Androgen suppression adjuvant to definitive radiotherapy in prostate carcinoma--long-term results of phase III RTOG 85-31

The role of hormonal treatment in prostate cancer

In 1941 Huggins and Hodges published for the first time the favorable effects of surgical castration and estrogen treatment on the progression of metastatic prostate cancer. However, this hormonal therapy is not without side effects. Since this pioneering milestone in history of prostate cancer, a further tremendous innovation did not take place. Today, due to intensive clinical, biochemical, nuclear-biological and molecular-biological research, many hormone active treatment variations are available. Besides traditional hormonal therapy, surgical or chemical castration, maximal androgen blockade, nontraditional forms of hormonal therapy, intermittent hormonal therapy, antiandrogens, 5-alpha-reductase inhibitors, and their combinations, we discuss options toward creating an increased number of side effect-oriented offers of hormonal treatment options, guaranteeing a longer and more comfortable exhaustion of the individual hormonal period of response and probably a longer survival. The prerequisite is a closer-than-ever monitoring by tumor marker and an early observation of symptomatic changes.

Systematic review of early vs deferred hormonal treatment of locally advanced prostate cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

To compare the effectiveness of hormonal treatment (luteinizing hormone-releasing hormone agonists and/or antiandrogens) as an early or as a deferred intervention for patients with locally advanced prostate cancer (LAPC), as radiotherapy is currently the standard treatment for LAPC, with hormonal treatment considered a reserve option.

METHODS

We systematically reviewed randomized controlled trials (RCTs) in patients with LAPC treated with standard care (radical prostatectomy, radiotherapy, and/or watchful waiting) or standard care plus hormonal treatment. Outcomes assessed were mortality and objective disease progression. The meta-analysis used a fixed-effects model.

RESULTS

Of the 108 trials identified, seven met the inclusion criteria and were of sufficient quality to be included in the analysis. Early intervention with hormonal treatment significantly reduced all-cause mortality compared with deferred treatment (relative risk, RR, 0.86; 95% confidence interval, CI, 0.82-0.91; P < 0.001). Similarly, early vs deferred use of hormonal treatment significantly reduced: prostate cancer- specific mortality (RR 0.72; 95% CI 0.65-0.79); overall progression (RR 0.74; 0.69-0.78); local progression (RR 0.65; 0.57-0.73); and distant progression (RR 0.67; 0.61-0.74; all P < 0.001). Results were robust to changes in inclusion/exclusion criteria and use of a random-effects model for the meta-analyses. Heterogeneity and publication bias had no significant effect on the analyses.

CONCLUSIONS

Early intervention with hormonal treatment for patients with LAPC provides significantly lower mortality and objective disease progression than deferring their use until standard care has failed.

Bulletin de synthèse de veille 2005 Recommandations pour la pratique clinique

This paper is based on the bulletin of synthesis 2005. Management of non metastatic prostate cancer. Recommendations for clinical practice of the French Urologial Association and the National Federation of Anticancer Centers.

Hormonal implications in the development and treatment of prostate cancer

In this article, the conflicting data concerning the androgen axis and prostate cancer development are reviewed in addition to how this pathway may be exploited to prevent the development of prostate cancer. The expanding role of hormone ablative therapy alone or in conjunction with standard therapies, the controversies of timing of therapy, and the completeness of ablation and its use on an intermittent basis are reviewed.

An update of the phase III trial comparing whole pelvic to prostate only radiotherapy and neoadjuvant to adjuvant total androgen suppression: updated analysis of RTOG 94-13, with emphasis on unexpected hormone/radiation interactions

PURPOSE

This trial was designed to test the hypothesis that total androgen suppression and whole pelvic radiotherapy (WPRT) followed by a prostate boost improves progression-free survival (PFS) by > or =10% compared with total androgen suppression and prostate only RT (PORT). This trial was also designed to test the hypothesis that neoadjuvant hormonal therapy (NHT) followed by concurrent total androgen suppression and RT improves PFS compared with RT followed by adjuvant hormonal therapy (AHT) by > or =10%.

METHODS AND MATERIALS

Patients eligible for the study included those with clinically localized adenocarcinoma of the prostate and an elevated prostate-specific antigen level of <100 ng/mL. Patients were stratified by T stage, prostate-specific antigen level, and Gleason score and were required to have an estimated risk of lymph node involvement of >15%.

RESULTS

The difference in overall survival for the four arms was statistically significant (p = 0.027). However, no statistically significant differences were found in PFS or overall survival between NHT vs. AHT and WPRT compared with PORT. A trend towards a difference was found in PFS (p = 0.065) in favor of the WPRT + NHT arm compared with the PORT + NHT and WPRT + AHT arms.

CONCLUSIONS

Unexpected interactions appear to exist between the timing of hormonal therapy and radiation field size for this patient population. Four Phase III trials have demonstrated better outcomes when NHT was combined with RT compared with RT alone. The Radiation Therapy Oncology Group 9413 trial results have demonstrated that when NHT is used in conjunction with RT, WPRT yields a better PFS than does PORT. It also showed that when NHT + WPRT results in better overall survival than does WPRT + short-term AHT. Additional studies are warranted to determine whether the failure to demonstrate an advantage for NHT + WPRT compared with PORT + AHT is chance or, more likely, reflects a previously unrecognized biologic phenomenon.

Radiation therapy in prostate cancer

Adenocarcinoma of the prostate is one of the most frequently diagnosed cancers of men in the Western hemisphere and is second only to lung cancer for male cancer mortality. Most patients are diagnosed in the early/clinically localized stage, which can be treated curatively with radiation therapy alone. Innovative methods such as brachytherapy, three-dimensional conformal radiotherapy (3D-CRT), and IMRT (intensity modulated radiotherapy) are able to deliver very high tumoricidal doses to the diseased prostate, with minimal side effects to the surrounding tissue. Radiation therapy combined with hormonal treatment can be curative in locally advanced disease. Radiation therapy is also very effective in alleviating symptoms of metastatic prostate cancer (bone metastases, spinal cord compression, and bladder outlet obstruction).

[Prevention of local recurrence using adjuvant radiotherapy after radical prostatectomy. Indications, results, and side effects]

Depending on the tumor stage, 15-60% of patients develop a rise in PSA from levels around zero following radical prostatectomy. It is unclear whether this involves a local, systemic, or a mixed form of local/systemic progression. In addition to a multitude of retrospective studies, the results of three randomized trials are available that have already been published in full or in abstract form. For pT3 prostate cancer with extraprostatic extension, data are available from three randomized trials that consistently evidence an absolute decrease in biochemical progression rate of 20% after 4-5 years. These findings confirm the results of numerous retrospective studies. The large majority of authors employ total radiation doses of 60 Gy with single doses of 2 Gy. One randomized trial has shown that an increased local control rate is the basis for prolonged biochemical progression-free survival. The rate of acute and late radiation sequelae after three-dimensionally planned prostatic fossa radiotherapy (RT) with 60 Gy is very low; the rate of more severe late sequelae is <2%. Data on the status of pT2 prostate cancer with positive surgical margins are worse. The current findings are controversial and require further investigations. Basically, however, adjuvant RT is also possible for pT2 cancers with positive surgical margins. The efficacy of adjuvant RT for patients with positive surgical margins of pT3 carcinomas, whether or not they achieve PSA levels around zero, has been substantiated. A prolongation of survival time has, however, not yet been established because the follow-up period is too short. Randomized trials are still needed for cases of organ-confined prostate cancer (pT2 R1). It is unclear whether adjuvant RT is superior to RT when PSA levels increase beyond zero after radical prostatectomy. Randomized trials addressing this issue are still lacking.

Adjuvant Radiotherapy after Radical Prostatectomy: Indications, Results and Side Effects

BACKGROUND

Within 5 years following radical prostatectomy, between 15 and 60% of patients with pT3 prostate carcinomas show an increasing prostate-specific antigen (PSA) level as a sign of local and/or systemic tumor progression. Apart from a large number of retrospective investigations, available results are present only from three randomized studies which have either been completely published or are only in abstract form.

RESULTS

For pT3 prostate carcinomas the data from the three randomized studies agree, showing an around 20% reduced biochemical progression rate after 4-5 years. With these data the results of numerous retrospective studies have been confirmed. The majority of the authors use total doses of 60 Gy with single doses of 2 Gy. From one randomized study an increased local control rate is proposed as the basis for the extended freedom from biochemical progression. The rate of acute and late side effects after three-dimensional radiotherapy with 60 Gy is very small and the rate of severe side effects is below 2%. The data for pT2 prostate carcinomas with positive margins are worse. Here controversy exists, and further investigations are required. In principle, however, adjuvant radiotherapy seems reasonable also for pT2 carcinomas with positive margins (determined by bNED - no biochemical evidence of disease).

CONCLUSIONS

The effectiveness of adjuvant radiotherapy for patients with pT3 tumors and positive margins with and without detectable PSA levels is discussed. A survival advantage has not been demonstrated to date. For patients with positive margins in organ-limited prostate carcinomas (pT2 R1) randomized studies are recommended. It is unclear whether adjuvant radiotherapy is superior to radiotherapy for PSA levels increasing from the undetectable range after radical prostatectomy. To answer this question randomized studies are needed.

Radical prostatectomy for clinical stage T3a disease

BACKGROUND

Men with clinical stage T3a disease are at high risk and are often encouraged to undergo radiation therapy with concomitant hormonal therapy. The long-term outcomes among men treated with radical prostatectomy for clinical stage T3a disease were examined.

METHODS

Among 3397 men treated by radical prostatectomy by 1 surgeon between 1987 and 2003, 62 (1.8%) men were identified who had clinical stage T3a disease. Among the 56 men not treated with neoadjuvant or adjuvant therapies before prostate-specific antigen (PSA) recurrence, the long-term outcomes of PSA-free survival, metastasis-free survival, and prostate cancer specific survival were examined. Median and mean follow-up after surgery were 10.3 and 13 years, respectively (range, 1-17).

RESULTS

Ninety-one percent of men in this group had pathological T3 disease. PSA-free survival at 15 years after surgery was 49%. Metastasis-free survival and cause-specific survival at 15 years after surgery were 73% and 84%, respectively. Among men with a PSA recurrence, 46% received secondary therapy before metastasis. The only preoperative or pathological feature that predicted risk of prostate cancer death was lymph node metastasis (hazard ratio [HR]: 9.22, 95% confidence interval [CI]: 1.06-80.02, P = .044). Among the 28 men with a PSA recurrence, PSA doubling time (PSADT) data were available for 23, of which 11 (48%) has a PSADT >/=9 months. No patient with a PSADT >/=9 months died of prostate cancer. A PSADT <9 months was significantly associated with increased risk of prostate cancer death (log-rank, P = .004).

CONCLUSIONS

In a select cohort of men with clinical stage T3a disease, radical prostatectomy alone provides long-term cancer control in about half of the men and results in a prostate cancer-specific survival of 84%. Among men with a PSA recurrence, PSADT at the time of recurrence is a useful determinant of risk of prostate cancer death.

What implications do the tolerability profiles of antiandrogens and other commonly used prostate cancer treatments have on patient care?

PURPOSE

Increased awareness of prostate cancer has led to earlier initiation of therapy, and the potential for a longer duration of treatment has led to a stronger emphasis on tolerability. Historically, the mainstay of treatment of hormone-sensitive prostate cancer has been castration-based therapy, but antiandrogens are now emerging as an alternative. This article reviews the tolerability profiles of antiandrogens as well as other existing treatments for prostate cancer and examines their implications on patient care.

METHODS

A search of online literature databases was conducted to identify recent articles and studies (1990-2006) that have reported adverse effects associated with treatment approaches for men with prostate cancer. The therapies reviewed here include castration, antiandrogens, a combination of castration and antiandrogens (CAB), estrogens, and chemotherapy.

RESULTS

Castration offers significant clinical benefits when used as monotherapy or as adjuvant therapy; however, it is associated with loss of bone mineral density, and a reduction in physical activity and sexual function, which can have a negative impact on quality of life. Detrimental effects on muscle mass, fat deposition, and cognitive function have also been reported. Recent data suggest that the non-steroidal antiandrogen, bicalutamide, confers a significant overall survival benefit when used as adjuvant to radiotherapy in patients with locally advanced disease. However, the survival data for bicalutamide are not as extensive as those available for LHRH agonists. Although they do not appear to have a significant impact on sexual and physical activity, non-steroidal antiandrogens are frequently associated with gynecomastia and breast pain, and some are associated with diarrhea. Estrogens have been used in patients with androgen-independent prostate cancer; however, cardiovascular toxicity has restricted their use. In patients whose prostate cancer has become hormone-refractory, treatment options include chemotherapeutic agents, such as docetaxel and mitoxantrone.

CONCLUSIONS

It is important for physicians to discuss the adverse effects of all the available treatment options with patients so that a therapy can be selected to meet their expectations in terms of overall survival and tolerability.

Differences and commonalities in the management of locally advanced prostate cancer: results from a survey of oncologists and urologists in the UK

OBJECTIVE

To determine the management practices used by UK oncologists and urologists for patients with locally advanced (non-metastatic) prostate cancer.

METHODS

Using a postal questionnaire, 155 practising specialist oncologists and urologists were surveyed in the UK. Their views were sought on a multidisciplinary approach to the management of locally advanced prostate cancer and their current management practices.

RESULTS

Over half of respondents recognized the need for both oncologists and urologists to take the lead in management decisions, but almost as many still expected the sole responsibility to lie within their own speciality. Radical radiotherapy (RT) was considered the current optimum treatment by most respondents, but 22% of urologists thought that radical prostatectomy is optimal. Most responders would use luteinizing hormone-releasing hormone agonists as neoadjuvant and adjuvant to RT but there was significant variation in the favoured duration of treatment of these drugs, and in the dose of RT.

CONCLUSION

This survey suggests that there are still wide variations in the management practices for locally advanced prostate cancer in the UK, and between urologists and oncologists. Improved consensus guidelines are required.

Goserelin acetate in combination with radiotherapy for prostate cancer

Improvements in longer-term survival rates have been demonstrated for locally advanced prostate cancer patients treated with adjuvant androgen deprivation therapy (ADT), and in subsets of men with clinically localized disease treated with ADT combined with external-beam radiotherapy (RT). In these studies, ADT was administered in the form of surgery (orchiectomy) or with a class of drugs called luteinizing hormone-releasing hormone agonists. Goserelin acetate is a member of this class, and 10 of 11 major Phase III trials demonstrating better outcomes with ADT and RT used goserelin acetate. The reduction in deaths from prostate cancer noted in the mid-1990s may largely be due to the early use of these agents in men with intermediate-to-high-risk disease.

Percutaneous radiotherapy for low-risk prostate cancer: options for 2007

Technical developments of radiotherapy (RT) over the recent years yielded in better conformation to the target volume thus increasing the therapeutic ratio and decreasing side effects. This paper discusses these options for low-risk prostate cancer. There has been evidence from randomized trials, that for low-risk PCA doses >70 Gy are significant better in case of biochemical disease-free survival (bNED). Image-guided radiotherapy (IGRT) has been proven in several studies for reduced safety margins around the prostate target volume. Intensity-modulated radiotherapy (IMRT) allow treatment with higher doses and 5-year results are reported from several studies. Data from several randomized trials about adjuvant RT after radical prostatectomy (RP) have been reported. In two phase-III trials a significant advantage of 20% bNED was demonstrated for doses between 76 and 79 Gy compared with 70 Gy. Using IGRT, the safety margin around the prostate can be reduced for about 30-50%. Doses of >80 Gy can be given safely to the prostate with IMRT and <5% grade-III/IV late side effects. Adjuvant RT for positive margins after RP has been of proven advantage. Three phase-III trials achieved a significant better bNED of 20% for 5 years. The effect of doses >70 Gy have been proven for low-risk PCA. IGRT resulted in reduced safety margins and a decrease of acute and late side effects. The addition of IMRT allowed higher doses to the prostate. Adjuvant RT after RP for positive margins achieved a significant better bNED.

State-of-the-art radiotherapy in the management of clinically localized prostate carcinoma

Four Phase III trials demonstrating higher prostate-specific antigen control rates in prostate cancer patients treated with higher doses of radiation have changed the standard of care. Emerging on-line technologies, improved imaging and computer algorithms, combined with an improved understanding of how best to apply them, have allowed radiation oncologists to move ever closer to the optimal application of curative radiation. This technology allows a higher dose to be delivered to tumor-bearing areas while minimizing the dose delivered to surrounding normal tissues. Real-time adaptive techniques have made each step more accurate, and commercialization has increasingly moved these advances further into the community setting. Phase III trials have also helped to define the role of hormonal therapy in combination with radiation and the benefits of prophylactic pelvic nodal radiotherapy in subsets of patients. We have also learnt how to optimize the use of prostate-specific antigen to better determine success and failure following radiotherapy.

Intensity-modulated radiation therapy for prostate cancer: Late morbidity and results on biochemical control

PURPOSE

To report on late morbidity and biochemical relapse-free survival (bRFS) after intensity-modulated radiation therapy (IMRT) for prostate cancer.

METHODS

Between 1998 and 2005 133 patients were treated with IMRT for T(1-4) N0 M0 prostate cancer. The median follow-up time was 36 months. In a first cohort, patients received a median planning target volume (PTV) dose of 74 Gy with a hard constraint on maximum rectum dose of 72 Gy (74R72, n=51). Later, median PTV and maximum rectum dose were increased to 76 and 74 Gy, respectively (76R74; n=82). We defined low-risk (n=20), intermediate-risk (n=70) and high-risk (n=43) groups. Androgen deprivation was given to patients in the intermediate- and high-risk group. Late gastro-intestinal (GI) and genito-urinary (GU) morbidity and biochemical relapse, in accordance with the ASTRO consensus, were recorded.

RESULTS

We observed grade 2 GI (17%) and GU (19%), grade 3 GI (1%) and GU (3%) late toxicities. Except for hematuria, the median duration of side-effects was 6 months. Biochemical relapse-free survival (bRFS) at 3 and 5 years was 88% and 83%, respectively, with a significantly better 3-year bRSF for the 76R74 than for the 74R72 group (p=0.01). Five-year bRFS for patients in the low-risk, intermediate-risk and high-risk group was 100%, 94% and 74%, respectively (p<0.01).

CONCLUSION

IMRT for localized or locally advanced prostate cancer combines low morbidity with excellent biochemical control.

Long-term side effects of androgen deprivation therapy in men with non-metastatic prostate cancer: A systematic literature review

Increasing numbers of men with non-metastatic disease are receiving androgen deprivation therapy (ADT) for a variety of indications, some of which are supported by evidence from randomized trials. Balanced against possible survival benefits and better disease control are data that ADT adversely affects quality of life, particularly in the areas of sexual function, physical function, and energy. There is some evidence of worsening upper extremity physical strength but no clear evidence of decline in daily function with ADT. The impact of ADT on cognitive function is not clear at this time. ADT is associated with declines in bone mineral density within 6-12 months of commencing treatment, with increased fracture rates within 5 years of treatment. ADT use is also associated with a 10-15g/L decline in hemoglobin, although the clinical significance of this drop appears to be limited for most patients. It is reasonable for physicians who are about to start men on ADT to obtain a baseline bone mineral density, to counsel them about the impact on sexual function and possible treatments for sexual dysfunction, and to encourage regular exercise. Further insight into adverse effects of ADT and strategies to minimize these adverse effects await data from ongoing studies.

Defining High Risk Prostate Cancer With Risk Groups and Nomograms: Implications for Designing Clinical Trials

PURPOSE

Death from prostate cancer is usually preceded by metastases and it usually occurs in men with high risk disease who experienced biochemical failure with a short prostate specific antigen doubling time. We developed a model for determining disease specific survival in prostate cancer.

MATERIALS AND METHODS

We used the model for defining high risk prostate cancer that was developed by the Radiation Therapy Oncology Group and combined it with the Kattan nomogram for predicting the risk of metastases. We selected 414 Radiation Therapy Oncology Group intermediate and high risk patients who were treated with external beam radiotherapy alone. Excluded were patients with low risk disease. The Kaplan-Meier product limit method was used to estimate the probability of freedom from biochemical failure, overall survival and disease specific survival.

RESULTS

A significant difference was observed in freedom from biochemical failure, disease specific survival and overall survival among the 3 tertiles created by the nomogram using the cutoff points less than 8.5%, 8.5% to 15% and greater than 15% (p <0.001, 0.0002 and 0.0003, respectively). Only the risk of metastases using the categorized nomogram score (less than 8.5% and 8.5% to 15% vs greater than 15%), not preradiotherapy prostate specific antigen or Radiation Therapy Oncology Group risk (Radiation Therapy Oncology Group 2 vs 3), was a significant predictor of disease specific and overall survival for intermediate/high risk patients and intermediate/high risk with 15% or less risk for metastases.

CONCLUSIONS

We combined a risk group stratification scheme for disease specific survival with a nomogram predicting the risk of metastases and created a model that may be useful for designing phase III trials with metastases and disease specific survival as study end points.

A Randomized Phase III Study of Neoadjuvant Hormonal Therapy in Patients with Localized Prostate Cancer

The primary objective of this randomized trial is to evaluate the benefit of the addition of neoadjuvant hormonal therapy to escalated-dose external-beam radiation therapy in the treatment of patients with intermediate-risk carcinoma of the prostate. A secondary objective of this study is to determine prognostic factors for radiation response. All patients will have tissue oxygenation measured and biopsies taken before treatment at the time of fiducial marker insertion for radiation treatment planning and daily monitoring. In addition, patients randomized to the neoadjuvant bicalutamide arm will be asked to consider having these studies repeated before initiation of radiation therapy (after 3 months of hormonal therapy).

[Difficult clinical cases in prostate cancer: multidisciplinary staff, the rational principles of adjuvant therapy and other therapeutic options]

Difficult clinical cases of locally advanced prostate cancer at high-risk of progression should be discussed during a collegial decision-making process with different clinical specialists (surgeon, radiotherapist, oncologist, chemotherapist). Scientific consensus exists to give an adjuvant therapy after initial curative local treatment in patients with unfavourable prognostic features. For patients with locally advanced prostate cancer extending beyond the capsule (pT3) or with positive surgical margins, studies have shown that immediate postoperative radiotherapy is to eradicate the microscopic disease left in the surgical bed. Studies have shown the potential benefit of cytotoxic chemotherapy in terms of overall survival and median time to progression in patients with metastatic hormone-refractory prostate cancer. Active clinical research is underway to study neoadjuvant systemic chemotherapy before radical prostatectomy. There are also currently several clinical trials that are investigating the addition of chemotherapy in patients at high-risk of progression in the postprostatectomy setting. Antiandrogen therapy after radical prostatectomy has been shown in randomised studies to significantly reduce the risk of objective clinical progression in patients with high-risk localized prostate cancer. Immediate hormonal therapy with bicalutamide is a valuable therapeutic option in men having prostate cancer with such clinicopathological features.

[Localized prostate cancer. Local treatment and what place for lymphadenectomy]

The pretreatment PSA level, the Gleason score, the presence of lymph-node metastases, the status of surgical positive margins are poor pathological risk factors for patients who have a pathologic stage T3 prostate cancer. The increase in PSA level during the year prior to diagnostic is associated with the risk of death due to prostate cancer following radical prostatectomy or external beam radiation therapy. The assessment of Locoregional extension is indicated for such patients. The extended pelvic lymphadenectomy remains the most accurate procedure for a correct staging of the detection of nodal involvement in these patients with high-risk localized prostate cancer. For such patients with a high-risk of progression and, whose the life expectancy is greater than 10 years, treatment must be a combined modality therapy since radical prostatectomy alone correlates with a poor clinical outcome. Adjuvant hormonal therapy following local curative treatment by prostatectomy (or radiotherapy) needs to be often considered. Collegial decision-making is by far the most appropriate setting for the discussion among medical specialists of these complex clinical cases for patients often having associated medical conditions and whose adjuvant treatment will have a significant impact of their future quality of life.

The Case for Systemic Therapy Alone for Prostate Cancer

PURPOSE

This review details clinical scenarios that may be appropriate for the use of primary androgen deprivation alone for organ confined prostate cancer.

MATERIALS AND METHODS

The Medline and National Cancer Institute clinical trials databases were used. Searches were made regarding current and potential data to guide therapeutic decision making.

RESULTS

Data integration that incorporates patient comorbidities and cancer histological features can identify patients at low vs high risk for death from prostate cancer. Observational databases have documented an increase in the use of primary androgen deprivation for low and high risk disease. Outcome data on androgen deprivation therapy alone in patients with metastatic as well as localized disease were reviewed. The potential of newer therapies, including chemotherapy, and therapies that target aberrant signaling pathways was also reviewed. The latter holds the potential to more effectively eradicate distant metastatic disease.

CONCLUSIONS

Patients with high risk prostate cancer are those with a high chance of relapse with systemic disease despite treatment with definitive local therapy. Moreover, a patient with multiple comorbidities, and associated short life expectancy and high risk cancer may be a suitable candidate for systemic therapy alone with the goal of local and systemic disease control. In contrast, deferred systemic therapy alone until local progression and/or metastatic disease can be considered in a patient with low risk, indolent disease and a life expectancy of less than 10 years with the goal of avoiding over treating most patients, who often do not require any therapy during life.

Bicalutamide (Casodex) 150 mg plus standard care in early non-metastatic prostate cancer: results from Early Prostate Cancer Trial 24 at a median 7 years' follow-up

Trial 24, one of three ongoing trials in the Early Prostate Cancer programme, is evaluating the efficacy and tolerability of bicalutamide (Casodex) 150 mg following standard care (radiotherapy, radical prostatectomy or watchful waiting) in patients with early, non-metastatic prostate cancer. At 7 years' median follow-up, addition of bicalutamide significantly improved objective progression-free survival (PFS) for patients with locally advanced disease, reducing the risk of progression by 34% versus standard care alone (hazard ratio 0.66; 95% confidence interval 0.55, 0.79; P<0.001). In localized disease, a significant difference in objective PFS was not found. There was no significant difference in overall survival.

Relationship between delay in radiotherapy and biochemical control in prostate cancer

PURPOSE

The aim of this study was to investigate whether a delay in radiotherapy is associated with a poorer biochemical control for prostate cancer.

METHODS

The time to treatment (TTT) from diagnosis of prostate cancer to radiotherapy was analyzed with respect to prostate-specific antigen (PSA) control in 1024 hormone-naive patients. The Kaplan-Meier PSA control curves for patients with TTT less than the median were compared with those for patients with TTT greater than the median in 3 predefined risk groups. Statistical significant differences in PSA control were further analyzed using Cox multivariate analysis with pretreatment PSA, Gleason score, T stage, and radiotherapy dose as covariates.

RESULTS

The median TTT and median follow-up are 3.7 months and 49 months respectively. Patients with a longer TTT have a statistically significant better PSA control than patients with a shorter TTT if they have intermediate- or high-risk disease. However in multivariate analysis TTT was not found to be significant in predicting PSA control, with pretreatment PSA and Gleason score emerging as highly significant in predicting PSA failure in both intermediate- and high-risk disease.

CONCLUSION

In this study in prostate cancer patients in British Columbia, there was no evidence that a longer time interval between diagnosis and radiotherapy was associated with poorer PSA control.

Case-Matched comparison of contemporary radiation therapy to surgery in patients with locally advanced prostate cancer

PURPOSE

Few studies critically compare current radiotherapy techniques to surgery for patients with locally advanced prostate cancer, despite an urgent need to determine which approach offers superior cancer control. Our objective was to compare rates of biochemical relapse-free survival (BFS) and surrogates of disease specific survival among men with high risk adenocarcinoma of the prostate as a function of treatment modality.

METHODS AND MATERIALS

Retrospective data from 409 men with prostate-specific antigen (PSA) > or =10 or Gleason 7-10 or Stage > or =T2b cancer treated uniformly at one university between March 1988 and December 2000 were analyzed. Patients had undergone radical prostatectomy (RP), brachytherapy implant alone (BTM), or external beam radiotherapy with brachytherapy boost with short-term neoadjuvant and adjuvant androgen deprivation therapy (BTC). From the total study population a 1:1 matched-cohort analysis (208 patients matched via prostate-specific antigen, Gleason score) comparing RP with BTC was performed as well.

RESULTS

Estimated 4-year BFS rates were superior for patients treated with BTC (BTC 72%, BTM 25%, RP 53%; p < 0.001). Matched analysis of BTC vs. RP confirmed these results (BTC 73%, BTM 55%; p = 0.010). Relative risk (RR) of biochemical relapse for BTM and BTC compared with RP were 2.92 (1.95-4.36) and 0.56 (0.36-0.87), (p < 0.001, p = 0.010). RR for BTC from the matched cohort analysis was 0.44 (0.26-0.74; p = 0.002).

CONCLUSIONS

High-risk prostate cancer patients receiving multimodality radiation therapy (BTC) display apparently superior BFS compared with those receiving surgery (RP) or brachytherapy alone (BTM).

Neoadjuvant mitoxantrone and docetaxel for high-risk localized prostate cancer

PURPOSE

Currently available treatment modalities for high-risk clinically localized prostate cancer have limited chances of achieving complete tumor elimination because of either inadequate local or metastatic tumor eradication. The goal of this phase I/II study is to evaluate the safety and efficacy of neoadjuvant docetaxel and mitoxantrone before prostatectomy.

MATERIALS AND METHODS

A total of 22 men with high-risk clinically localized prostate cancer underwent weekly treatment with docetaxel (35 mg/m(2)), with increasing doses of mitoxantrone (2-5 mg/m(2)) for a 12 of 16-week treatment cycle before prostatectomy. Testosterone and prostate-specific antigen (PSA) measurements were made before and after chemotherapy.

RESULTS

The maximally tolerated dose for mitoxantrone was 4 mg/m(2), and the primary toxicity was neutropenia. Testosterone levels were maintained throughout treatment. PSA reductions were observed in 95% of patients, with a median reduction of 41%. The surgery was well tolerated after chemotherapy, without any major complications. Negative surgical margins were attained in 76% of patients.

CONCLUSIONS

Administration of multi-agent chemotherapy before prostatectomy was safe in this population. This regimen appeared to have antineoplastic activity as evidenced by PSA reductions in the absence of significant testosterone changes. The benefit of chemotherapy for improving surgical margin rates could not be determined outside of a phase III trial because the effect of patient or surgeon factors could not be dissected from the potential effect of neoadjuvant therapy. Continued study of novel agents in the neoadjuvant setting is warranted because this approach allows for the rapid identification of active agents and for molecular investigation into the mechanism of drug activity.

Neo-adjuvant and adjuvant hormone therapy for localised and locally advanced prostate cancer

BACKGROUND

Hormone therapy for early prostate cancer has demonstrated an improvement in clinical and pathological variables, but not always an improvement in overall survival. We performed a systematic review of both adjuvant and neo-adjuvant hormone therapy combined with surgery or radiotherapy in localised or locally advanced prostate cancer.

OBJECTIVES

The objective of this review was to undertake a systematic review and, if possible, a meta-analysis of neo-adjuvant and adjuvant hormone therapy in localised or locally advanced prostate cancer.

SEARCH STRATEGY

We searched MEDLINE (1966-2006), EMBASE, The Cochrane Library, Science Citation Index, LILACS, and SIGLE for relevant randomised trials. Handsearching of appropriate publications was also undertaken.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of patients with localised or locally advanced prostate cancer, that is, stages T1-T4, any N, M0, comparing neo-adjuvant or adjuvant hormonal deprivation in combination with primary therapy (radical radiotherapy or radical prostatectomy) versus primary therapy alone were included in this review.

DATA COLLECTION AND ANALYSIS

Data were extracted from eligible studies and assessed for quality, and included information on study design, participants, interventions, and outcomes. Comparable data were pooled together for meta-analysis with intention-to treat principle.

MAIN RESULTS

Men with prostate cancer have different clinical outcomes based on their risk (T1-T2, T3-T4, PSA levels and Gleason score). However, the majority of studies included in this review did not report results by risk groups; therefore, it was not possible to perform sub-group analysis. Neo-adjuvant hormonal therapy prior to prostatectomy did not improve overall survival (OR 1.11, 95% CI 0.67 to 1.85, P = 0.69). However, there was a significant reduction in the positive surgical margin rate (OR 0.34, 95% CI 0.27 to 0.42, P < 0.00001) and a significant improvement in other pathological variables such as lymph node involvement, pathological staging and organ confined rates. There was a borderline significant reduction of disease recurrence rates (OR 0.74, 95% CI 0.55 to 1.0, P = 0.05), in favour of treatment. The use of longer duration of neo-adjuvant hormones, that is either 6 or 8 months prior to prostatectomy, was associated with a significant reduction in positive surgical margins (OR 0.56, 95% CI 0.39 to 0.80, P = 0.002). In one study, neo-adjuvant hormones prior to radiotherapy significantly improved overall survival for Gleason 2 to 6 patients; although, in two studies, there was no improvement in disease-specific survival (OR 0.99, 95% CI 0.75 to 1.32, P = 0.97). However, there was a significant improvement in both clinical disease-free survival (OR 1.86, 95% CI 1.93 to 2.40, P < 0.00001) and biochemical disease-free survival (OR 1.93, 95% CI 1.45 to 2.56, P < 0.00001). Adjuvant androgen deprivation following prostatectomy did not significantly improve overall survival at 5 years (OR 1.50, 95% CI 0.79 to 2.85, P = 0.2); although one study reported a significant disease-specific survival advantage with adjuvant therapy (P = 0.001). In addition, there was a significant improvement in disease-free survival at both 5 years (OR 3.73, 95%CI 2.30 to 6.03, P < 0.00001) and 10 years (OR 2.06, 95% CI 1.34 to 3.15, P = 0.0009). Adjuvant therapy following radiotherapy resulted in a significant overall survival gain apparent at 5 (OR 1.46, 95% CI 1.17 to 1.83, P = 0.0009) and 10 years (OR 1.44, 95% CI 1.13 to 1.84, P = 0.003); although there was significant heterogeneity (P = 0.09 and P = 0.07, respectively). There was also a significant improvement in disease-specific survival (OR 2.10, 95% CI 1.53 to 2.88, P = 0.00001) and disease-free survival (OR 2.53, 95% CI 2.05 to 3.12, P < 0.00001) at 5 years.

AUTHORS' CONCLUSIONS

Hormone therapy combined with either prostatectomy or radiotherapy is associated with significant clinical benefits in patients with local or locally advanced prostate cancer. Significant local control may be achieved when given prior to prostatectomy or radiotherapy, which may improve patient's quality of life. When given adjuvant to these primary therapies, hormone therapy, not only provides a method for local control, but there is also evidence for a significant survival advantage. However, hormone therapy is associated with significant side effects, such as hot flushes and gynaecomastia, as well as cost implications. The decision to use hormone therapy should, therefore, be taken at a local level, between the patient, clinician and policy maker, taking into account the clinical benefits, toxicity and cost. More research is needed to guide the choice, the duration, and the schedule of hormonal deprivation therapy, and the impact of long-term hormone therapy with regard to toxicity and the patient's quality of life.

Luteinizing hormone-releasing hormone agonists in the treatment of prostate cancer: A review of their discovery, development, and place in therapy

BACKGROUND

Early identification of the biological activity of luteinizing hormone-releasing hormone (LHRH) paved the way for the synthesis of analogues with enhanced potency and biological properties. Early testing in animal models and humans provided insight into the potential clinical uses of these substances, and, within 10 years, LHRH-agonist therapy had become available for use in patients with advanced prostate cancer (PC). Over time, the role of LHRH-agonist therapy has expanded to include use as part of multimodal treatment regimens throughout the course of the disease.

OBJECTIVES

This article reviews the discovery and development of LHRH agonists and summarizes the clinical evidence for their efficacy in PC.

METHODS

Relevant clinical studies were identified through searches of the English-language literature indexed on MEDLINE through May 2006. The main search terms were prostate cancer and LHRH agonist.

RESULTS

Results of the initial therapeutic trials of sustained-release depot formulations of LHRH agonists in patients with PC were reported in the mid-1980s, indicating that these agents were effective and well tolerated in improving clinical symptoms and producing medical castration. Longer-term studies and subsequent meta-analyses of randomized controlled trials in patients with advanced PC found no significant differences in overall survival when single-therapy androgen suppression was achieved through the use of LHRH-agonist therapy or orchiectomy. Randomized trials have reported significant improvements in disease-free and overall survival in patients with locally advanced or high-grade PC treated with LHRH agonists in addition to radiotherapy. Several prospective randomized trials have reported decreases in rates of positive surgical margins with short-term (6 weeks to 4 months) neoadjuvant LHRH-agonist therapy in patients with stage T1 to T3a PC undergoing prostatectomy. Definitive comparisons of immediate and delayed treatment in patients with biochemical relapse have not been reported. However, the results of several studies suggest that immediate LHRH-agonist therapy (or orchiectomy) may improve the course of disease progression and survival. The risks of long-term treatment (eg, osteoporosis; fracture; anabolic loss of muscle mass, with a tendency toward weight gain) must be considered carefully in patients who are likely to receive chronic LHRH-agonist therapy. Intermittent schedules have been developed to reduce the adverse effects associated with LHRH-agonist therapy; some reports support sparing effects on bone and muscle mass and relative improvements in toxicities during off-therapy periods, whereas others have documented continuing decreases in bone mineral density (BMD), with the rate of bone loss highest during the early cycles of therapy. Bisphosphonate therapy has been shown to increase BMD in patients with PC and may therefore be beneficial when overt symptoms of osteopenia or osteoporosis are present.

CONCLUSIONS

LHRH-agonist therapy has been the mainstay of treatment for advanced PC for >20 years. Clinical evidence supports expanding use of these agents at an earlier stage of disease and as part of multimodal regimens that include radiotherapy. There is a need for further study of the efficacy of adjuvant LHRH-agonist therapy along with prostatectomy, in patients with biochemical failure, in intermittent regimens, and in conjunction with cytotoxic therapies in late-stage disease.

Changing the patterns of failure for high-risk prostate cancer patients by optimizing local control

PURPOSE

Standard therapies for high-risk prostate cancer have resulted in suboptimal outcomes with both local and distant failures. Prostate-specific antigen (PSA) and distant metastases rates as well as biopsy outcomes are reported after a regimen of trimodality therapy with hormonal, radioactive seed, and external beam radiation therapy to demonstrate how patterns of failure are changed when local control is optimized.

METHODS AND MATERIALS

From 1994 to 2003, a total of 360 patients with high-risk prostate cancer were treated with trimodality therapy. Patients were defined as being at high risk if they possessed at least one of the following high-risk features: Gleason score 8 to 10, PSA>20, clinical stage t2c to t3, or two or more intermediate risk features: Gleason score 7, PSA>10 to 20, or stage t2b. Patients were followed for a median of 4.25 years (range, 2 to 10 years).

RESULTS

The actuarial 7-year freedom from PSA failure and freedom from distant metastases (FFDM) rates were 83% and 89% respectively. Patients (n=51) developing PSA failure exhibited aggressive disease behavior with short PSA doubling times (median, 5 months) and a 7-year freedom from distant metastases rate of 48%. Local control was high. The last posttreatment biopsy results were negative in 97% of cases (68 of 70 patients). In multivariate analysis, only PSA>20 predicted biochemical failure (p=0.04), and only seminal vesicle status predicted developing distant failure (p=0.01).

CONCLUSIONS

Trimodality therapy results in excellent local control that alters patterns of failure, resulting in similar actuarial biochemical and distant failure rates. Most failures appear to be distant and exhibit biologically aggressive behavior.

Interstitial Low Dose Rate Brachytherapy for Prostate Cancer — A Focus on Intermediate- and High-risk Disease

AIMS

To investigate the role of brachytherapy in intermediate- and high-risk prostate cancer. We report our results and a review of published studies.

MATERIALS AND METHODS

Between March 1999 and April 2003, 300 patients were treated with low dose rate 1-125 interstitial prostate brachytherapy and followed prospectively. The patients were stratified into low-, intermediate- and high-risk groups and received brachytherapy alone or in combination with external beam radiotherapy (EBRT) and/or neoadjuvant androgen deprivation (NAAD). One hundred and forty-six patients were classified as low risk, 111 as intermediate risk and 43 as high risk. Biochemical freedom from disease and prostate-specific antigen (PSA) nadirs were analysed for risk groups and for treatment received in each risk group.

RESULTS

The median follow-up was 45 months (range 33-82 months) with a mean age of 63 years. Actuarial 5-year biochemical relapse-free survival for the low-risk group was 96%, 89% for the intermediate-risk group and 93% for the high-risk group. When stratified by treatment group, low-risk patients had a 5-year actuarial biochemical relapse-free survival of 94% for brachytherapy alone (n=77), 92% for NAAD and brachytherapy (n=66) and 100% for NAAD, EBRT and brachytherapy (n=3). In the intermediate-risk patients, biochemical relapse-free survival was 93% for brachytherapy alone (n=15), 94% for NAAD and brachytherapy (n=67), 75% for EBRT and brachytherapy (n=4) and 92% for NAAD, EBRT and brachytherapy (n=25). In the high-risk group, biochemical relapse-free survival was 100% for brachytherapy alone (n=2), 88% for NAAD and brachytherapy (n=7), 80% for EBRT and brachytherapy (n=5) and 96% for NAAD, EBRT and brachytherapy (n=29). Overall 3- and 4-year PSA = 0.5 ng/ml were achieved by 71 and 86%, respectively, and a 4-year PSA = 0.2 ng/ml was achieved by 63%.

CONCLUSION

Although the role of combination treatment with pelvic EBRT and androgen therapy is not clear, our early results show that many patients with intermediate- and high-risk disease have excellent results with brachytherapy.

The addition of bicalutamide 150 mg to radiotherapy significantly improves overall survival in men with locally advanced prostate cancer

PURPOSE

Castration therapy adjuvant to radiotherapy can significantly improve overall survival compared with radiotherapy alone in patients with locally advanced prostate cancer. Although many of the adverse effects of castration therapy are manageable, they can have a detrimental effect on quality of life. Here we evaluate the efficacy and tolerability of the non-castration-based therapy bicalutamide ('Casodex') 150 mg adjuvant to radiotherapy in patients with T1-4, M0, any n prostate cancer.

METHODS

The subset of patients within the early prostate cancer (EPC) program who received radiotherapy with curative intent (n = 1,370) were included in the analysis. These patients were randomized to receive oral bicalutamide 150 mg once daily (n = 699) or placebo (n = 671).

RESULTS

The median follow-up for patients included in this analysis was 7.2 years. In patients with locally advanced disease (n = 305), bicalutamide adjuvant to radiotherapy significantly improved: progression-free survival (PFS), reducing the risk of objective progression by 44% compared with radiotherapy alone [hazard ratio (HR) 0.56; 95% confidence interval (CI) 0.40, 0.78; P < 0.001). Prostate-specific antigen (PSA)-PFS, reducing the risk of PSA progression by 59% compared with radiotherapy alone (HR 0.41; 95% CI 0.30, 0.55; P < 0.001). Overall survival, reducing the risk of death by 35% compared with radiotherapy alone (HR 0.65; 95% CI 0.44, 0.95; P = 0.03). This significant overall survival benefit for bicalutamide was driven by a lower risk of prostate cancer-related deaths (16.1 vs 24.3%, respectively). There was no significant difference in PFS or overall survival in patients with localized disease (n = 1,065).

CONCLUSIONS

In patients with locally advanced disease, bicalutamide 150 mg adjuvant to radiotherapy demonstrates significant clinical benefits in terms of overall survival, PFS and PSA-PFS compared with radiotherapy alone. The overall survival benefit in these patients is consistent with prior studies evaluating castration-based therapies adjuvant to radiotherapy (Bolla et al. in Lancet 360:103-108, 2002; Pilepich et al. in Int J Radiat Oncol Biol Phys 61:1285-1290, 2005). In addition, the clinical benefit of bicalutamide 150 mg in locally advanced patients, but not in those with localized disease, is consistent with the overall results from the EPC program (McLeod et al. BJU Int 97:247-254, 2006). Given the quality-of-life advantages of bicalutamide relative to castration, bicalutamide 150 mg adjuvant to radiotherapy is an attractive alternative for men with locally advanced prostate cancer.

Timing and patterns of recurrences and deaths from prostate cancer following adjuvant pelvic radiotherapy for pathologic stage T3/4 adenocarcinoma of the prostate

To determine the timing and patterns of late recurrence after radical prostatectomy (RP) alone or RP plus adjuvant radiotherapy (RT). Between 1970 and 1983, 159 patients underwent RP for newly diagnosed adenocarcinoma of the prostate and were found to have positive surgical margins, extracapsular extension and/or seminal vesicle invasion. Of these, 46 received adjuvant RT and 113 did not. The RT group generally received 45-50 Gy to the whole pelvis, then a boost to the prostate bed (total dose of 55-65 Gy). In the RP group, 62% received neoadjuvant/adjuvant androgen deprivation vs 17% in the RT group. Patients were analyzed with respect to timing and patterns of failure. Only one patient was lost to follow-up. The median follow-up for surviving patients was nearly 20 years. The median time to failure in the surgery group was 7.5 vs 14.7 years in the RT group (P=0.1). Late recurrences were less common in the surgery group than the RT group (9 and 1% at 10 and 15 years, respectively vs 17 and 9%). In contrast to recurrences, nearly half of deaths from prostate cancer occurred more than 10 years after treatment. Deaths from prostate cancer represented 55% of all deaths in these patients. Recurrences beyond 10 years after RP in this group of patients were relatively uncommon. Despite its long natural history, death from prostate cancer was the most common cause of mortality in this population with locally advanced tumors, reflecting the need for more effective therapy.

Long-Term Followup of a Randomized Study of Locally Advanced Prostate Cancer Treated With Combined Orchiectomy and External Radiotherapy Versus Radiotherapy Alone

PURPOSE

In a randomized study we compared the combination of orchiectomy and radiotherapy to radiotherapy alone as treatment for locally advanced prostate cancer. Patients who were treated only with radiotherapy initially underwent castration therapy at clinical progression, providing the opportunity to compare immediate vs deferred endocrine intervention.

MATERIALS AND METHODS

In this prospective study 91 patients with locally advanced prostate cancer were randomized to receive external beam radiotherapy (46) or combined orchiectomy and radiotherapy (45) after surgical lymph node staging. Survival rates were calculated.

RESULTS

During 14 to 19 years of followup 87% of the patients in the radiotherapy group and 76% in the combined orchiectomy and radiotherapy group died (log rank p = 0.03). Prostate cancer mortality was 57% and 36%, respectively (log rank p = 0.02). The difference in favor of combined treatment was mainly caused by lymph node positive tumors. For node negative tumors there was no significant difference in the survival rates.

CONCLUSIONS

Immediate androgen deprivation should be considered instead of deferred endocrine treatment started at clinical progression for prostate cancer with spread to regional lymph nodes. While awaiting evidence from randomized trials, one should consider full dose radiotherapy for local control of locally advanced prostate cancer even when it is lymph node positive.

Update on Radiation Therapy in Prostate Cancer

Higher doses of radiation result in improved clinical control of prostate cancer,and the recent advances in prostate cancer radiotherapy are designed to escalate dose while minimizing toxicity. To achieve this goal, tighter treatment margins are needed, which require more accurate delineation of the prostate target and normal tissue at the time of treatment planning and before actual daily treatments. Modem radiation therapy techniques can deposit conformal dose virtually anywhere in the body; however, this precise therapy is of no value if it is not accurately hitting the target. Whether dose escalation is achieved by external beam techniques (eg, IMRT, protons) or brachytherapy, these ba-sic planning and delivery considerations are essentially the same. Future directions in prostate radiation therapy will use even higher radiation doses,alternative fractionation patterns, intraprostatic targets (eg, prostate tumor seen on MRI), and improved patient selection regarding which patients will benefit the most from these advanced techniques.

Management of prostate cancer. Part 2: localized and locally advanced disease

Prostate cancer is the most prevalent nondermatological malignancy affecting men in the Western world. An increase in public awareness has led to earlier detection. Accepted treatments for localized prostate cancer include active surveillance, radical prostatectomy, interstitial brachytherapy, external beam radiotherapy and watchful waiting. The authors discuss the rationale for the different approaches together with outcomes including toxicity. Novel approaches are also explored. The management of locally advanced disease has long been a challenge and the evolving evidence is reviewed.

Radical prostatectomy for clinical T4 prostate cancer

BACKGROUND

Occasionally, patients with clinical T4 (cT4) prostate cancer undergo surgery. Published data on outcomes after radical prostatectomy (RP) in patients with such advanced stage disease and on the impact of adjuvant radiation therapy (RT) and hormone therapy (HT) are nonexistent.

METHODS

Data from the Surveillance Epidemiology and End Results (SEER) data base were reviewed for the 7-year period from 1995 to 2001. Specifically, data were analyzed for 1093 patients with cT4, lymph node-negative or lymph node-positive, M0 prostate cancer without distant lymph node involvement or a history of other cancer. Using follow-up data through 2002, postdiagnosis survival was examined in 5 treatment groups: radical prostatectomy (RP) either alone or in combination with other therapy, radiation therapy (RT) alone, hormone therapy (HT) alone, RT plus HT, and no treatment (NT). All results were expressed as 1-year, 3-year, and 5-year observed survival and corresponding relative survival. Mortality across treatment categories was compared by using a Cox proportionate hazards model controlling for age, year of diagnosis, race, tumor grade, regional lymph node involvement, clinical tumor extension, and SEER registry.

RESULTS

Observed and relative survival rates were lowest among patients who received NT and highest among patients who underwent RP. Adding adjuvant RT or HT to RP conferred no survival benefit. Multivariate survival analyses revealed a significant increase in mortality among HT-only patients and among patients who received NT compared with patients who underwent RP. The differences in survival among treatment types were most pronounced in a relatively small group of patients who had positive regional lymph node extension. In all other patients, the results suggested a modest (but not significant) improvement in survival after RT plus HT.

CONCLUSIONS

SEER data revealed that patients who underwent RP for cT4 prostate cancer had increased survival compared with patients who received RT alone or HT alone and had a survival comparable to that of patients who received RT plus HT. The benefit of RP appears to be limited to a relatively small subset of patients who have regional lymph node extension.

Antiandrogen treatments in locally advanced prostate cancer: are they all the same?

PURPOSE

The objectives are to review the published literature and to evaluate the weight of evidence for clinical effectiveness, safety, and tolerability of the currently available antiandrogens in the treatment of locally advanced prostate cancer. This article covers efficacy as monotherapy relative to castration and as adjuvant to radiotherapy and radical prostatectomy as well as adverse-effect and quality-of-life data.

METHODS

The current literature from online databases between 1986 and the present, relating to antiandrogen treatments in men with locally advanced disease given either as monotherapy or as adjuvant to radical radiotherapy or prostatectomy, was reviewed. Antiandrogens researched included the non-steroidal antiandrogens, bicalutamide ('Casodex'), flutamide, and nilutamide, and the steroidal antiandrogen cyproterone acetate (CPA).

RESULTS

The most comprehensively investigated and reported antiandrogen is bicalutamide, which has shown survival outcomes similar to those observed with castration in patients with locally advanced prostate cancer. In contrast, only limited clinical data are available for the other non-steroidal antiandrogens (flutamide and nilutamide) and the steroidal antiandrogen CPA in patients with locally advanced disease. In terms of safety and tolerability, CPA is associated with loss of libido and erectile dysfunction. CPA is also associated with cardiovascular risk and there have been occasional reports of fatal fulminant hepatitis and hepatocellular carcinoma. Gynecomastia is quite rare with CPA, which is in contrast to the non-steroidal antiandrogens. There are no direct comparisons between the three non-steroidal antiandrogens in terms of quality of life, but available evidence suggests that bicalutamide has a more favorable safety and tolerability profile than nilutamide and flutamide. Unlike CPA, non-steroidal antiandrogens appear to be better tolerated than castration, allowing patients to maintain sexual activity, physical ability, and bone mineral density, but these agents have a higher incidence of gynecomastia and breast pain (mild to moderate in > 90% of cases). Gynecomastia and breast pain, however, can be effectively managed.

CONCLUSIONS

The available evidence indicates that the different antiandrogens should not be regarded as equivalents in clinical practice and so the choice of treatment for patients with prostate cancer should be made on an individual basis. It is, therefore, important for clinicians to discuss the efficacy and tolerability profiles of all available treatment options with their patients to enable them to choose a treatment program that best fits with their lifestyle.

Association of neoadjuvant hormonal therapy with adverse health-related quality of life after permanent iodine-125 brachytherapy for localized prostate cancer

OBJECTIVES

To characterize the influence of neoadjuvant hormonal therapy (NHT) on health-related quality of life after permanent iodine-125 brachytherapy (BT) for prostate cancer.

METHODS

A cross-sectional survey using the Expanded Prostate Cancer Index Composite health-related quality-of-life instrument was administered to 134 consecutive patients a median of 29 months after BT. A separate group of 111 patients with comparable demographic characteristics without any prior treatment for prostate cancer rendered the baseline information (control group). The scores and symptom rates were compared. The effect of NHT was tested for independence in a multivariate analysis.

RESULTS

In contrast to patients who received NHT, prostatic edema was hardly detectable 30 days after implantation in patients who received BT alone (comparing median preimplant and postimplant volumes), resulting in a greater dose to the prostate and anterior rectal wall. However, compared with the control group and the patients who received BT alone, the addition of NHT to BT led to lower health-related quality-of-life scores in all domains. Score differences of more than 10 points with a statistical significance were found for the urinary bother, sexual function/bother, and hormonal function/bother domains. Apart from the sexual function scores (patient age shown to be the crucial factor), the influence of NHT remained independent on multivariate analysis.

CONCLUSIONS

The results stress the need for well-considered administration of NHT before BT and the need for reporting the use of NHT in studies dealing with BT-related toxicity.

[High-dose rate brachytherapy for high-risk prostate cancer]

To estimate disease-free survival it is necessary to allocate patients into tumor risk groups: locally advanced prostate carcinoma with extracapsular spread or localized prostate carcinoma of tumor stage T2c or one of the risk factors PSA >20 or Gleason > or =8 apply for the high-risk group. Intermediate-risk carcinomas are those belonging to tumor stage T2b or with PSA >10-20 or Gleason 7. Particularly for patients with intermediate and high-risk disease early PSA relapse is of major interest. This phenomenon could be a consequence of current inadequate imaging of lymph node or bone metastasis or as a consequence subclinical metastatic spread remains undetectable during radical treatment. However, tumor biology itself could lead to the progression of the disease in the high-risk group. As a consequence, risk-adapted therapy is very important in these cases. The applied radiation dose plays an important role in radiotherapy. Several publications have shown that the biochemical relapse correlates with the generally accepted risk factors and the radiation dose. Regarding this, high-quality treatment planning and HDR brachytherapy combined with EBRT (external beam radiation therapy) leads to good treatment results in selected groups. So far in our own experience, HDR brachytherapy in combination with EBRT is a successful form of treatment with few acute and late side effects in the first 42 patients examined. First results concerning to PSA relapse-free time, quality of life, miction, and erectile function are promising.

Tolerability, efficacy and pharmacokinetics of bicalutamide 300 mg, 450 mg or 600 mg as monotherapy for patients with locally advanced or metastatic prostate cancer, compared with castration

OBJECTIVE

To evaluate the pharmacokinetics, tolerability and effect on endocrinology of bicalutamide given as once-daily monotherapy at doses of >150 mg to patients with locally advanced (M0) or metastatic (M1) prostate cancer, with efficacy as a secondary endpoint.

PATIENTS AND METHODS

Patients were initially enrolled to receive bicalutamide 300 mg in a non-randomized phase, after which further patients were randomized to higher bicalutamide doses (in 150 mg increments) or castration. Overall, 248 patients received bicalutamide at 300 mg (21), 450 mg (95) or 600 mg (42), or castration (90).

RESULTS

Systemic exposure to bicalutamide stabilised at a dose of approximately 300 mg, as determined by pharmacokinetic analysis. The tolerability of high doses of bicalutamide was similar to that of the 150 mg dose, with no increase in the incidence of adverse events. Patients receiving bicalutamide had early increases in the mean levels of oestradiol, testosterone and luteinizing hormone, which were maintained throughout the study. Levels of these hormones rapidly decreased in the castration group and remained low. From baseline (first day of treatment) to 12 weeks there was an equivalent reduction in prostate-specific antigen (PSA) levels across all four groups. At a median follow-up of 5 years, there was no significant survival difference between patients who received bicalutamide and those who received castration, either in M0 or M1 disease.

CONCLUSION

The low median PSA level (180 ng/mL) of patients with M1 disease might account for the lack of survival difference between the treatment groups. Further studies are needed to assess whether high-dose bicalutamide monotherapy can provide equivalent efficacy to castration in patients with M1 prostate cancer.

Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy

BACKGROUND

Appropriate timing of androgen deprivation treatment (ADT) for prostate cancer is controversial. Our aim was to determine whether immediate ADT extends survival in men with node-positive prostate cancer who have undergone radical prostatectomy and pelvic lymphadenectomy compared with those who received ADT only once disease progressed.

METHODS

Eligible patients from 36 institutes in the USA were randomly assigned in 1988-93 to receive immediate ADT (n=47) or to be observed (n=51), with ADT to be given on detection of distant metastases or symptomatic recurrences. Patients were followed up every 3 months for the first year and every 6 months thereafter. The primary endpoint was progression-free survival; secondary endpoints were overall and disease-specific survival. Analysis was by intention to treat. To ensure that the treatment groups were comparable, we did a retrospective central pathology review of slides and regraded the Gleason scores for available samples. This trial predates the requirement for clinical trial registration.

FINDINGS

At median follow-up of 11.9 years (range 9.7-14.5 for surviving patients), men assigned immediate ADT had a significant improvement in overall survival (hazard ratio 1.84 [95% CI 1.01-3.35], p=0.04), prostate-cancer-specific survival (4.09 [1.76-9.49], p=0.0004), and progression-free survival (3.42 [1.96-5.98], p<0.0001). Of 49 histopathology slides received (19 immediate ADT, 30 observation), 16 were downgraded from the original Gleason score (between groups < or = 6, 7, and > or = 8) and five were upgraded. We recorded similar proportions of score changes in each group (p=0.68), and no difference in score distribution by treatment (p=0.38). After adjustment for score, associations were still significant between treatment and survival (overall, p=0.02; disease-specific, p=0.002; progression-free survival, p<0.0001).

INTERPRETATION

Early ADT benefits patients with nodal metastases who have undergone prostatectomy and lymphadenectomy, compared with those who receive deferred treatment. The beneficial effects of early ADT, rather than an imbalance in risk factors, are likely to explain the differences in outcomes between treatments.

Radiotherapy in the management of common genitourinary malignancies

A continued role for radiation therapy in the multidisciplinary management of genitourinary malignancies seems certain. Treatment outcomes continue to improve, accompanied by diminishing rates of toxicity. With continued technologic advances in the delivery of radiation, including the use of adaptive radiotherapy, the discovery and application of novel treatment agents, and the combined efforts of urologists, medical oncologists, and radiation oncologists, patients who have genitourinary malignancies have an excellent chance of cure.

Rising prostate-specific antigen values during neoadjuvant androgen deprivation therapy: The importance of monitoring

PURPOSE

To assess the impact of a rising prostate-specific antigen (PSA) level in patients receiving neoadjuvant androgen deprivation therapy (N-ADT) before external beam radiotherapy for prostate cancer.

METHODS AND MATERIALS

From prospectively collected data, we identified 182 patients who received between 3 and 12 months of N-ADT before definitive external beam radiotherapy and who had at least three PSA readings during the neoadjuvant period. One hundred fifty patients had PSA values that continued to fall (Non-Rise group), but 32 had a PSA value that started to rise (Rise group). The two groups were compared by Mann-Whitney U and Pearson chi-square tests. Kaplan-Meier and log-rank analyses were performed for time to treatment failure, cause-specific survival (CSS), and overall survival (OS).

RESULTS

The median follow-up was 62.5 months for the Non-Rise group and 53 months for the Rise group. Patients who sustained a PSA rise during the N-ADT period had a shorter time to PSA relapse (p = 0.013), poorer CSS (p = 0.027), and poorer OS (p = 0.03). Multivariate analysis confirms the significance of a PSA rise during the N-ADT period for CSS (p = 0.035) and OS (p = 0.038).

CONCLUSIONS

A subset of patients treated with N-ADT develop a rising PSA profile that likely represents early androgen resistance. They have significantly worse outcome.