Nasty or Nice? Findings from a UK Survey to evaluate the impact of the National Institute for Health and Clinical Excellence (NICE) clinical guidelines on the management of prostate cancer

AIMS

Although the National Institute for Health and Clinical Excellence clinical guideline 58 (CG58) for prostate cancer management was expected to have a positive effect, several recommendations raised concern among UK physicians. We conducted a survey of UK oncologists in 2008 and a second, similar survey in 2010 to assess views on these recommendations and to evaluate the change in opinion over time.

MATERIALS AND METHODS

Two semi-structured questionnaires were issued by the British Uro-oncology Group to society members in September 2008 and October 2010.

RESULTS

In 2008, 61 UK oncologists completed the survey; 60% agreed that CG58 would make a positive contribution towards improving patient care. There was strong opposition towards active surveillance as the first-line treatment for men with low-risk localised prostate cancer (49% disagreement); implementing 5 yearly flexible sigmoidoscopy post-prostate radiotherapy (51% disagreement); offering follow-up outside of the hospital (e.g. by general practitioners in primary care) for men with a stable prostate-specific antigen for ≥2 years (44% disagreement); and recommendations against docetaxel retreatment (47% disagreement) or bisphosphonate use (58% disagreement). In 2010, 77 UK oncologists completed the survey. The results were largely consistent with 2008, although several recommendations, particularly for localised disease, seem to have promoted a change in clinical practice, suggesting that they are facilitating a standardised approach. Compared with 2008, the 2010 results indicate a shift in favour of active surveillance (80% agreement) and primary care follow-up (59% agreement), but increasing opposition for docetaxel retreatment (57% disagreement). Opinions remained divided for flexible sigmoidoscopy and bisphosphonates.

CONCLUSIONS

Despite initial concerns, the CG58 seems to have had a positive impact on prostate cancer management in the UK, with adherence likely facilitating a standardised approach. However, with new data emerging, these findings underscore the need to regularly update guidelines. A revision of the CG58 is anticipated by 2014.

Evaluation of circulating tumor cell (CTC) enumeration as an efficacy response biomarker of overall survival (OS) in metastatic castration-resistant prostate cancer (mCRPC): Planned final analysis (FA) of COU-AA-301, a randomized, double-blind, placebo-controlled, phase III study of abiraterone acetate (AA) plus low-dose prednisone (P) post docetaxel

LBA4517

Background: A preplanned interim analysis of COU-AA-301 showed that AA, a selective androgen biosynthesis (CYP17) inhibitor, significantly improves OS in mCRPC. This is the first phase III study to prospectively assess CTC as a surrogate biomarker as part of a regulatory qualification process, here using updated OS data. Methods: 1,195 patients (pts) with mCRPC post docetaxel were randomized 2:1 to AA (1 g QD) + P (5 mg BID) (n = 797) or placebo + P (n = 398). CTCs (screening and baseline [BL]; post BL at weeks 4, 8 and 12) were enumerated (cells/7.5 mL) at MSKCC and The ICR using CellSearch and analyzed with other prognostic covariates as dichotomous and continuous variables using updated OS data at 775 events (prior to crossover from placebo to AA). CTC (as part of a biomarker panel - LDH, PSA, Hg, AlkPhos) was examined as a surrogate for OS. Multivariate (Cox model) analyses were conducted. Results: At median follow up (FU) of 20.2 mo, the difference in median OS between the 2 groups improved from 3.9 to 4.6 mo (AA 15.8 mo vs placebo 11.2 mo; HR = 0.74; p < .0001). CTC counts were evaluated in 972 pts at screening and BL, 838 at 4 wks, 783 at 8 wks and 723 pts at 12 wks. High concordance between screening and BL values was observed (r = 0.83). CTC conversion using standard definition for unfavorable (CTC ≥ 5) and favorable (CTC < 5) counts was predictive of OS as early as 4 wks after treatment and its inclusion significantly reduced the treatment effect at all post-treatment time points (HR: from 0.74 to 0.97). A reduced model incorporating CTCs and LDH was developed. Conclusions: The magnitude of the treatment effect of AA on OS increased with longer FU. Using standard definition of CTC conversion, the biomarker panel demonstrated a level of surrogacy for OS by correlating well with survival and in a model-adjusted analysis dramatically attenuating the treatment effect. BL CTCs and CTC conversion, along with LDH, were key predictors of OS. Future trials will further evaluate the CTC-based surrogate developed from COU-AA-301.

A population-based study of prostate cancer chemotherapy

The use of chemotherapy in the treatment of prostate cancer is a relatively recent development, with no published data on the patterns of care in the UK. We carried out a population-based study to assess variation in the use of prostate cancer chemotherapy over time in a UK cancer network.

Alkaline phosphatase (ALP) normalization and overall survival in patients with bone metastases from castration-resistant prostate cancer (CRPC) treated with radium-223

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Background: Radium-223 (Alpharadin) is a first-in-class alpha-pharmaceutical. It targets bone metastases with high-energy alpha-radiation of extremely short range that spares bone marrow. Radium-223 has a profound effect on serum markers of bone metabolism, including ALP, in patients with bone metastases from CRPC. In an exploratory analysis, we studied whether this effect is associated with a meaningful clinical benefit.

Methods: Patients with CRPC and bone metastases were treated in 2 randomized phase II studies. BC1-02 was a placebo-controlled study of radium-223 (50 kBq/kg) every 4 weeks for 12 weeks. BC1-04 evaluated radium-223 (25, 50, or 80 kBq/kg) every 6 weeks for 12 weeks. Baseline total ALP values > 128 U/L were considered elevated; those decreasing to below 128 U/L during treatment with radium-223 were defined as normalized, and those remaining above that value as non-normalized.

Results: In BC1-02, ALP normalization was seen in 12/26 (46%) patients treated with radium-223. Median survivals of those with and without ALP normalization were 102 weeks and 42 weeks, respectively (log-rank P < 0.001). In BC1-04, ALP normalization was seen in 25/75 (33%) cases: 5/29 (17%) in the 25 kBq/kg group, 10/25 (40%) with 50 kBq/kg, and 10/21 (48%) with 80 kBq/kg, indicating a dose-response relationship. Median survivals for the 25 patients with, and the 50 patients without, ALP normalization were 102 weeks and 58 weeks, respectively (log-rank P = 0.0086).

Conclusions: Inpatients with metastatic CRPC and bone metastases treated with radium-223, ALP normalization was associated with significantly better overall survival. These data support the rationale for the ongoing ALSYMPCA phase III trial of radium-223.

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Diffusion-weighted magnetic resonance imaging for monitoring prostate cancer progression in patients managed by active surveillance

OBJECTIVES

We studied patients managed by active surveillance to determine whether there was a difference over time in apparent diffusion coefficients (ADCs) derived from diffusion-weighted MRI in those who progressed to radical treatment (progressors, n = 17) compared with those who did not (non-progressors, n = 33).

METHODS

50 consecutive patients (Stage T1/2a, Gleason grade ≤ 3+4, prostate-specific antigen (PSA) <15 ng ml⁻¹, <50% cores positive) were imaged endorectally (baseline and 1-3 years follow-up) with T₂ weighted (T₂W) and echo-planar diffusion-weighted MRI sequences. Regions of interest drawn on ADC maps with reference to the T₂W images yielded ADC(all) (b = 0-800), ADC(fast) (b = 0-300) and ADC(slow) (b = 300-800) for whole prostate (minus tumour) and tumour (low signal-intensity peripheral zone lesion in biopsy-positive octant).

RESULTS

Tumour and whole prostate ADC(all) and ADC(fast) were significantly reduced over time in progressors (p = 0.03 and 0.03 for tumours, respectively; p = 0.02 and 0.007 for the whole prostate, respectively). There were no significant changes in ADC over time in non-progressors. A 10% reduction in tumour ADC(all) indicated progression with a 93% sensitivity and 40% specificity (A(z) of receiver operating characteristic (ROC) curve = 0.68). Percentage reductions in whole prostate ADC(all), ADC(fast) and ADC(slow) were also significantly greater in progressors than in non-progressors (p = 0.01, 0.03 and 0.008, respectively).

CONCLUSION

This pilot study shows that DW-MRI has potential for monitoring patients with early prostate cancer who opt for active surveillance.

High-density tissue microarrays from prostate needle biopsies

Background

Formalin-fixed prostate biopsies are frequently the only tissue collected at the time of prostate cancer diagnosis. There is therefore a requirement for techniques that allow the use of these prostate biopsy specimens in a high-throughput analysis of immunohistochemical and fluorescence-in-situ-hybridisation-detected biomarkers.

Methods

The authors have previously described methods that allow tissue microarray (TMA) construction from prostate biopsies. Here, we describe significant technical innovations that provide an easier and more robust system of biopsy–TMA construction.

Results and discussion

The TMAs produced are of a high density (up to 104 cores each, 8×13) and allow a multiplex analysis of biomarkers in the context of clinical trials.

The moral primacy of the human being

Can the view that medical science is more important than the individual properly persuade recruitment to trials? This paper considers the nature and interests of the person and their relationships to the concepts of science and society; and analyses a conception of value used to balance the interests of science and research subjects. The implications of arguments opposing the primacy of the individual are set out to indicate their implausibility; while the primacy principle is described to show its necessity in any moral society. Finally, the importance of fully informed consent to participate is explained with the requirement that the individual human life provide the criteria of moral value for human life.