A PROSPECTIVE ANALYSIS OF TIME TO NORMALIZATION OF SERUM TESTOSTERONE AFTER WITHDRAWAL OF ANDROGEN DEPRIVATION THERAPY

Impact of salvage therapy for biochemical recurrence on health-related quality of life following radical prostatectomy

OBJECTIVE

To determine the impact of salvage therapy for prostate-specific antigen (PSA) recurrence on the health-related quality of life (HRQOL) of patients after radical retropubic prostatectomy (RP).

METHODS

Between January 2000 and December 2003, a total of 249 patients who underwent RP were available for 2-year follow up. Of the respondents, 203 men did not show evidence of recurrence (group A), and 46 men received salvage hormonal therapy and/or radiotherapy after RP because of a rise in PSA (group B). The general and prostate-target HRQOL was assessed with the Medical Outcomes Study 36-Item Short Form and University of California, Los Angeles Prostate Cancer Index, respectively. Patients completed the HRQOL instruments by mail at baseline and at 24 months after RP.

RESULTS

All of the patients completed both questionnaires. At baseline no significant differences were found between the two groups in any of the HRQOL domains. There were significant improvements in mental health and social function for the patients without biochemical recurrence postoperatively. Repeated measure anova revealed significantly different patterns of alteration in several general HRQOL domains among the treatment groups. The urinary and bowel domains were equivalent between the two treatment groups at baseline and 24 months after RP. The patients treated with salvage hormonal therapy tended to show delayed recovery of sexual function.

CONCLUSION

Using a self-administered questionnaire, biochemical recurrence following RP was found to impose a substantial burden in patients with localized prostate cancer.

Short- vs long-term androgen suppression plus external beam radiation therapy and survival in men of advanced age with node-negative high-risk adenocarcinoma of the prostate

BACKGROUND

The study evaluated whether the use of 3 years as compared with 6 months of androgen suppression therapy (AST) combined with external beam radiation therapy (RT) in the treatment of high-risk prostate cancer was associated with prolonged survival in advanced age men.

METHODS

A pooled analysis of 311 men enrolled in 3 prospective randomized trials between 1987 and 2000 who received 6 months or 3 years of AST and RT for locally advanced or high-grade localized adenocarcinoma of the prostate comprised the study cohort. Cox regression multivariable analysis was performed adjusting for known prognostic factors to determine whether the treatment received was associated with time to death after randomization. The median age and follow-up was 70 and 5.9 years, respectively, during which 82 (26%) deaths occurred.

RESULTS

Treatment received was not significantly associated with survival time after randomization (adjusted hazard ratio [AHR]: 1.1; 95% confidence interval [CI]: 0.7, 1.8; P = .70), whereas age at randomization (AHR: 1.05; 95% CI: 1.01, 1.09; P = .02) was. The presence of Gleason score 8 to 10 cancers approached significance (AHR: 1.6; 95% CI: 0.9, 2.6; P = .09).

CONCLUSIONS

After adjusting for known prognostic factors, the treatment of node-negative, high-risk prostate cancer using 3 years as compared with 6 months of AST with RT was not associated with prolonged survival in men of advanced age. The European Organization for Research and Treatment of Cancer randomized trial will help answer whether unknown confounding factors affected the results of the study.

Locally advanced prostate cancer—biochemical results from a prospective phase II study of intermittent androgen suppression for men with evidence of prostate-specific antigen recurrence after radiotherapy

BACKGROUND

Biochemical results from a prospective Phase II trial of intermittent androgen suppression for recurrent prostate cancer after radiotherapy were analyzed for correlations to the onset of hormone-refractory disease.

METHODS

Patients with histologically confirmed adenocarcinoma of the prostate and a rising serum prostate-specific antigen (PSA) level after external beam irradiation of the prostate were treated intermittently with a 36-week course of cyproterone acetate and leuprolide acetate. Then, patients were stratified according to their serum PSA range at the start of each cycle and were followed with further biochemical testing until disease progression was evident.

RESULTS

The mean PSA reduction was 95.2% irrespective of stratification group. A baseline serum PSA level <10 microg/L and a serum PSA nadir <or=0.2 microg/L were associated with the longest time off treatment. The overall mean nadir PSA value in the progression group at 1.40 +/- 0.19 microg/L was 2.6-fold greater than the value of 0.55 +/- 0.88 microg/L in the no-progression group (P = .0002). Recovery of serum testosterone to a level of >or=7.5 nmol/L was observed in 75%, 50%, 40%, and 30% of men in Cycles 1 to 4, respectively, and was sufficient to normalize the level of hemoglobin in each cycle, which dropped by an average of 10.8 g/L during treatment (P < .0001).

CONCLUSIONS

The length of the off-treatment interval during cyclic androgen withdrawal therapy was related inversely to baseline and nadir levels of serum PSA. Nadir PSA was a powerful predictor of early progression to androgen independence.

Individual variation of hormonal recovery after cessation of luteinizing hormone-releasing hormone agonist therapy in men receiving long-term medical castration therapy for prostate cancer

OBJECTIVE

To evaluate the process of hormonal recovery after cessation of luteinizing hormone-releasing hormone (LHRH) agonist treatment in patients who had received long-term LHRH agonist therapy for prostate cancer.

MATERIAL AND METHODS

Men who had successfully undergone androgen deprivation therapy with only monthly LHRH agonist therapy for > 30 months were enrolled and the administration of LHRH agonist was discontinued. Serum total testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and prostate-specific antigen (PSA) were measured before the cessation of LHRH agonist therapy and every 4 weeks thereafter, and the administration of LHRH agonist remained suspended until the total testosterone level recovered to > 50 ng/dl.

RESULTS

Ten patients were enrolled in the study. The median (range) castration period and the levels of serum LH, FSH, total testosterone and PSA at cessation of therapy were 39 (30-56) months,<0.5 (<0.5-1.8) mIU/ml, 6.4 (3.0-15.9) mIU/ml, 15.3 (5.8-34.7) ng/dl and 0.13 (0.02-0.89) ng/ml, respectively. Testosterone recovered to > 50 ng/dl in all cases. There were large variations in the times required for recovery of LH and FSH (30-100 days) and serum testosterone (30-330 days). PSA began to increase at various testosterone levels, and there was a large variation (0-83%; median 41%) in the ratio of the androgen suppression (testosterone < 50 ng/dl) time to the period of LHRH agonist cessation.

CONCLUSIONS

There was considerable variation in the hypothalamus-pituitary-testicular hormone profiles during recovery from long-term medical castration. These findings are noteworthy when interruption of androgen deprivation therapy is applied with the intention of delaying the progression of hormone-refractory cancer or improving the patient's quality of life.

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).

Duration of Testosterone Suppression after a 9.45mg Implant of the GnRH-Analogue Buserelin in Patients with Localised Carcinoma of the Prostate

OBJECTIVES

(1) To determine the duration of androgen deprivation after a single buserelin implant 9.45 mg in the neoadjuvant setting in combination with curative radiation therapy of carcinoma of the prostate, and (2) to evaluate the time to recovery of gonadal function, and the incidence and duration of hypogonadal symptoms.

METHODS

We prospectively evaluated 21 men with carcinoma of the prostate who received one implant of 9.45 mg buserelin subcutaneously. Release of buserelin, changes in serum testosterone concentration, hot flushing and sexual function over a 12-month study period were recorded.

RESULTS

Testosterone was suppressed below the castration limit (0.58 ng/ml=2 nmol/l) for 224 days (range, 139-309). The mean time to first return of testosterone above the castration limit was 246 days (range, 168-344); 50% of pre-treatment value was reached after 285 days (range, 218-370). The prevalence of hot flushing was 19 of 21 patients (90%) at 12 weeks. At the end of the study period, serum testosterone had reached 80% (range, 33%-166%) of pre-treatment concentration, sexual interest was present in 52%, erection was possible in 60%, and hot flushing remained in 24%.

CONCLUSION

A single injection of 3-month buserelin implant 9.45 mg suppresses serum testosterone below the castration limit for at least 6 months. Testosterone secretion recovers by 8-12 months. Hypogonadal symptoms decreased with the restoration of serum testosterone secretion. These data are clinically relevant regarding the dose schedule for buserelin and the patient information provided.

Intermittent androgen deprivation: clinical experience and practical applications

Prostate cancer is more frequently being diagnosed at an earlier age, men are dying of prostate cancer at an older age, and men are now treated with androgen deprivation for biochemical relapse. As a result, the amount of time that patients are potentially subjected to androgen deprivation is increasing. Intermittent androgen deprivation (IAD) has been investigated as a potential alternative to continuous androgen deprivation (CAD) in order to improve quality of life and potentially delay the progression to androgen independence. Along with the increased use of primary hormonal therapy in clinically localized prostate cancer, IAD may supplant the traditional surgical or radiotherapy options, specifically in men who have underlying co-morbidities and decreased life expectancy. There are ongoing multi-institutional, randomized trials that will lend insight into the utility, efficacy, and feasibility of IAD versus CAD. This article discusses the theoretical benefits and rationale of IAD and reviews the completed and on-going IAD trials. Finally, the controversies, practical applications, and future directions of IAD are addressed.

Intermittent use of testosterone inactivating pharmaceuticals using finasteride prolongs the time off period

PURPOSE

Men with prostate cancer treated intermittently with TIP benefit from improved quality of life when TOP with recovered testosterone is prolonged. We examined factors influencing the duration of TOP.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 101 men treated with intermittent TIP in a 9-year period. Men with positive bone scan, men in whom a PSA nadir of less than 0.1 ng/ml on TIP failed to be achieved and maintained and men in whom testosterone failed to recover to greater than 150 ng/dl during the first 12 months of TOP were excluded. Potential factors predicting prolonged TOP or accelerated time to AIPC were studied with Cox regression analysis.

RESULTS

Patient characteristics were clinical stage T1c-T2a in 51 and T2b-T3b in 11, PSA relapse in 29, and T3c, D0 or D1 in 10. Median PSA was 7.6 ng/ml, Gleason score was 3 + 4 = 7 and TIP duration was 15.8 months. The 60 group 1 patients received finasteride and the 41 in group 2 received no finasteride. Median TOP in groups 1 and 2 was 31 and 15 months, respectively, using Kaplan-Meier analysis. Cox regression analysis indicated that longer TIP, finasteride and increased age predicted longer TOP. A slow PSA decrease while on TIP, higher baseline PSA and increased Gleason score predicted shorter TOP. Cox regression analysis indicated that only higher clinical stage but not finasteride predicted the earlier onset of AIPC.

CONCLUSIONS

Finasteride doubles the duration of TOP. AIPC was not increased by finasteride after almost 9 years of observation.

Time course of serum testosterone and luteinizing hormone levels after cessation of long-term luteinizing hormone-releasing hormone agonist treatment in patients with prostate cancer

INTRODUCTION

In order to elucidate the influence of hormone-releasing hormone (LH-RH) agonist therapy cessation on pituitary/testicular function and its clinical implications, we investigated prospectively hormonal (luteinizing hormone: LH; testosterone: T) responses in patients with prostate cancer who received long-term LH-RH 10 agonist therapy.

PATIENTS AND METHODS

A consecutive 32 patients who had received LH-RH agonist therapy over 24 months were enrolled. As a baseline, T and LH were measured at the time of LH-RH agonist therapy cessation, monthly for 3 months, and subsequently, every 3 months.

RESULTS

The median duration of LH-RH agonist therapy was 30 months (24-87 months) with median follow-up duration of 24 months following cessation. All patients had castrated T levels and suppressed LH levels at baseline. Median duration of castrated T levels following cessation was 6 months. Median time to normalization of T levels was 24 months. LH levels returned to normal within 3 months in all cases. Patients who received androgen deprivation therapy for 30 months or longer required a longer time for recovery of T levels. Patients over 65 years of age showed a statistically significant longer time for recovery of T levels (P=0.0167).

CONCLUSIONS

Long-term LH-RH agonist therapy has remarkable effects on serum T level that last for a significant time after cessation, a fact that should be applied to the interpretation of both PSA and serum T levels after cessation of androgen deprivation therapy.

Intermittent androgen ablation in patients with biochemical failure after pelvic radiotherapy for localized prostate cancer

PURPOSE

To assess the efficacy of intermittent androgen ablation (IAA) in patients with biochemical failure after radiotherapy for prostate cancer.

METHODS AND MATERIALS

Thirty-nine patients received a luteinizing hormone-releasing hormone analog every 2 months for a total of 4 doses. IAA was then discontinued if serum prostate-specific antigen (PSA) fell to a normal level with a castrate level of testosterone. Therapy was restarted when the serum PSA level reached > or = 10 ng/mL and was discontinued if hormone resistance or unacceptable toxicity occurred.

RESULTS

Median PSA was 9.1 ng/mL at the time of first IAA. The median time between the first and the second cycles was 20.1 months, decreasing to 15.5 months between the third and fourth cycles. Two patients discontinued the treatment because of severe hot flushes. Four patients developed hormone resistance. With a median follow-up of 56.4 months, 5-year survival is 92.3%. Three patients died of unrelated causes. The incidence of distant metastasis is 6.8%.

CONCLUSIONS

The use of IAA seems to be a safe and effective treatment for patients with biochemical failure post radiotherapy and no evidence of metastatic disease. The use of IAA limits hormone-related side effects and health care costs without an apparent increase in the risk for the development of metastatic disease.

Tumor control outcomes of patients treated with trimodality therapy for locally advanced prostate cancer

OBJECTIVES

To evaluate, in a pilot study, the tumor control outcomes of our approach and define the pretreatment characteristics that predict a response to therapy. Patients with advanced clinically localized prostate cancer have a high likelihood of prostate-specific antigen (PSA) failure 3 to 5 years after initial treatment. We adopted trimodality therapy (neoadjuvant and adjuvant androgen ablation, external beam radiotherapy [RT], and a brachytherapy boost) to augment biochemical disease-free survival in this patient population.

METHODS

From 1997 to 2000, 93 patients with clinical Stage T2b or greater, or PSA level greater than 10 ng/mL, or Gleason score 7 or greater were treated with external beam RT followed by palladium-103 brachytherapy. Two to three months before external beam RT, an 8 to 9-month regimen of leuprolide and an oral antiandrogen was initiated. Patients were followed up at 3 to 4-month intervals with PSA determination and digital rectal examination. Perineural invasion, the percentage of cancer in biopsy cores, pretreatment PSA level, clinical T stage, and Gleason score were analyzed as prognostic factors for biochemical failure defined by both the American Society for Therapeutic Radiology and Oncology (ASTRO) criteria and PSA level greater than 0.2 ng/mL.

RESULTS

The median length of follow-up was 45 months. The overall probability of biochemical failure using a PSA level greater than 0.2 ng/mL at 4 years was 79% (95% confidence interval 69% to 89%). With the ASTRO criteria, the overall failure rate at the same point was 77% (95% confidence interval 68% to 87%). Gleason score (P = 0.07) showed a trend toward predicting biochemical failure using the PSA level greater than 0.2 ng/mL criterion.

CONCLUSIONS

Trimodality RT offers excellent tumor control in patients with poor prognosis who often relapse early. Longer follow-up will be important to determine whether these results are durable over time.

Gonadotropin-releasing hormone agonists and fracture risk: a claims-based cohort study of men with nonmetastatic prostate cancer

PURPOSE

Gonadotropin-releasing hormone (GnRH) agonists decrease bone mineral density, a surrogate for fracture risk, in men with prostate cancer. We conducted a claims-based cohort study to characterize the relationship between GnRH agonists and risk for clinical fractures in men with nonmetastatic prostate cancer.

PATIENTS AND METHODS

Using medical claims data from a 5% national random sample of Medicare beneficiaries, we identified a study group of men with nonmetastatic prostate cancer who initiated GnRH agonist treatment from 1992 to 1994 (n = 3,887). A comparison group of men with nonmetastatic prostate cancer who did not receive GnRH agonist treatment during the study period (n = 7,774) was matched for age, race, geographic location, and comorbidity. Clinical fractures were identified using inpatient, outpatient, and physician claims during 7 years of follow-up.

RESULTS

In men with nonmetastatic prostate cancer, GnRH agonists significantly increased fracture risk. The rate of any clinical fracture was 7.88 per 100 person-years at risk in men receiving a GnRH agonist compared with 6.51 per 100 person-years in matched controls (relative risk, 1.21; 95% CI, 1.14 to 1.29; P < .001). Rates of vertebral fractures (relative risk, 1.45; 95% CI, 1.19 to 1.75; P < .001) and hip/femur fractures (relative risk, 1.30; 95% CI, 1.10 to 1.53; P = .002) were also significantly higher in men who received a GnRH agonist. GnRH agonist treatment independently predicted fracture risk in multivariate analyses. Longer duration of treatment conferred greater fracture risk.

CONCLUSION

GnRH agonists significantly increase risk for any clinical fracture, hip fractures, and vertebral fractures in men with prostate cancer.

A rational approach to androgen therapy for hypogonadal men with prostate cancer

With earlier detection and improved survival from early stage prostate cancer, it is likely that the numbers of men presenting with hypogonadal symptoms following curative surgery for their cancer will increase. Although testosterone supplementation is effective in improving symptoms of hypogonadism, traditionally such therapy has been contraindicated in patients who have had prostate cancer. This paper reviews the evidence that testosterone therapy can be safely given to selected men with hypogonadism who have had prostate cancer but currently have no evidence of disease by clinical and prostate-specific antigen (PSA) criteria. Such patients should be treated cautiously and followed closely.

Intermittent Androgen Castration: A Biological Reality during Intermittent Treatment in Metastatic Prostate Cancer?

INTRODUCTION

To assess the effects of intermittent maximal androgen blockade (IMAB) on testosterone (T) levels during on- and off-treatment periods.

MATERIALS AND METHODS

A total of 51 patients with metastatic prostate cancer underwent a 6-months period of continuous maximal androgen blockade (MAB) consisting of leuprorelin (3.75 mg at monthly intervals) plus flutamide (250 mg t.i.d.) followed by IMAB. During each cycle, the cut-off prostate-specific antigen (PSA) levels to stop and resume treatment were 4 and 10 ng/ml, respectively. IMAB continued until progression under treatment occurred. Monthly PSA and T measurements were performed in central laboratories.

RESULTS

From the 51 patients included (mean age 67.6 years), 27, 16, 12, 8 and 5 underwent a second, third, fourth, fifth and sixth cycle, respectively (mean follow up: 17 months). Before treatment, 4 patients had a T lower than normal laboratory value but these recovered all to a normal T value at the end of the first cycle. During the 6 cycles, only 8 patients did not recover a normal T at least once during the off-treatment periods (OTP). The mean T values at the end of each OTP did not change during these 6 cycles (Anova test, p=0.621) with a mean stable recovery delay of 32-43 days (Anova test, p=0.722).

CONCLUSION

IMAB protocol with an initial 6-month treatment period can result in an intermittent castration with the recovery of normal T levels in most patients during six consecutive cycles of treatment.

A PROSPECTIVE ANALYSIS OF THE TIME TO NORMALIZATION OF SERUM ANDROGENS FOLLOWING 6 MONTHS OF ANDROGEN DEPRIVATION THERAPY IN PATIENTS ON A RANDOMIZED PHASE III CLINICAL TRIAL USING LIMITED HORMONAL THERAPY

PURPOSE

Patients with prostate cancer are treated with neoadjuvant, adjuvant and intermittent therapy with gonadotropin-releasing hormone agonists (GnRH-A). While these are largely successful in decreasing testosterone (T) and dihydroxytestosterone (DHT) to castrate levels, discontinuation of such therapy often results in continued suppression of androgens for variable periods of time. We present the largest published series of patients evaluating the timing of T and DHT increase after cessation of GnRH therapy.

MATERIALS AND METHODS

Serial T and DHT measurements were prospectively obtained every 3 months while on GnRH-A then monthly upon discontinuation of GnRH-A. Analysis of time from the second 3-month GnRH-A administration to T and DHT increase was undertaken.

RESULTS

A total of 80 evaluable patients had a median time to T 50 ng/dl or greater of 12.9 weeks and a median time to T normalization (212 ng/dl or greater) of 16.6 weeks. Low baseline T was associated with a prolonged time to T 212 ng/dl or greater (p = 0.0086) and a similar trend was seen in patients older than 66 years (p = 0.08). There were 62 evaluable patients with a median of 14.9 weeks to DHT 150 pg/ml or greater. There was no association with Gleason score at diagnosis, on study prostate specific antigen, type of prior definitive therapy, or any prior hormonal therapy and time to increase in circulating androgens.

CONCLUSIONS

After 6 months of GnRH-A therapy in these patients, DHT and T levels did not return to normal for a median of 14.9 and 16.6 weeks, respectively.

PSA bouncing after short term androgen deprivation and 3D-conformal radiotherapy for localized prostate adenocarcinoma and the relationship with the kinetics of testosterone

OBJECTIVES

To assess the factors effecting PSA bounce and to identify any possible relationship with biochemical control after 3-D conformal radiotherapy (3D-CRT) and total androgen deprivation (TAD) for prostate cancer by evaluating four previously described PSA bounce definitions.

METHODS

Between January 1998 and January 2001, 83 consecutive patients with clinically localized prostate cancer were treated by 3D-CRT with neoadjuvant 3 months and/or 6 months adjuvant TAD. All patients had a pretreatment PSA level, at least eight post-external beam radiotherapy (EBRT) PSA and testosterone levels and minimum two years of follow-up. Total radiotherapy dose was 73.6 Gy at ICRU reference point. Four previous definitions of PSA bounce were used: Critz definition (>or=0.1 ng/mL), Cavanagh definition (>or=0.2 ng/mL), Hanlon definition (>or=0.4 ng/mL) and Rosser definition (>or=0.5 ng/mL) according to original methodology performed to report PSA bounce. Biochemical failure was defined in accordance with the ASTRO consensus guidelines.

RESULTS

The median follow-up time was 40 months. PSA bounce was recorded as follows: Critz definition, 33 patients (40%); Cavanagh definition, 21 patients (25%); Hanlon definition, 11 patients (13%); and Rosser definition, 7 patients (8%). In multivariate analysis, pre-EBRT PSA level and the duration of TAD for Critz definition; age, pre-EBRT PSA and the duration of TAD for Cavanagh definition; age and duration of TAD for Hanlon definition; age and pre-biopsy PSA for Rosser definition were significant independent prognostic factors determining PSA bounce. A significant increase of mean testosterone level in bouncers was detected at the 6th-9th and 18th-21st months. PSA bounce did not predict for PSA failure in multivariate analysis.

CONCLUSIONS

We observed no correlation between biochemical failure and PSA bounce. The longer duration of TAD and older age were found to be inversely proportional with PSA bouncing in this cohort. Notably, recovery of testosterone might cause PSA bouncing.

Undetectable prostate specific antigen at 6-12 months

BACKGROUND

The concept of a prostate-specific antigen (PSA) "nadir" has been used as a predictive marker for treatment success in patients treated with radiotherapy for localized prostate carcinoma. However, this approach is not applicable in patients who are concomitantly treated with short-term hormonal therapies. To address this, the authors sought to develop a new predictive marker in such patients after prostate brachytherapy (BT).

METHODS

Between March 1997 and November 2002, 194 men with clinical Stage T1A-T3N0M0 prostate carcinoma (according to the 1992 International Union Against Cancer/American Joint Committee on Cancer TNM classification system) were treated with interstitial palladium (103Pd3) BT and androgen ablation therapy with or without external beam radiotherapy (EBRT). Based on tumor characteristics, 127 patients received an antiandrogen, finasteride, and BT whereas 67 received an antiandrogen, leuprolide, and EBRT followed by a BT boost. Hormonal therapy was initiated 2-3 months before any radiotherapy for a total duration of 8-9 months. Follow-up included physical examination and determining the PSA level at 3-month intervals. Postoperative serum testosterone was evaluated in preoperatively potent patients with erectile dysfunction > 6 months after therapy. A PSA level < or = 0.06 ng/mL or < or = 0.20 ng/mL detected during a 6-12-month window after the implant were evaluated as predictors of biochemically disease-free survival (DFS), defined as the time to a PSA level > or = 1.0 ng/mL.

RESULTS

Of the 194 patients, 163 were available for analysis. The median length of follow-up was 48 months. In those patients with a PSA level < or = 0.20 ng/mL at 6-12 months, the DFS at 48 months after the implant was 96% (95% confidence interval [95% CI], 91-99%) compared with the remainder of the patients, whose DFS decreased to 80% (95% CI, 65-89%) (P < 0.001). When a PSA level < or = 0.06 ng/mL was used as an indicator, the 48-month DFS was 99% (95% CI, 91-100%) compared with that for patients with a PSA level > 0.06 ng/mL, in whom the DFS was 85% (95% CI, 74-92%) (P = 0.004). Furthermore, because testosterone levels may occasionally remain low after the cessation of luteinizing hormone-releasing hormone agonist therapy and result in erectile dysfunction and an artificially low PSA level, the authors reviewed the serum testosterone levels in 23 patients who were so treated and were experiencing erectile dysfunction. None had PSA values below the lower limit of normal.

CONCLUSIONS

A PSA level < or = 0.20 ng/mL or < or = 0.06 ng/mL measured at 6-12 months after BT appears to be a useful predictive marker for detecting early success in patients with prostate carcinoma who are treated with neoadjuvant androgen ablation and BT. These markers may be used to identify those patients who are at an increased risk of biochemical failure and may be useful in stratifying patients for closer follow-up, long-term adjuvant therapies, or clinical trials. A longer follow-up period will be needed to verify whether these are predictive of long-term cancer control.

Determinants of long-term quality of life and voiding function of patients treated with radical prostatectomy or permanent brachytherapy for prostate cancer

OBJECTIVE

To assess the long-term quality of life (QoL) outcomes of three treatments for localized prostate cancer: radical prostatectomy (RP); brachytherapy monotherapy (BTM); and BT combined with external beam radiotherapy (BTC).

PATIENTS AND METHODS

In August 2000, questionnaires were mailed to men with T1c-T3 adenocarcinoma of the prostate treated with either RP, BTM ((103)Pd monotherapy) or BTC. Questionnaires included validated outcome measures, i.e. the Functional Assessment of Cancer Therapy - General (FACT-G), American Urological Association Symptom Score (AUA-SS), Urinary Function Questionnaire for men after RP, and the Brief Sexual Function Inventory. Returned questionnaires were assessed using cross-sectional analysis.

RESULTS

Data from 214 patients were included in the analysis (60 RP, 102 BTM and 52 BTC); the median follow-up was 18.8, 25.5 and 29.9 months, respectively. There were differences between both BT groups and the RP group in total AUA-SS and obstructive subscale symptom scores, with the former having worse symptom scores at a longer follow-up. Differences in overall QoL were not detected between groups using the total FACT-G but the BTC group generally had worse scores in the physical well-being subscale. The BT groups had higher continence rates with time after treatment. Sexual function was better with BT initially, but these differences did not persist at a longer follow-up. There were significant correlations between the FACT-G and the urinary symptom scores, and the degree of sexual function.

CONCLUSIONS

Although patients treated with BTM and RP have a different spectrum of side-effects, their overall long-term QoL is similar, with urinary and sexual function being the primary determinants of this outcome. Men treated with BTC have a worse QoL.

Intermittent androgen deprivation therapy for prostate cancer

Androgen deprivation therapy for prostate cancer is associated with several complications, including loss of libido, hot flashes, night sweats, psychological stress, osteoporosis, anemia, fatigue, loss of muscle mass, glucose intolerance, and changes in lipid profile. The natural history of prostate cancer while on such therapy is the attainment of an incurable androgen-independent state. Early diagnosis by prostate-specific antigen screening, longer life expectancies, and a penchant for immediate therapy pose a problem where clinicians have to balance the potential benefits of early hormonal therapy with the risks of development of these metabolic and psychological complications. Intermittent androgen deprivation offers clinicians a prospect to improve quality of life in patients with prostate cancer by harmonizing the benefits of androgen ablation with a reduction in treatment-related side effects and expenditure. In this review we discuss the challenges and opportunities of this mode of therapy and shed light on some of the underlying molecular mechanisms.

Changes in prostate-specific antigen and hormone levels following withdrawal of prolonged androgen ablation for prostate cancer

We conducted a study in order to characterize changes after withdrawal of androgen ablation (AA) for prostate cancer. AA was withdrawn in 38 Japanese patients with prostate cancer who had undergone this therapy for various periods. Patients were stratified into those who had undergone AA for less than 24 months (Group 1, n=12) and those with longer periods of AA (Group 2, n=26). Serial changes in hormones and prostate-specific antigen (PSA) were prospectively monitored following cessation of AA. The median durations of AA in the two groups were 8.5 and 54.5 months, respectively. Levels of total testosterone (T), luteinizing hormone and PSA increased significantly with time. At the end of 2 y, 30/38 patients (78.9%) had T levels above 50 ng/dl and 19/38 (50%) had levels above 320 ng/dl. Patients in Group 2 required significantly longer duration for T recovery. Complete T recovery is not always accompanied by rising PSA. Recovery of T levels is often slow following cessation of prolonged AA. Expression of PSA after AA is often variable and unpredictable. Thus, interpretation of outcomes in clinical trials incorporating AA needs caution and careful consideration.

Temporal effect of neoadjuvant androgen deprivation therapy on PSA kinetics following permanent prostate brachytherapy with or without supplemental external beam radiation

PURPOSE

To evaluate the effect of neoadjuvant androgen deprivation therapy on PSA kinetics following brachytherapy with or without supplemental external beam radiation therapy (XRT), to evaluate the magnitude and duration of the peak PSA, and to compare potential differences in PSA response curves between biochemically disease-free and failed patients.

MATERIALS AND METHODS

From November 1995 through August 2000, 179 consecutive patients with clinical T1b-T3a NxM0 (2002 AJCC) prostate cancer received neoadjuvant androgen deprivation therapy (median, 4 months) prior to brachytherapy using (103)Pd or (125)I with or without supplemental XRT. The median follow-up was 56 months. Following brachytherapy, PSA determinations were obtained at 3 months and then every 6 months thereafter. A median and mean of 9 and 9.5 PSA determinations, respectively, were obtained per patient. Biochemical disease-free survival was defined by the ASTRO and Houston definitions with both definitions used to determine the rate of overestimation of early biochemical failure secondary to testosterone recovery.

RESULTS

Although a trend for higher baseline and peak PSA was noted in (125)I monotherapy patients, the difference between the 4 groups was not statistically significant (p = 0.088). Changes in PSA over time, however, were statistically significant (p = 0.042). For all 4 groups, the peak PSA occurred approximately 15-21 months following brachytherapy. For biochemically disease-free patients, the median PSA increase above nadir was 0.1 ng/mL, and the median number of consecutive rises in PSA was 1. Using the ASTRO and Houston definitions, only 2.3% and 0.6% of patients would have been inadvertently scored as failures.

CONCLUSIONS

In brachytherapy patients receiving 3-6 months of neoadjuvant androgen deprivation therapy, the median PSA increase above nadir was 0.1 ng/mL. The ASTRO and Houston definitions of biochemical failure inadvertently scored only 2.3% and 0.6% of patients as failures.

High-risk localized prostate cancer: primary surgery and adjuvant therapy

High risk localized prostate cancer includes patients with palpable disease outside the capsule (clinical stage T3) as well as those with apparently localized disease but with adverse prognostic factors such as Gleason 8-10 tumors or very extensive disease on biopsy. The goals of therapy for these patients are to achieve both long-term local control and to remain free of metastatic disease. The ideal treatment to achieve these goals is unknown. We present a review of the outcome of contemporary reported series of such patients treated with primary radical prostatectomy, with or without neoadjuvant or adjuvant therapies. Over 80% of the patients overall achieved a 5-year disease-specific survival, though well under 50% have undetectable prostate specific antigen at that time point. We also review what is known about the choice and timing of adjuvant therapies, and describe current cooperative group studies underway to answer some of these questions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Longitudinal comparison of sexual function after 3-dimensional conformal radiation therapy or prostate brachytherapy

PURPOSE

The risk of erectile dysfunction can influence treatment decisions for localized prostate cancer. To estimate the risk from 2 popular radiotherapies we compared erectile function and overall satisfaction with sexual function after 3-dimensional (D) conformal radiation therapy and transperineal prostate brachytherapy.

MATERIALS AND METHODS

A total of 128 patients with prostate cancer underwent 3-D conformal radiation therapy (median dose 70.2 Gy. to the planning target volume) and 60 underwent palladium transperineal prostate brachytherapy (median dose 90 or 115 Gy. to 80% of the prostate with or without external nonconformal beam radiation therapy. Of the 128 patients 47 (37%) also received a luteinizing hormone releasing hormone (LH-RH) agonist (3 to 4 months), whereas 26 (43%) of the 60 patients received external beam radiation therapy and LH-RH (8 to 9 months). We evaluated erectile function and overall satisfaction with questions from validated, self-administered questionnaires. Patients responded to the questions serially before any prostate cancer therapy and at regular followup visits thereafter. We used the time until a patient returned to baseline erectile function and overall satisfaction to compare treatment modalities.

RESULTS

Median followup was 21 months. Of patients receiving 3-D conformal radiation therapy with or without LH-RH agonists 65% (95% CI 47% to 82%) and 67% (53% to 81%), respectively, returned to baseline overall satisfaction within 12 months after treatment versus 23% (9% to 50%) and 56% (38% to 75%) of the patients treated with transperineal prostate brachytherapy with or without external beam radiation therapy and LH-RH agonists, respectively. Reductions in overall satisfaction appeared to relate to changes in erectile function.

CONCLUSIONS

These data suggest that in the absence of LH-RH agonist use 3-D conformal radiation therapy and transperineal prostate brachytherapy have a similar impact on erectile function and overall satisfaction. Differences observed in erectile function and overall satisfaction in the 2 groups of patients who received adjuvant LH-RH may be due to the different duration of therapy (3 versus 8 months). Longer followup will be needed to evaluate this hypothesis.

Normalization of serum testosterone levels in patients treated with neoadjuvant hormonal therapy and three-dimensional conformal radiotherapy for prostate cancer

PURPOSE

To determine the expected time to serum testosterone normalization after short-course neoadjuvant androgen deprivation therapy (NAAD) and three-dimensional conformal radiotherapy for patients with localized prostate cancer and to identify pretreatment predictors that correlated with the time to testosterone normalization.

METHODS

Between 1993 and 1999, 88 patients with localized prostate cancer, treated with NAAD and external beam radiotherapy, were prospectively monitored after treatment with sequential testosterone levels. NAAD was administered before and during the entire course of radiotherapy and discontinued at the end of treatment. The median duration of NAAD was 6 months. The actuarial rate of serum testosterone normalization from the end of treatment was evaluated, and the presence or absence of androgen deprivation-related symptoms was correlated with serum testosterone levels. Symptoms assessed included weight gain, loss of libido, breast tenderness, breast enlargement, hot flashes, and fatigue.

RESULTS

Serum testosterone levels returned to the normal range in 57 (65%) of the 88 patients and failed to normalize in 31 patients (35%). The median time to normalization was 18.3 months. The actuarial rate of normalization at 3, 6, 12, and 24 months was 10%, 26%, 38%, and 59%, respectively. In a multivariate analysis, a pretreatment testosterone level in the lower range of normal was the only variable that predicted for delayed testosterone normalization after NAAD (p = 0.00047). Among 45 patients with information concerning androgen deprivation-related symptoms recorded 1 year after cessation of NAAD, 24 (53%) had normalized testosterone levels, but in 21 patients (47%), the levels had not yet returned to normal. At 1 year, only 1 (4%) of 24 patients whose testosterone level had returned to normal experienced NAAD-related symptoms compared with 14 (67%) of 21 patients who did not have normal testosterone levels (p <0.001).

CONCLUSION

Testosterone levels often remain depressed for extended periods after cessation of short-course NAAD. Lower baseline testosterone levels predict for a delay in testosterone normalization, and the persistence of symptoms related to androgen deprivation correlates with low testosterone levels.

Testosterone recovery following prolonged adjuvant androgen ablation for prostate carcinoma

BACKGROUND

This study was conducted to describe the rate and completeness of the recovery of testosterone production following prolonged temporary androgen ablative therapy in men with prostate carcinoma undergoing curative radiation therapy.

METHODS

Two-hundred and sixty-seven men treated with between 3 months and 3 years of adjuvant androgen ablation (AA) were followed at 6-month intervals following cessation of their androgen deprivation therapy. A comparative group of 518 men not undergoing AA were also followed.

RESULTS

Drugs used included low dose cyproterone/stilboestrol (CPA/DES) in combination (56%) and 1 month depot (18%) and 3 month depot (25%) leutinizing hormone releasing hormone agonist (LHRHa). Seventy-nine percent of men in the current study recovered normal testosterone levels (10nmol/L), and 93% recovered levels of at least 5nmol/L. In comparison, men who had never received androgen ablative therapy showed a fall of testosterone, with 17% having sub-normal levels after 3 years. Median time to testosterone recovery was 10 months. Factors associated on multivariate analysis with delayed testosterone recovery included advanced age (P = 0.008), low pre-therapy testosterone (P = 0.04), and the use of 3 month LHRHa preparations as compared with CPA/DES (P = 0.002) or 1 month LHRHa preparations (P = 0.015). The duration of drug use was not significantly associated with time to testosterone recovery.

CONCLUSIONS

Long-acting LHRHa preparations appear to have a more prolonged action than previously supposed. Most men treated for up to 2 years recover normal testosterone levels after cessation of adjuvant androgen ablation, and the limited data available in the current study on patients treated for 3 years also suggests most will recover.

Prospective assessment of voiding and sexual function after treatment for localized prostate carcinoma: comparison of radical prostatectomy to hormonobrachytherapy with and without external beam radiotherapy

BACKGROUND

Voiding and sexual function after treatment are major determinants of quality of life in prostate carcinoma patients. Erectile dysfunction, incontinence, and urinary symptoms, both obstructive and irritative, have a significant negative impact on patient quality of life. This prospective study was undertaken to evaluate voiding, sexual function, and their impact on patients with localized prostate carcinoma who were treated with radical retropubic prostatectomy (RP) and to compare these patients with patients who were undergoing hormonobrachytherapy with external bean radiotherapy (HBTC) and patients who were undergoing hormonobrachytherapy without external beam radiotherapy (HBT).

METHODS

Patients treated for localized prostate carcinoma with either RP or interstitial palladium-103 (103Pd) HBTC or HBT were prospectively administered a voiding and sexual function questionnaire before any treatment was initiated and at posttreatment visits. Questionnaire components included the American Urological Association Symptom Score (AUASS) and specific items that addressed urinary control and sexual function from the University of California at Los Angeles Prostate Cancer Index. Questionnaire results were compiled, and differences among treatment groups were assessed over time.

RESULTS

From January 1997 to November 1999, 127 consecutive patients were treated with either unilateral or bilateral nerve-sparing RP (42 patients), HBTC (40 patients) or HBT (45 patients) by 2 surgeons proficient in all procedures. Using the overall score and the obstructive subscale (OAUA) of the AUASS, the RP group showed a posttreatment decrease in scores compared with both HBTC and HBT groups. OAUA scores of HBTC and HBT groups were significantly greater than scores in RP patients over the course of the study. HBTC patients had increased irritative symptoms initially when compared with RP patients, and, although not statistically significant, the magnitude of the difference persisted over the course of the study. Total AUASS and subscale scores for the RP group returned to near baseline levels within 12 months. The use of incontinence pads was a criterion for urinary incontinence, and the proportion of patients returning to baseline continence was lower in RP patients over the course of the study. No notable differences in Voiding Bother (VB) scores were found. Initially RP patients experienced worse Sexual Function (SF) scores; however, scores for RP patients changed over time and approached the levels seen in HBTC patients at 18 months. The Sexual Function Bother (SFB) scores also were higher initially in the RP group but then decreased to similar levels observed for HBTC patients by 18 months. None of the treatment groups returned to near baseline SF or SFB scores during the course of this study.

CONCLUSIONS

Comparison of voiding function indicated that HBTC and HBT patients initially have more obstructive voiding symptoms, whereas urinary incon- tinence is initially worse in RP patients. Initially RP patients demonstrated worse SF and SFB scores, but RP patients returned to HBTC levels within 18 months.