Progression from high-grade prostatic intraepithelial neoplasia to cancer: a randomized trial of combination vitamin-E, soy, and selenium

PURPOSE

High-grade prostatic intraepithelial neoplasia (HGPIN) is a putative precursor of invasive prostate cancer (PCa). Preclinical evidence suggests vitamin E, selenium, and soy protein may prevent progression of HGPIN to PCa. This hypothesis was tested in a randomized phase III double-blind study of daily soy (40 g), vitamin E (800 U), and selenium (200 μg) versus placebo.

PATIENTS AND METHODS

Three hundred three men in 12 Canadian centers were analyzed. The main eligibility criterion was confirmed HGPIN in at least one of two biopsies within 18 months of random assignment. Treatment was administered daily for 3 years. Follow-up prostate biopsies occurred at 6, 12, 24, and 36 months postrandomization. The primary end point was time to development of invasive PCa. Kaplan-Meier plots and log-rank tests were used to compare two treatment groups for this end point.

RESULTS

For all patients, the median age was 62.8 years. The median baseline prostate-specific antigen (PSA; n = 302) was 5.41 ug/L; total testosterone (n = 291) was 13.4 nmol/L. Invasive PCa developed among 26.4% of patients. The hazard ratio for the nutritional supplement to prevent PCa was 1.03 (95% CI, 0.67 to 1.60; P = .88). Gleason score distribution was similar in both groups with 83.5% of cancers graded Gleason sum of 6. Baseline age, weight, PSA, and testosterone did not predict for development of PCa. The supplement was well tolerated with flatulence reported more frequently (27% v 17%) among men receiving micronutrients.

CONCLUSION

This trial does not support the hypothesis that combination vitamin E, selenium, and soy prevents progression from HGPIN to PCa.

Abstract 2260: CD151 immunoreactivity at diagnosis predicts early biochemical failure and metastasis in prostate cancer

Background: One in seven men will be diagnosed with prostate cancer (PCa) during their lifetime and nearly 25% of those will die as a result of metastatic disease. Current diagnostic methods for PCa fail to predict which patients harbor occult metastases and although Epstein's criteria are useful in establishing relative risk, a significant number of patients diagnosed with “low risk” PCa develop metastasis. Clearly, there is a need for more accurate prognostic tools to determine which patients are at higher risk of suffering metastasis. We have previously demonstrated that tetraspanin CD151 plays a role in tumor cell motility and metastasis that is dependent upon an extracellular epitope recognized by the monoclonal antibody 1A5 (mAb 1A5). We surmised that this antibody might specifically recognize a pool of CD151 that is relevant for clinical metastasis. In this study, we evaluate the role of CD151 as detected by mAb 1A5 as a molecular prognostic factor for PCa disease progression and metastasis. Methods: Specimens from 99 patients who underwent radical prostatectomy (RP) between 1994-1998 with pathological pT2 and pT3 were assessed by immunohistochemistry using mAb 1A5 with a mean follow up of 12.1 years ± 1.6 SD. After deparaffinization, immunohistochemical analysis was carried out and protein expression was categorized as negative (score=0); or positive in weak (1), moderate (2) and strong (3). CD151 analysis was also performed in benign tissue around and away from the tumor as internal negative control. Additionally, 36 diagnostic biopsy specimens of patients who had documented metastasis during their follow up were assessed for CD151 immunoreactivity. A database of patient demographic factors, disease factors and relevant survival information was generated and correlated with disease-free progression and survival. Results: CD151 immunoreactivity was higher in malignant tissue than in either benign tissue around (p=0.01) or away from the tumor (p<0.01) in RP specimens. There was a strong correlation between CD151 expression in the prostatic luminal epithelium and time to biochemical recurrence (p=0.022) following RP. Importantly, there was a significant correlation between CD151 expression and metastasis (p<0.01) in these patients. In biopsies obtained at diagnosis, CD151 immunoreactivity was associated with overall metastasis (p<0.01), bone metastasis (p=0.01), and hormone resistance (p<0.01). Conclusions: Patients who were CD151 positive as assessed with mAb 1A5 had earlier biochemical failure and a significantly higher incidence of metastasis. In the RP group, these early failures likely represented a subset of patients that harbored unrecognized micrometastatic disease. The detection of CD151 adds significant prognostic value to the prediction of biochemical failure and shows considerable promise at initial biopsy to discriminate patients with higher risk of metastasis.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 2260. doi:10.1158/1538-7445.AM2011-2260

Long-term results of salvage cryotherapy for prostate cancer

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Background: The optimum treatment of Prostate cancer recurrence following external bean radiation therapy (EBRT) remains a controversial topic. The primary problem with comparing salvage techniques following EBRT is the lack of long term data. We reviewed the long- term overall survival, disease-specific survival and disease free survival of patients who have undergone salvage cryotherapy to the prostate gland.

Methods: A retrospective analysis was performed on all patients undergoing salvage cryotherapy for locally recurrent prostate cancer after EBRT by a single surgeon at a single institution from 1995-2004. Patients preoperative, perioperative and postoperative data was reviewed and recorded. Should a patient no longer be followed by the urology service the Patients and the patient's primary care physician or urologist were contacted. Mortality data, PSA results, bone scan results and any details of hormone therapy were recorded for this study.

Results: 187 patients were included in the current study from which 176 patients had records available for follow up giving a follow up rate of 94%. Mean follow up was 7.46 years (1-14 years). 52 patients were followed for greater than 10 years. Average time to prostate cancer recurrence in patients who developed recurred was 2.3 years and average time to hormone therapy in these patients was 2.8 years. Overall survival at 10 years was high at 87%. Risk factors for recurrence of tumour identified were presalvage PSA, preradiation and presalvage gleason score. Preradiation gleason score had little impact on survival. PSA nadir of >1.0ng/mL was highly predictive of early recurrence. Disease-free survival rates of between 39 and 64% depending on risk factors.

Conclusions: Cryotherapy has a definite role in the management of prostate cancer, representing a minimally invasive salvage treatment with acceptable 10 year disease free survival (DFS) of upwards of 39% and specific groups attaining 10 year DFS of 64%. Presalvage PSA and Gleason score are the best predictors of disease recurrence, whilst preradiation gleason score did not correlate with risk of disease recurrence. A PSA Nadir greater than 1 ng/mL indicates a poor prognosis in which early ADT should be strongly considered.

No significant financial relationships to disclose.

Long-term outcome of randomized trial between cryoablation and external beam therapy for locally advanced prostate cancer (T2C-T3B)

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Background: Our primary objective is to assess and compare the survival outcomes between cryoablation (CRYO) and external beam radiation therapy (EBRT) in locally advanced prostate cancer.

Methods: This is a single institution, retrospective study. Our institution ethics board had approved this study. Patients were initially recruited for the trial between 1999 and 2002. The inclusion criteria for the trial were patients with cT2c–cT3b prostate cancer, PSA < 25ng/ml, with negative metastatic evaluation on CT and bone scan. Patients with evidence of metastasis, prior pelvic radiotherapy or hormone therapy, prostate volume > 75 ml or American Society of Anesthesiology Risk class > 3 were excluded. The biochemical failure was based on the Phoenix criteria (PSA nadir + 2ng/dl). Patients were subjected for regular trans-rectal ultrasound and biopsy until 24 months of follow-up (at 3, 6, 12, 18, 24 months for CRYO and at 18, 24 months for EBRT) and then as clinically indicated. Biochemical disease-free survival (bDFS), disease-specific survival (DSS) and overall survival (OS) were analyzed with Kaplan-Meier curve.

Results: Sixty-two patients completed the trial with a median follow-up of 105.2 (± 35.8) months. Preoperative demographic and clinicopathological characteristics of both groups were comparable. All patients received neoadjuvant hormonal therapy for 3 months prior and continued for 3 months after the procedures. The prostate volume before the therapy was smaller in the CRYO group (31.3 ml vs 40.9 ml; p≤0.01). There was greater reduction in the prostate volume in the CRYO group after the intervention (–54% vs 34%; p≤0.01).Three patients in the cryotherapy arm and 2 patients in the radiotherapy arm were crossed over to the other modality at the time of biochemical or biopsy proven progression. The DSS and the OS were comparable between both groups. The 8-year bDFS rate was significant lower in the CRYO group (17.4% vs 59.1%; p=0.01).

Conclusions: This randomized trial showed that CRYO was suboptimal in attaining bDFS at 8 years in patients with locally advanced prostate cancer (cT3). Other recent randomized trial showed favorable outcome with CRYO for localized prostate cancer.

No significant financial relationships to disclose.

Robotic-assisted radical prostatectomy in a system of universal health care with limited access to high-tech resources

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Background: The goal of radical prostatectomy (RP) is to minimize the positive surgical margin (PSM) rate. Robotic- assisted radical prostatectomy (RALP) has the theoretical advantages of enhanced ability to identify surgical dissection planes to improve surgical outcome but is associated with a learning curve. The objective is to review the PSM rate and intra- and postoperative complications (Clavien grading) correlating with possible risk factors in a low-density RALP by a high-volume, open RP surgeon working in the Canadian Healthcare System.

Methods: The data of 56 RALP from April 2004 to Dec 2009 by one surgeon contemporaneously performed 830 RP. PSM was analyzed and correlated with clinical variables. Univariable and multivariable analyses were used.

Results: PSM 19 (34%) cases. At univariable analysis, no association was observed between PSM and age BMI, PSA, number positive cores, % positive cores, Gleason biopsy and clinical stage. Pathological Gleason (p=0.012), pathological stage (p= 0.003) and % tumor in surgical specimen (p=<0.001) were associated with increased risk of PSM. At multivariable the % tumor in surgical specimen (p<0.001) were only independent predictive factor for PSM. According to localization of PSM Apical 9 (48%), PLR 4 (21%), PLL 4 (21%) and bladder neck 1 (5%). Mean follow-up 23 months. In PSM, 12 (63%) showed an undetectable PSA (≤0.01ng/mL) at 3 months. Using Clavien grading, 9 surgical complication in 9(16%) patients: 6 (grade 1–2) and 3 (grade 3–4). 4 patients with PSM had complications, 2 (grade1-2) and 2 (grade 3–4). At multivariable analyses, BMI (p=0.008) was the only predictive factor for occurrence of complications.

Conclusions: The pathological stage and tumor (%) in the surgical specimen were independent predictive factor for PMS. Applying the Clavien grading, most of the patients presented minor complications. The Canadian Universal Healthcare system with limited access to high-tech resources may not be ideal for introducing an expensive new surgical technique, especially for an ubiquitous procedure such as RP. However, results of our low-density series or sporadic cases were not inferior to reported initial experience series of RALP in the literature.

No significant financial relationships to disclose.

Identification of caries risk factors in toddlers

The purpose of this study was to identify risk factors to predict caries progression in toddlers in primary-healthcare settings for the cost-effective targeting of preventive and referral strategies. We examined 329 children (26 ± 6 mos old) twice, one year apart, in Indiana, USA. A 107-item structured interview was used to collect information from the primary caregiver and child on factors/beliefs/perceptions/behaviors that could affect caries development, transmission of bacteria, medical-dental health, and access to care. Bacterial levels, gingivitis, dental plaque, and caries experience were assessed. Multiple-variable logistic regression models of caries progression toward cavitation included family caries experience, transmission-related behaviors, dietary factors, health beliefs, and lower income, but differed in selected predictors/predictive power by race/ethnicity. Addition of clinical variables did not significantly improve the prediction.

Audit of sudden deaths in the accident and emergency department of a tertiary hospital in Trinidad and Tobago

OBJECTIVE

To determine the proportion of deaths due to confirmed myocardial infarction (CMI) and the aetiology of sudden death at the Port-of-Spain General Hospital (A&E) department for January to June 2008.

METHODS

This retrospective study utilized the death register to determine the number of A&E deaths for the study period. Patients dying from MI were investigated using records to obtain ECG and postmortem reports.

RESULTS

During the study period, 150 patients were certified dead in the A&E department. Cardiovascular causes accounted for 42.7% (n = 64) of deaths. Confirmed MI accounted for 27.3% (n = 41) of deaths and 3.3% (n = 5) were certified by a private practitioner without post-mortem examination and were classed as unconfirmed MI. Trauma related deaths followed with 27.3% (n = 41). Deaths from firearm injury were the next most common, 19.3% (n = 29). The mean age of patients dying from CMI was 64.1 years with a male to female ratio of 2:1. Males died from CMI on average 6.3 years before females. Mortality peaked for females in the 80 - 89-year age group while for males it was the 60- 69-year age group. Afro-Trinidadians accounted for 58.5% (n = 24) deaths due to CMI. More CMI patients had combined DM and HTN 36.6% (n = 15) than either condition alone. Afro-Trinidadians were more likely to be hypertensive and Indo-Trinidadians, diabetic. Death on arrival was the most common presentation for MI patients, 65.9% (n = 27).

CONCLUSIONS

This study shows that the main cause of death in the A&E Department at the Port-of-Spain General Hospital was MI. Trauma related deaths followed. Men died from MI at an earlier age than women. Most MI patients were dead on arrival.

Immunotherapy for metastatic prostate cancer: where are we at with sipuleucel-T?

IMPORTANCE OF THE FIELD

Prostate cancer is the leading malignancy in North American men and despite improvements in treatments 20 - 30% of patients will relapse. Immunotherapy using activated mononuclear cells is a way to harness the body's adaptive immune response to fight metastatic prostate cancer.

AREAS COVERED IN THIS REVIEW

In 2005, at least 10 therapeutic cancer vaccines, designed to confer active, specific immunotherapy against tumor-associated antigens, were in clinical trials. These covered potential fields of immunological strategy to overcome castration-resistant prostate cancer.

WHAT THE READER WILL GAIN

A literature review was performed using the search terms sipuleucel-T, Provenge and APC8015 or APC-8015, and restricted to English language articles from 2000 to 2010. The immunological design and development of sipuleucel-T are summarized. The efficacy and safety of sipuleucel-T are discussed based on current data from clinical trials. Ongoing clinical trials involving sipuleucel-T are summarized.

TAKE HOME MESSAGE

Efficacy and safety with sipuleucel-T has been demonstrated in Phase I/II trials. The latest data from a Phase III trial shows that sipuleucel-T has met the primary endpoint of survival benefit. Further work is needed to understand the mechanisms behind cancer vaccine failure and elucidate the population for whom this vaccine will be suitable.

High-intensity focused ultrasound for prostate cancer: a systematic review

High-intensity focused ultrasound (HIFU) has recently been promoted as a non-invasive treatment option for prostate cancer. This systematic review sought to evaluate the evidence comparing it with standard treatment in patients with localised prostate cancer. The literature review included searches of MEDLINE, EMBASE, the Cochrane Library, annual meetings' abstracts and websites of evidence-based practice guideline producers. Studies were included if they were randomised controlled trials comparing HIFU with current management approaches, or were meta-analyses, systematic reviews or practice guidelines addressing HIFU. No randomised controlled trials or meta-analyses were identified. Seven systematic reviews and two practice guidelines were identified; neither contained randomised controlled trials. Adjusting the selection criteria to include case series found 34 clinical studies of HIFU. Twenty-nine evaluated HIFU as the primary treatment and five examined HIFU as salvage treatment for recurrence after radiotherapy. In most studies the outcomes used to determine efficacy were negative biopsy rates or prostate-specific antigen (PSA) levels. Among the 29 studies of HIFU as the primary treatment, negative biopsy rates ranged from 35 to 95% in 21 studies, a PSA nadir of ≤0.5 ng/ml ranged from 55 to 91% in 10 studies and mean PSA nadirs ranged from 0 to 1.9 ng/ml in 17 studies. Five studies reported 5-year disease-free survival rates ranging from 55 to 95%. Among five studies of HIFU as salvage treatment, negative biopsy rates ranged from 73 to 84% in four studies, a PSA nadir of ≤0.5 ng/ml ranged from 57 to 66% in three studies and mean PSA nadirs were 1.97 and 2.38 ng/ml in two studies, respectively. Current evidence on HIFU use in prostate cancer patients is of low quality, rendering it difficult to draw conclusions about its efficacy. Until results from case series are confirmed in prospective studies, the widespread use of HIFU is not supported.

Contemporary results of focal therapy for prostate cancer using cryotherapy

With the increasing diagnosis of prostate cancer, there have been concerns expressed regarding the potential over-treatment that may ensue following the diagnosis of localized prostate cancer. Minimally invasive treatments such as cryotherapy have been used successfully to treat the entire gland, however complications such as incontinence and erectile dysfunction can still occur. Focal cryotherapy is a modification of the standard cryotherapy technique, aiming to only treat the portion of the prostate gland which has the cancer of clinical significance. The potential advantage of this is the minimization of complications; however the remainder of the prostate is still viable and so can develop cancer subsequently. There have been several published studies demonstrating promising efficacy with a low morbidity rate using focal cryotherapy to treat prostate cancer, however further follow up is required before definitive conclusions can be reached. The appropriate selection of patients and subsequent follow up are areas needing further research and the development of improved imaging modalities.

Statistics of flexible chain configurations

When Monte Carlo methods are employed to study the statistical dimensions of flexible polymer chains, it is necessary that the sampling be statistically unbiased. One Monte Carlo procedure is the so-called "slithering snake" technique, which has proved to be very useful. A question arises, however, as to how long it takes for a "slithering snake" to be completely regenerated to avoid biasing the samples around a particular configuration. It is demonstrated theoretically and verified by Monte Carlo studies that the number of iterations required to completely regenerate a sample polymer is a quadratic function of the chain length. This verification applies to chains in dilute solution but may not hold for bulk polymers.

High-intensity focused ultrasound: where are we and where to from here?

High-intensity focused ultrasound (HIFU) has evolved significantly from early work treating cerebral lesions. The ability to treat deep soft-tissue lesions without damaging superficial structures led to it being used for prostate cancer treatment both in the primary and salvage setting. Primary HIFU treatment for prostate cancer leads to 5-year disease free survival rates of up to 70-80% in selected patients with little morbidity; however, comparative studies with established treatment modalities are lacking. Salvage treatment with HIFU leads to significantly more morbidity than primary treatment yet the morbidity appears the same or less than other salvage treatments following external-beam radiation treatment. We believe that with the development of more advanced imaging techniques combined with multimodality prostate imaging that HIFU's future lies in focal treatment of prostate cancer.

The Relationship between Breast Cancer and Research; a Bibliometric Study

Background: Thousands of articles are published every year in the medical literature relating to the diagnosis and treatment of cancer patients. An area of contention of late has been the amount of research time and money being devoted to breast cancer, to what some believe is to the detriment of research into other forms of malignancy. The aims of this study were to further investigate the relationship between malignancy and research, in order to better quantify the degree to which breast cancer is being over- or under-represented in the research world.Methods: Bibliometrics is the science of studying written communication by systematic measurement and analysis of research publications. In this study, we examined research output over a one-year period for the 26 most commonly diagnosed cancers in the UK. Our strategy was based on that employed by a group in Edinburgh in 2001, and involved correlating research output with incidence and mortality statistics. In addition, we sought to elucidate changes in research output over time and then to correlate these changes with improvements in survival. The survival data used was that published by Coleman et al in 2004, and represents changes in survival over 5 year periods between 1986 and 1999 in England and Wales.Results: A total of 73,798 publications were included in this study. Breast cancer received more research attention than any other malignancy in the time period of this study. Proportional to its incidence and associated mortality, however, breast cancer was markedly underrepresented. This relationship was consistent across publication and study types, and in the higher impact journals. There was a strong positive correlation between improvement in 5-year survival and research output (p = 0.003). Those malignancies enjoying the greatest increases in output included those involving the prostate, non-hodgkins lymphoma, breast and vaginal cancer.Conclusions: This study was intended to provide a snapshot-in-time of research output in malignancy. It has shown that, on the basis of both incidence and mortality, breast cancer is not receiving disproportionate attention by the research community, contrary to popular opinion. Whilst the absolute figures clearly reflect the success of the breast cancer advocacy community in raising and maintaining the profile of the disease, the evidence suggests that, if anything, breast cancer is not receiving the interest it deserves, based on its burden to society.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1080.