; however, this approach has detrimental effects on quality of life (QOL). A cross-sectional study was undertaken to evaluate the impact on QOL, voiding function, and sexual function of an alternative hormone-deprivation approach.

METHODS

Three hundred fifty patients with clinical T1c-T2b prostate carcinoma were treated from March 1997 to August 2000 either with palladium 103 brachytherapy (BTM) without hormone therapy or with 8 months of adjuvant and neoadjuvant hormone-deprivation therapy with an antiandrogen and finasteride (BTM+H), were mailed the Functional Assessment of Cancer Therapy (FACT) global well being QOL instrument (FACT-G), the American Urological Association symptom score (AUASS), and specific items addressing urinary control and sexual function from validated instruments. Differences between treatment groups were assessed as a function of time since treatment.

RESULTS

Seventy-two percent of patients responded to the questionnaire. No differences in overall FACT-G scores, AUASS scores, or AUASS subscale scores between the BTM group and the BTM+H group were found. The BTM+H group initially had lower personal well being FACT-G subscale scores, more urinary incontinence, and lower odds of attaining an erection sufficient for intercourse initially, although these differences disappeared with longer follow-up.

CONCLUSIONS

The use of neoadjuvant and adjuvant antiandrogen and finasteride with brachytherapy is associated with QOL equal to that of brachytherapy alone for the treatment of patients with localized prostate carcinoma, allowing the advantages of hormone manipulation in terms of tumor control without its downside.

The role of antiandrogen monotherapy in the treatment of prostate cancer

The mainstay of hormonal therapy in prostate cancer has been medical or surgical castration, both of which are associated with loss of libido and impotence, and may not always be acceptable to the patient. Antiandrogen monotherapy is an alternative treatment option to castration. There are two types of antiandrogen, i.e. steroidal (cyproterone acetate, CPA), and nonsteroidal (bicalutamide, flutamide and nilutamide). Data comparing survival outcome with CPA and castration are limited and conflicting. Furthermore, CPA is associated with loss of libido and erectile dysfunction. Large phase III trials have established that monotherapy with bicalutamide 150 mg once daily provides a survival outcome that is not significantly different to that after castration in men with locally advanced, non-metastatic disease, while conferring significant advantages for sexual interest and physical capacity. Current data are inadequate to draw conclusions on the comparative efficacy of flutamide and castration, while nilutamide is not licensed for monotherapy. Recent data reveal that bicalutamide 150 mg given once daily in addition to standard care (radical prostatectomy, radiotherapy or 'watchful waiting') significantly delays the progression of early (localized or locally advanced) prostate cancer. Bicalutamide has a more favourable side-effect profile than the other antiandrogens and is more likely to promote compliance.

Prostate-specific antigen dynamics predict risk of progression in advanced prostate cancer treated with bicalutamide plus castration

OBJECTIVE

The aim of this study was to investigate the prognostic value of prostate-specific antigen (PSA) dynamics in patients treated with combined androgen blockade (CAB).

METHODS

Patients with locally advanced or metastatic prostate cancer (n = 317) received bicalutamide (50 mg once daily) plus either goserelin acetate or surgical castration for 48 weeks. Cox's proportional hazard analysis was used to determine whether the decline of PSA following the use of this combination is predictive of a delay in progression.

RESULTS

PSA levels at weeks 4 and 12 were statistically significant prognostic markers in predicting disease progression. The PSA rate of change to week 12 was also a statistically significant prognostic marker, although the PSA rate of change at week 4 did not reach statistical significance. These results were statistically less robust than those for PSA levels. Bicalutamide plus castration was well tolerated and effective in advanced prostate cancer.

CONCLUSION

These results suggest that PSA dynamics at weeks 4 and 12 may predict time to progression in advanced prostate cancer treated with CAB.

Diagnosis and management of treatment-related osteoporosis in men with prostate carcinoma

Osteoporosis is a complication of androgen deprivation therapy in men with prostate carcinoma. Androgen deprivation therapy, caused by either bilateral orchiectomy or treatment with a gonadotropin-releasing hormone agonist, decreases bone mineral density and increases fracture risk. Other factors including diet and lifestyle may contribute to bone loss. There is limited information regarding the best strategy to prevent osteoporosis in men with prostate carcinoma. Lifestyle modification including smoking cessation, moderation of alcohol consumption, and regular weight-bearing exercise should be encouraged. Supplemental calcium and vitamin D are also recommended. Additional treatment may be warranted for men with osteoporosis, fractures, or high rates of bone loss during androgen deprivation therapy. Intravenous pamidronate, a second-generation bisphosphonate, prevents bone loss during androgen deprivation therapy. Zoledronic acid, a more potent third-generation bisphosphonate, not only prevents bone loss but also increases bone mineral density during androgen deprivation therapy. Other bisphosphonates may be effective although they have not been evaluated in this clinical setting. Treatment with estrogens or selective estrogen receptor modulators may also be effective. Monotherapy with bicalutamide or other antiandrogens may cause less bone loss than androgen deprivation therapy.

[First line therapy in the treatment of metastatic prostate cancer]

Hormonal therapy has been the main treatment for advanced prostate cancer for the past six decades. Maximum androgen blockade (MAB), combination therapy with castration and antiandrogens, has been compared with castration monotherapy since the late 1980s. However, the results of the different trials have been conflicting. Recently published meta-analyses have revealed that MAB with non-steroidal antiandrogens is slightly superior to monotherapy (surgical or medical castration) in the treatment of advanced prostate cancer, and that MAB has more adverse effects. The question of whether the modest survival advantage of MAB balances with the increase in adverse effects should be investigated. Some studies indicated that the survival of metastatic prostate cancer patients treated with immediate therapy was similar to that of men in whom treatment was delayed. Hormonal therapy has side effects and is costly, and delayed treatment may be beneficial to elderly men with silent metastasis. Intermittent hormonal therapy is a controversial approach to management of advanced prostate cancer, although laboratory data suggest that intermittent androgen deprivation may prolong the duration of androgen dependence. Intermittent hormonal therapy for patients with metastatic prostate cancer needs to be assessed in a randomized trial to determine the effect on overall survival and quality of life. Our results in a randomized clinical trial of chemo-endocrine therapy versus endocrine therapy alone suggested that the addition of chemotherapy (cisplatin plus pirarubicin) to initial endocrine therapy might be beneficial to patients with advanced prostate cancer, especially an aggressive form of prostate cancer. However, chemo-endocrine therapy should be considered an experimental approach at present.

Cross-sectional study of bone turnover during bicalutamide monotherapy for prostate cancer

OBJECTIVES

Monotherapy with bicalutamide increases serum concentrations of testosterone and estradiol. Because estrogens play an important role in male bone metabolism, bicalutamide monotherapy may have fewer adverse effects on bone than androgen-deprivation therapy with a gonadotropin-releasing hormone agonist.

METHODS

In a cross-sectional study, we compared gonadal steroid levels and biochemical markers of bone turnover among three groups of men with prostate cancer: hormone-naive men, men treated with a gonadotropin-releasing hormone agonist, and men receiving bicalutamide monotherapy. Men with bone metastases or metabolic bone disease were excluded. Fifty-five eligible subjects were included in the analyses.

RESULTS

Serum testosterone and estradiol concentrations were lower in men treated with a gonadotropin-releasing hormone agonist than in hormone-naive men or men receiving bicalutamide monotherapy (P <0.001 for each comparison). Serum testosterone and estradiol concentrations were higher in men receiving bicalutamide monotherapy than in the hormone-naive men (P <0.001). The mean serum urinary excretion of deoxypyridinoline, urinary excretion of N-telopeptide, and serum osteocalcin were significantly higher in men treated with a gonadotropin-releasing hormone agonist than in the other groups (P <0.05 for each comparison). In contrast, biochemical markers of bone turnover were similar for hormone-naive men and men receiving bicalutamide monotherapy (P >0.05 for each comparison).

CONCLUSIONS

Biochemical markers of bone turnover are elevated in men receiving gonadotropin-releasing hormone agonist treatment but not in men receiving bicalutamide monotherapy. These observations suggest that bicalutamide monotherapy may maintain bone mineral density and prevent fractures.

Bicalutamide monotherapy versus flutamide plus goserelin in prostate cancer: updated results of a multicentric trial

OBJECTIVES

To compare the efficacy of bicalutamide monotherapy to maximal androgen blockade in advanced prostatic cancer.

PATIENTS AND METHODS

Previously untreated patients with histologically proven stage C or D (American Urological Association Staging System) disease were randomly allocated to either bicalutamide (B) or goserelin plus flutamide (G+F). After disease progression, patients treated with B were assigned to castration. The primary endpoint for this trial was overall survival. Prostate cancer-specific survival and progression were included among secondary endpoints.

RESULTS

In total 108 patients received B and 112 received G+F. At a median follow-up time of 54 months (range 1-89), 151 patients progressed and 113 died. There was no significant difference in the duration of either progression-free or overall survival. Hazards of progression, death and cancer-specific death, corrected by disease stage, tumor grade and baseline PSA level, showed that patients initially assigned to B had a higher risk of progression but a comparable risk of death and cancer-specific death with the exception of patients with G3 tumors who had an increased risk of death).

CONCLUSIONS

In patients with well or moderately well differentiated tumors, B monotherapy followed by castration may offer the same survival chance as maximal androgen deprivation. In those patients it thus represents a reasonable choice that can avoid the side effects of androgen deprivation for considerable periods of time.

An evaluation of bicalutamide in the treatment of prostate cancer

Prostate cancer is a major health problem in men, causing significant morbidity and mortality. Although traditionally considered a disease of old age, improved diagnostic techniques have resulted in earlier diagnosis and many men are now treated while still physically and sexually active. Current therapies for prostate cancer, which include medical or surgical castration, have a significant impact on many aspects of quality of life. The non-steroidal antiandrogen bicalutamide (Casodex, AstraZeneca) has a favourable tolerability profile with demonstrated efficacy in several stages of prostate cancer and represents an alternative therapeutic strategy to castration. Mature survival data from men with previously untreated, locally-advanced disease reveal that bicalutamide monotherapy provides survival benefits that do not differ significantly from castration, while offering important advantages with respect to the maintenance of physical capacity and sexual interest. Recent data from a prospective randomised trial, the largest prostate cancer treatment study ever conducted, demonstrate that immediate therapy with bicalutamide (alone or as an adjuvant to therapy of curative intent) significantly reduces the risk of objective disease progression in patients with localised or locally-advanced prostate cancer. Antiandrogens are also used in combination with castration (combined androgen blockade) for advanced disease. Another large, randomised trial demonstrated that combined androgen blockade with bicalutamide is associated with a similar survival outcome to combined androgen blockade with flutamide and is better tolerated. The evidence reviewed demonstrates that bicalutamide currently has a favourable risk:benefit ratio in several stages of prostate cancer. The role of bicalutamide will be further defined by ongoing studies.

Emerging role of adjuvant hormonal therapy

Recent years have seen a downward shift in the most common disease stage at diagnosis and in the age of patients diagnosed with prostate cancer. Although younger men with clinically localized disease are generally offered radiotherapy or radical prostatectomy, such treatment does not always produce a cure. Adjuvant hormonal therapy (medical or surgical castration) has been shown to extend progression-free survival in both the radiotherapy and surgical settings, and overall survival benefits have also been demonstrated in some studies. However, castration is associated with sexual dysfunction that may be unacceptable, particularly among younger patients. The ongoing bicalutamide (Casodex; AstraZeneca Pharmaceuticals, Wilmington, DE) Early Prostate Cancer program is evaluating the efficacy and tolerability of bicalutamide 150 mg as immediate therapy, either alone or as an adjuvant to therapy of curative intent, in patients with localized or locally advanced prostate cancer. This is the largest clinical trial program in prostate cancer treatment to date, comprising 3 randomized, double-blind, placebo-controlled studies with a total of 8113 patients. At median follow-up period of 3 years and after 922 progression events, the bicalutamide group had a significant reduction of 42% in the risk of objective progression compared with patients who received placebo plus standard care. The risk of prostate-specific antigen progression was also significantly reduced by 59%. As expected, gynecomastia and breast pain were the most frequently reported side effects of bicalutamide therapy. A longer follow-up period will determine whether the reduced risk of progression will translate into cause-specific and overall survival benefit for these patients.

A randomised comparison of bicalutamide ('Casodex') 150 mg versus placebo as immediate therapy either alone or as adjuvant to standard care for early non-metastatic prostate cancer. First report from the Scandinavian Prostatic Cancer Group Study No. 6

OBJECTIVES

To assess the efficacy and tolerability of bicalutamide 150 mg ('Casodex'(1)) as immediate therapy, either alone or as adjuvant to treatment of curative intent, in patients with early (T1b-T4, any N, M0) prostate cancer.

METHODS

This randomised, double-blind study was conducted in the Nordic countries as part of the 'Casodex' Early Prostate Cancer programme. Patients received bicalutamide 150 mg (n=607) or placebo (n=611) in addition to standard care.

RESULTS

More than 80% of patients had not received therapy of primary curative intent. Median follow-up in both groups was 3 years. Median exposure to study treatment in the bicalutamide and standard care alone groups was 2.5 and 2.3 years, respectively. Bicalutamide reduced the risk of objective disease progression by 57% compared with standard care alone (HR 0.43; 95% CI 0.34, 0.55; p<<0.0001). Survival data were immature (11.4% deaths) with no difference between the two treatment groups.

CONCLUSIONS

Bicalutamide 150 mg as immediate therapy, either alone or as adjuvant to treatment of curative intent, significantly reduces the risk of disease progression in patients with early prostate cancer. The trial is ongoing to assess whether the reduction in risk of objective progression translates into an overall survival benefit.

Secondary hormonal therapies in the treatment of prostate cancer

Patients with androgen-independent prostate cancer demonstrate progression of disease, despite chemical or surgical castration, and have a poor prognosis. Cancer progression may be manifest as an asymptomatic increase in serum prostate-specific antigen (PSA) or may be accompanied by symptomatic and/or radiographic evidence of tumor growth. Observation remains a reasonable choice for asymptomatic patients. However, many patients remain anxious about withholding further treatment and, although studies have not demonstrated a survival benefit with second-line hormonal therapy, it may be appropriate to consider these therapies. In patients who have radiographic and/or symptomatic progression, the use of second-line hormonal therapy is more easily justified. Treatment options include: (1) secondary use of antiandrogens (eg, high-dose bicalutamide), (2) therapies targeted against adrenal steroid synthesis (eg, ketoconazole, aminoglutethimide, and corticosteroids), and (3) estrogenic therapies (eg, diethylstilbestrol). Symptomatic improvement and PSA-level decreases of > or =50% have been reported in approximately 20% to 80% of patients with androgen-independent prostate cancer who receive such second-line hormone therapies, with a typical response duration of 2 to 6 months. Toxicity is generally mild for these oral therapies, although serious side effects, including adrenal insufficiency, liver toxicity, and thrombosis, may occur. In conclusion, secondary hormonal therapies have a significant role in the treatment of patients with androgen-independent prostate cancer. Further research is needed to understand their optimal use.

Delaying/reducing the risk of clinical tumour progression after primary curative procedures

The advent of prostate-specific antigen (PSA) testing and increased patient awareness has led to patients being diagnosed with prostate cancer at an earlier stage and a younger age than previously. Adjuvant hormonal therapy to radiotherapy or prostatectomy has been shown to reduce the risk of tumour progression, and in some studies survival benefits have been demonstrated. The non-steroidal antiandrogen bicalutamide ('Casodex') has undergone extensive evaluation and is currently undergoing clinical trials as immediate therapy, either alone or as adjuvant to treatment of curative intent in patients with localized or locally advanced disease. Data from the first analysis of one of the studies in the Early Prostate Cancer (EPC) programme involving 3,603 patients have shown that, after a median follow-up of 2.6 years, the risk of prostate cancer progression was significantly reduced (by 43%) in patients receiving bicalutamide 150 mg compared with those receiving standard care alone (HR 0.57; 95% CI 0.48, 0.69; p << 0.0001). The risk of PSA progression was also significantly reduced (by 63%). At this stage the survival data are still immature. Side effects of bicalutamide were mostly gynaecomastia and breast pain, which is consistent with its pharmacology. Overall withdrawal rates were similar in the bicalutamide 150 mg and standard care alone groups. In the bicalutamide 150 mg group, withdrawals were mainly due to side effects, whereas in the group receiving standard care alone, withdrawals were mainly due to disease progression. The programme is ongoing, and survival data are awaited.

Effects of complete androgen blockade for 12 and 24 weeks on the pathological stage and resection margin status of prostate cancer

AIMS

To compare the pathological stage and surgical margin status in patients undergoing either immediate radical prostatectomy or 12 and 24 weeks of neoadjuvant hormonal treatment (NHT) in a prospective, randomised study.

METHODS

Whole mount sections of 393 radical prostatectomy specimens were evaluated: 128 patients had immediate surgery, 143 were treated for 12 weeks and 122 for 24 weeks with complete androgen blockade.

RESULTS

Histopathology revealed organ confined tumours in 40.4% of patients with clinical stage B disease in the immediate surgery group, whereas 12 and 24 weeks of NHT increased the number of organ confined tumours to 54.6% and 64.8%, respectively. Among patients with clinical stage C tumours, pathological staging found organ confined disease in 10.4%, 31.4%, and 61.2% in the immediate surgery, 12 weeks of NHT, and 24 weeks of NHT groups, respectively. Preoperative NHT caused a significant decrease in positive margins both in patients with clinical stage B and C disease. The extent of margin involvement was not influenced by preoperative treatment.

CONCLUSIONS

Neoadjuvant androgenic suppression is effective in reducing both the pathological stage and the positive margin rate in patients with stage B and C prostatic cancer undergoing radical surgery. Some beneficial effects are evident in those patients treated for 24 weeks, and it is reasonable to assume that the optimal duration of NHT is longer than three months.