Prognostic factors in progression-free survival and corrected survival in patients with advanced prostatic cancer: results from a randomized study comprising 150 patients treated with orchiectomy or estrogens

In a population-based randomized study comparing 150 patients with advanced prostatic cancer treated with orchiectomy or estrogen, some possible prognostic factors were analyzed. The observation period was 78 to 114 months. M category, T category, tumor grade, performance status, pain, prostatic acid phosphatase, sedimentation rate, hemoglobin and serum creatinine level were all statistically significantly related to the interval to progression and to disease-specific death on univariate analyses. Variables that were statistically significant on multivariate analyses were M category, T category, sedimentation rate and patient age. The sedimentation rate predicted the intervals to progression and to disease-specific death, with the relative hazard and 95% confidence interval for the latter end point being 1.018 (range 1.010 to 1.027) for each millimeter increase in sedimentation rate per hour. An analysis that was stratified according to the extent of the disease as measured on a bone scan showed that the sedimentation rate was the only prognostic factor of statistical significance with an estimate of relative hazard of 1.52 if the sedimentation rate was elevated 20 mm. per hour. Progression-free survival but not disease-specific survival was statistically significantly better in the estrogen group (relative hazard 0.47), as assessed by multivariate analysis in which all variables were taken into account.

Pyrrolidino-4-iodotamoxifen and 4-iodotamoxifen, new analogues of the antiestrogen tamoxifen for the treatment of breast cancer

New tamoxifen analogues were tested for their antiproliferative activity both in vitro and in vivo. Binding studies showed that both 4-iodotamoxifen and pyrrolidino-4-iodotamoxifen and 2.5-fold higher affinities for the estrogen receptor compared with tamoxifen. Pyrrolidino-4-iodotamoxifen was also 1.5-fold more effective in causing inhibition of estrogen-induced growth of MCF-7 cells compared with tamoxifen at 10(-6) M. The 4-iodotamoxifen analogue was similar to tamoxifen in its inhibitory action at 10(-6) M. Antiproliferative activities of these drugs were tested using the nitrosomethylurea-induced rat mammary tumor model. Pyrrolidino-4-iodotamoxifen caused regression in 92% of rats, whereas tamoxifen caused regression in 75% of rats. The agonist activity of the analogues was determined using the immature rat and mouse uterotrophic assays. Both tamoxifen and 4-iodotamoxifen had similar partial agonist activity, and this was greater than that seen with pyrrolidino-4-iodotamoxifen. Furthermore, pyrrolidino-4-iodotamoxifen caused a dose-dependent inhibition of estrogen-induced vaginal cornification, whereas tamoxifen and 4-iodotamoxifen did not. These studies demonstrate that pyrrolidino-4-iodotamoxifen is more effective than tamoxifen in inhibiting tumor regression and that its reduced uterotrophic activity and increased estrogen receptor binding may give it significant clinical advantages over the parent compound.

[A prospective study of nylestriol on plasma lipids in postmenopausal women]

A prospective, double-blind clinical study has been carried out in 90 chinese women with postmenopausal period covering 0.5 to 21 years by administering a synthetic long-acting estriol derivative-nylestriol in the regimen of 2 mg every 2 weeks for 1 year (49 treated and 41 placebo). The result were: Total cholesterol (TC) and triglyceride (TG) remained unchangeable (P greater than 0.05), while high-density-lipoprotein cholesterol (HDL-C) increased after 6 months, low-density lipoprotein cholesterol (LDL-C) and TC/HDL-C,LDL-C/HDL-C ratios decreased after 3 months of medication (P less than 0.05); FSH were restrained (P less than 0.05), but LH did not change significantly (P greater than 0.05). One third of the women with intact uterus had spotting withdraw bleeding and another one third had moderate amount after the addition of medroxyprogesterone acetate 6 mg daily for 7 days at the end of the 12 months treatment. Side effects included breakthrough bleeding (10.3%), breast tenderness (11.8%), leukorrhagia (29.4). None showed abnormal liver function (GPT).

[Current treatments of cancer of the prostate]

Cancer of the prostate mainly occurs in elderly men and is becoming more frequent as the general European population gets older. Only through continuing progress in the already well developed therapeutic methods will mortality due to this cancer be curtailed. Prognosis of cancer limited to the prostate gland has been improved by radical surgery which reduces morbidity and mortality and advanced radiotherapy techniques. The potentially curable forms, still mainly detected by systematic rectal examination, can be defined better with magnetic resonance imagery and biological markers. Hormonal treatment for more extended or metastatic cancers is now based on several effective, well tolerated products. Chemotherapy has not been able to solve the problem of hormonal escape for which other therapeutic techniques are now under study.

[Ischemic cardiopathy in women]

Life expectancy in western women is 8 years larger compared to men. This is due to the higher incidence of ischemic heart disease in men at least before reaching 45 years of age. This may also be due to differences in blood lipoprotein levels, differences in smoking habits, use of hormonal contraceptives, plasma iron levels, parity and other risk factors also found in men. After menopause the difference in the incidence of ischemic heart disease progressively decreases, basically because of a decrease in estrogen secretion. However, the role of estrogen supplement treatment in this group of women in the prevention of ischemic heart disease has not yet been clearly defined. The objectives of this study are to review the risk factors involved in the development of ischemic heart disease in women, the changes brought about by menopause and the possible beneficial effects of supplemental estrogens in the postmenopausal period.

Effects of orchidectomy and different modes of high dose estrogen treatment on circulating "free" and total 1,25-dihydroxyvitamin D in patients with prostatic cancer

Serum levels of total 1,25-dihydroxyvitamin D (1,25(OH)2D), vitamin D binding protein (DBP), sex hormone binding globulin (SHBG), testosterone, estradiol 17 beta (E2) and the "free" 1,25(OH)2D index were measured before and during treatment in prostatic cancer patients treated by orchidectomy (n = 15), with combined i.m. polyestradiol phosphate (PEP) + oral ethinyl estradiol (EE) (n = 10) and with i.m. PEP only for 3 months, followed by addition of oral EE (n = 9). Total concentrations of 1,25(OH)2D and DBP were unaffected by orchidectomy and treatment with i.m. PEP only, but were significantly elevated during treatment including oral EE. SHBG levels were unaffected by orchidectomy, slightly increased by i.m. PEP only and greatly increased by oral EE. The free 1,25(OH)2D index was slightly elevated by treatment including oral EE. Evidence was obtained that the increase in 1,25(OH)2D levels observed during oral estrogen treatment was secondary to the estrogen-augmented increase in DBP and not a result of an estrogen-stimulated synthesis of 1,25(OH)2D. Furthermore, the stimulatory effect of estrogen on DBP concentrations seemed to be dependent on the route of administration of the hormone.

[The role of echography in the complex dynamic examination of patients with retardation of sexual development]

Seventy-nine patients with sexual development retardation were examined, 24 of these suffered from ovarian genesis condition and 55 from central genesis condition. The findings evidence that detection of the uterus and gonads presenting as cords is one of the diagnostic criteria indicating gonadal dysgenesis. Echographic examinations carried out over the course of therapy yield a more accurate picture of ovarian function. No increase in uterine size on the echogram after discontinuation of hormonal therapy and the appearance of follicles in the ovaries after treatment point to normally functioning ovaries and helps specify the origin of sexual development retardation. In sexual development retardation of a central origin ultrasonic scanning helps assess the therapy efficacy and predict its outcome.

Estrogen replacement therapy

In summary, oral estrogens are often prescribed to relieve menopause symptoms. They should not be used in women who have had breast cancer, thrombophlebitis, hypertension, gallstones, or undiagnosed abnormal genital bleeding. Hormone replacement therapy has proven to be very useful in preventing osteoporosis, hot flashes, night sweats, and vaginal dryness. More information is needed before they should be recommended for the prevention of heart disease in postmenopausal women.

Effects of ethinyl oestradiol/polyoestradiol phosphate and estramustine phosphate on some proteins related to haemostasis in prostatic carcinoma patients

Twenty-four previously untreated patients with carcinoma of the prostate were prospectively randomized to one of the following treatments: (1) ethinyl oestradiol combined with polyoestradiol phosphate (EE/EP); (2) estramustine phosphate (EM); (3) bilateral orchiectomy. The effects on some plasma proteins related to haemostasis were studied by measuring the concentrations of alpha-1-antitrypsin, orosomucoid, haptoglobin, antithrombin III, C1-inhibitor and von Willebrand's factor before and 3 months after the start of treatment. Orchiectomy induced a reduction of alpha-1-antitrypsin and haptoglobin, while the other studied proteins were unaffected. It was found that both EE/EP and EM treatment induced significant decreases of orosomucoid, haptoglobin, antithrombin III and C1-inhibitor, while the same treatment increased the plasma concentration of alpha-1-antitrypsin. None of these treatments showed any influence on the plasma concentration of the von Willebrand factor. No differences were observed between EE/EP and EM for any of the studied proteins, suggesting comparable oestrogenic effects of these forms of treatment in patients with prostatic carcinoma. The findings are discussed in relation to the proposed difference in thromboembolic complications between EE/EP and EM treatments of prostatic carcinoma patients.

Reduction of cardiovascular disease-related mortality among postmenopausal women who use hormones: evidence from a national cohort

A national sample of 1944 white menopausal women greater than or equal to 55 years old from the epidemiologic follow-up of participants in the National Health and Nutrition Examination Survey was reviewed to investigate the role of hormone therapy in altering the risk of death from cardiovascular disease. Women in the study were observed for up to 16 years after the baseline survey in 1971 to 1975. By 1987 631 women had died; 347 of these deaths were due to cardiovascular disease. History of diabetes (relative risk, 2.38; 95% confidence interval 1.73 to 3.26), previous myocardial infarction (relative risk, 2.12; 95% confidence interval 1.56 to 2.86), smoking (relative risk, 2.18; 95% confidence interval, 1.69 to 2.81), and elevated blood pressure (relative risk, 1.49; 95% confidence interval, 1.14 to 1.94) were strong predictors of cardiovascular disease-related death in this cohort. After adjusting for known cardiovascular disease risk factors (smoking, cholesterol, body mass index, blood pressure, previous myocardial infarction, history of diabetes, age) and education, the use of postmenopausal hormones was associated with a reduced risk of death from cardiovascular disease (relative risk, 0.66; 95% confidence interval, 0.48 to 0.90). The same protective effect provided by postmenopausal hormone therapy was seen in women who experienced natural menopause (relative risk, 0.69; 95% confidence interval, 0.45 to 1.06).

Moderate exercise does not enhance the positive effect of estrogen on bone mineral density in postmenopausal women

We studied the effects of physical activity and two types of estrogen treatment in a prospective study in 78 healthy postmenopausal women. A control group and two treatment groups receiving estradiol valerate and medroxyprogesterone acetate in 1- or 3-month cycles were monitored for 1 year. Half of each group took part in an exercise program. Lumbar and femoral bone mineral density increased in both of the estrogen-treatment groups. Physical exercise with estrogen treatment did not result in further increases in bone mineral densities.

Estrogen replacement therapy and osteoporosis

Estrogen cannot replace bone that has been lost nor...straighten curvature of the spine or restore lost height. Usually, however, it can arrest the disease's progression.

Cardiovascular and all-cause mortality in prostatic cancer patients treated with estrogens or orchiectomy as compared to the standard population

Four hundred and seventy-seven prospectively randomized patients with prostatic carcinoma were treated with a combination of intramuscular polyestradiol phosphate (PEP) and oral ethinyl estradiol, with intramuscular PEP alone, or with orchiectomy. The cardiovascular and all-cause mortality of the two estrogen therapy modalities and orchiectomy were compared with those of the Finnish male population in general. The age-standardized rate ratios (approximately relative risk) for cardiovascular mortality and for all-cause mortality were 1.51 and 2.31 in the combination estrogen therapy group, 0.17 and 1.50 in the PEP monotherapy group, and 0.78 and 1.78 in the orchiectomy group, respectively. Further mortality rates by cause for all three treatment groups were standardized for age using the age-specific person-years at risk as standard. Age-standardized mortality from cardiovascular diseases was very low in the PEP group, as compared to other treatment modalities, and the mortality rates for prostatic cancer were about equal in all three treatment groups. It is concluded that intramuscular PEP monotherapy is associated with low cardiovascular mortality and with an all-cause and prostatic cancer mortality equal to orchiectomy.

[Diagnosis and therapeutic correction of changes in the cardiovascular system of patients with prostatic cancer treated with estrogens]

Estrogen-related cardiovascular dysfunction was noted in 23 out of 30 patients with prostatic cancer (PC). Coronary subjects with PC suffered from cardiac pain evident on ECG necessitating correction by effective doses of coronary active drugs. PC patients with essential hypertension exhibited frequent headache, progressive edema of the legs, drastic hypertensive reactions. It is held that estrogen therapy for prostatic cancer should be preceded and monitored by therapeutic evaluation responsible for optimal conditions to prevent and early diagnose cardiovascular complications.

Comparison of primary orchiectomy and polyoestradiol phosphate in the treatment of advanced prostatic cancer. Finnprostate Group

The primary clinical efficacy of orchiectomy and polyoestradiol phosphate (PEP) 160 mg/month i.m. was evaluated by progression and cancer mortality rates in a Finnish multicentre study comprising 200 prostatic cancer patients. After the minimum follow-up time of 2 years there was a significant difference between the groups--orchiectomy delayed progression of the disease more effectively. The follow-up time is rather short for prostatic cancer, but on the basis of this preliminary study the dose of PEP seems to be insufficient in the treatment of advanced prostatic cancer.

[Tall stature and its correction in girls]

The paper presents a classification of tall stature and clinical and hormonal findings in 35 girls in the age range of 11 to 18 years with constitutional tall stature. They showed a normal decline in growth hormone (GH) concentrations in the second phase of pubertal maturation. Concentrations of GH clearly correlated with the menstrual status. They were low in regularly menstruating girls, higher in non-menstruating girls and highest in tall girls with irregular menstrual cycles. Estrogen therapy in 7 girls decelerated growth rates and promoted epiphyseal ossification. Regular menstrual cycles established after withdrawal of therapy in all patients.

[The use of LHRH analogs in gynecologic oncology]

The use of LHRH analogues in gynecological oncology is related to the capacity of these compounds to determine pharmacological sterilisation which represents an alternative to surgical ovariectomy in the treatment of hormone-sensitive carcinoma. The modes of administration, metabolism and mechanisms of action of these drugs are illustrated. A section of the action of these drugs are illustrated. A section of the work is dedicated to the side-effects; they are divided into adverse effects, in the accepted meaning of the term, and the consequences of secondary hypoestrogenism. The paper concludes with the presentation of experimental data, both in animal studies and in vitro, which are the basis for the use of analogue therapy in the treatment of advanced stage breast cancer.

Effect of parenteral oestrogen on the coagulation system in patients with prostatic carcinoma

Patients with prostatic carcinoma on oral oestrogen therapy have an altered coagulation system and suffer cardiovascular side effects. Oestrogens--especially oral oestrogens--are potent inducers of liver synthesised proteins, including coagulation factors. We have assessed the effect of non-oral oestrogen on the coagulation system in patients with prostatic carcinoma. Twelve patients were given monthly intramuscular injections of 320 mg polyoestradiol phosphate (PEP). No additional oestrogens were given. No change was found in any of the coagulation factors, including factor VII, with the exception of a significant decrease in antithrombin III. No patient, including 38 patients treated with PEP, had any cardiovascular complications after a mean follow-up period of 12.9 +/- 0.7 months; 76% of the patients responded to treatment. Parenteral administration of oestrogen caused a less marked change in the coagulation system than oral administration and should be the treatment of choice for prostatic carcinoma.

[Effectiveness of hormonal therapy of endometrioid ovarian cysts]

Patients with ovarian endometriosis have been examined during the follicular and luteal phase of the ovulatory and the second phase of the anovulatory cycles. Estradiol and progesterone blood concentrations measured on operation days and during the respective ovulatory phases were in a normal range. Ovulation and endometrial hyperplasia reduced basal progesterone concentrations. Comparison of findings on steroid receptor systems in the endometrium and endometrioid ovarian cysts indicated that they were identical. The findings were different in ovulation and endometrial hyperplasia. These patterns provided criteria for endometrial response to female sex hormones by assaying endometrial intracellular steroid receptor systems in normally ovulating patients with ovarian endometriosis.

The effect of parenteral estrogen versus orchiectomy on blood coagulation and fibrinolysis in prostatic cancer patients

The effects of parenterally given polyestradiol phosphate (80 or 160 mg i.m. monthly) and bilateral subcapsular orchiectomy on blood coagulation and fibrinolytic parameters were compared in 11 patients with prostatic carcinoma. Estrogen therapy lowered antithrombin III, plasminogen and plasminogen activator inhibitor activities, whereas these parameters remained unchanged in orchiectomized patients. There were no significant changes in platelet count, fibrinogen, factor VII, protein C and alpha 2-antiplasmin in either group. Estrogen had unfavorable effects on hemostatic laboratory parameters in the direction of a hypercoagulable state. However, no thromboembolic complications were encountered.

Effects of orchiectomy and polyestradiol phosphate therapy on serum lipoprotein lipids and glucose tolerance in prostatic cancer patients

In 17 prostatic cancer patients, changes in the plasma lipoprotein pattern, including high density lipoprotein (HDL) subfractions, and in glucose tolerance were compared after 6 months on parenteral polyestradiol phosphate (PEP; Estradurin, 80 or 160 mg/month) with the respective changes in orchiectomized patients. In the estrogen group there was no change in the total serum cholesterol level, whereas in the orchiectomy group an increase of 10% was observed. Estrogen therapy resulted in a significant increase of serum HDL (11%) and HDL2 cholesterol (26%) levels; in the orchiectomy group these fractions remained unchanged. Estrogen therapy induced a significant decrease in total serum triglycerides (24%) and in low density lipoprotein triglycerides (27%); in the orchiectomy group reverse changes were observed. PEP treatment caused changes in the serum lipoprotein pattern, which apparently decreases the risk of atherosclerosis.

Adrenocortical function in prostatic cancer patients: effects of orchidectomy or different modes of estrogen treatment on basal steroid levels and on the response to exogenous adrenocorticotropic hormone

Basal serum levels and ACTH-induced increments ('delta-values') of dehydroepiandrosterone (DHA) and its sulfate (DHAS), 4-androstene-3,17-dione (A-4), 17 alpha-hydroxyprogesterone (17-OHP), cortisol and testosterone and serum albumin levels were studied in patients with prostatic cancer before treatment and after orchidectomy or during estrogen treatment (intramuscular polyestradiol phosphate during the first 3 months, followed by another 3 months with additional oral ethinyl estradiol). Orchidectomy as well as single drug intramuscular or oral + intramuscular estrogens exerted a similar suppressive effect on basal levels of A-4 and 17-OHP. Orchidectomy caused a slight decrease in basal DHAS, while combined oral + intramuscular estrogens caused a pronounced decrease in basal DHAS and also in DHA. Single drug intramuscular estrogens did not affect basal DHA or DHAS levels. Increased basal cortisol levels appeared during combined oral + intramuscular estrogen therapy. delta DHA and delta A-4 values were unaffected by endocrine treatment, but delta 17-OHP and delta cortisol increased slightly after orchidectomy and during estrogen therapy. Significantly decreased albumin levels were only observed during combined oral + intramuscular estrogen treatment. Determination of estriol, which is a major metabolite of estradiol originating from polyestradiol phosphate, revealed significantly higher estriol levels during combined oral + intramuscular estrogen treatment than during single drug intramuscular estrogen therapy, indicating an increased induction of hepatic 16 alpha-hydroxylase activity. The pronounced decreases in DHAS and also in DHA during combined oral + intramuscular estrogen treatment are probably another reflexion of the liver side effects of oral estrogens.

High dose polyoestradiol phosphate with and without acetosalicylic acid versus orchiectomy in the treatment of prostatic cancer. Finnprostate Group

The clinical efficacy of high dose (160 mg) polyoestradiol phosphate (PEP) was compared with that of orchiectomy in a prospective randomised multicentre study including 200 prostatic cancer patients. The effect of daily low dose (75 mg) acetosalicylic acid (ASA) on possible cardiovascular complications during the first 6 months of therapy was also evaluated. Oestrogen-treated patients had more progressions, but follow-up was too short to draw any definite conclusions on the efficacy of treatment. There was no cardiovascular mortality and there were no thromboembolic complications in any treatment group. It was concluded that parenteral high dose PEP is not associated with an increased risk of cardiovascular complications and there is no need for daily low dose ASA.