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Dragomir A, Dinea D, Vanhuyse M, Cury FL, Aprikian AG. Drug costs in the management of metastatic castration-resistant prostate cancer in Canada. BMC Health Serv Res 2014; 14:252. [PMID: 24927758 PMCID: PMC4099156 DOI: 10.1186/1472-6963-14-252] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 06/06/2014] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND For Canadian men, prostate cancer (PCa) is the most common cancer and the 3rd leading cause of cancer mortality. Men dying of PCa do so after failing castration. The management of metastatic castration-resistant prostate cancer (mCRPC) is complex and the associated drug treatments are increasingly costly. The objective of this study was to estimate the cost of drug treatments over the mCRPC period, in the context of the latest evidence-based approaches. METHODS Two Markov models with Monte-Carlo microsimulations were developed in order to simulate the management of the disease and to estimate the cost of drug treatments in mCRPC, as per Quebec's public healthcare system. The models include recently approved additional lines of treatment after or before docetaxel (i.e. abiraterone and cabazitaxel). Drug exposure and survival were based on clinical trial results and clinical practice guidelines found in a literature review. All costs were assigned in 2013 Canadian dollars ($). Only direct drug costs were estimated. RESULTS The mean cost of mCRPC drug treatments over an average period of 28.1 months was estimated at $48,428 per patient (95% Confidence Interval: $47,624 to $49,232). The mean cost increased to $104,071 (95% CI: $102,373 - $105,770) per patient when one includes abiraterone initiation prior to docetaxel therapy. Over the mCRPC period, luteinizing hormone-releasing hormone agonists (LHRHa) prescribed to maintain castrate testosterone levels accounted for 20.4% of the total medication cost, whereas denosumab prescribed to decrease bone-related events accounted for 30.5% of costs. When patients received cabazitaxel in sequence after abiraterone and docetaxel, the mCRPC medications cost per patient per month increased by 60.2%. The total cost of medications for the treatment of each annual Canadian cohort of 4,000 mCRPC patients was estimated at $ 193.6 million to $416.3 million. CONCLUSIONS Our study estimates the direct drug costs associated with mCRPC treatments in the Canadian healthcare system. Recently identified effective yet not approved therapies will become part of the spectrum of mCRPC treatments, and may potentially increase the cost.
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Affiliation(s)
- Alice Dragomir
- Department of Surgery, Division of Urology, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
- Research Institute of McGill University Health Center, 2155 Guy St, Montreal, Quebec H3H 2R9, Canada
| | - Daniela Dinea
- Department of Surgery, Division of Urology, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
- Faculty of Pharmacy, University of Montreal, CP 6128 Succursale Centre-Ville, Montreal, Quebec H3C 3 J7, Canada
| | - Marie Vanhuyse
- McGill University Health Center, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
- Department of Oncology, Division of Medical Oncology, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
| | - Fabio L Cury
- McGill University Health Center, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
- Department of Oncology, Division of Radiation Oncology, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
| | - Armen G Aprikian
- Department of Surgery, Division of Urology, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
- Research Institute of McGill University Health Center, 2155 Guy St, Montreal, Quebec H3H 2R9, Canada
- McGill University Health Center, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
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Abstract
The incidence of prostate cancer increases with age. Current evidence suggests that prostate cancer is under treated in patients aged ≥70 years, despite evidence of efficacy and acceptable toxicity. Radical cystectomy and definitive radiotherapy are often denied owing to fears of post-operative complications and radiotherapy-associated gastrointestinal and genitourinary toxicity. However, modern radical prostatectomy techniques provide excellent clinical outcomes with low perioperative morbidity. Moreover, volume-restricted intensity-modulated radiation therapy is a significant improvement over previous 2D conformal radiotherapy with similar efficacy and lower toxicity. Androgen-deprivation therapy is also under-prescribed among the elderly, owing to concerns of increases in cardiac deaths and osteoporosis acceleration. However, prospective trials have not identified any increase in cardiovascular mortality among elderly men receiving androgen-deprivation therapy compared to age-matched controls. Most patients on androgen deprivation eventually progress to a castration-resistant state. At this stage, the disease still responds to newer agents that target the androgen pathway and to chemotherapy. Among the elderly, chemotherapy is under-prescribed even though it has been demonstrated to be palliative and improve survival. We describe the trends in prostate cancer management in the elderly and the importance of assessing comorbidity status, tumour characteristics, and health status, including a complete geriatric evaluation, before making treatment recommendations.
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Affiliation(s)
- Gautam G Jha
- Division of Haematology, Oncology and Transplantation, University of Minnesota, MMC394, 420 Delaware Street, Minneapolis, MN 55455, USA
| | - Vidhu Anand
- Department of Urologic Surgery, University of Minnesota, MMC394, 420 Delaware Street, Minneapolis, MN 55455, USA
| | - Ayman Soubra
- Department of Urology, University of Minnesota, MMC394, 420 Delaware Street, Minneapolis, MN 55455, USA
| | - Badrinath R Konety
- Department of Urology, University of Minnesota, MMC394, 420 Delaware Street, Minneapolis, MN 55455, USA
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Arrabal-Martín M, Anglada-Curado F, Cózar-Olmo J, Soler-Martínez J, Moreno-Jiménez J, Castiñeiras-Fernández J, Ledo-Cepero M, Beardo-Villar P, Requena-Tapia M, Zuluaga-Gómez A. Pre-chemotherapy abiraterone acetate. A proposal of a treatment algorithm in castration resistant prostate cancer. Actas Urol Esp 2014; 38:327-33. [PMID: 24342031 DOI: 10.1016/j.acuro.2013.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 10/16/2013] [Accepted: 10/21/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Prostate cancer treatment remains a challenge for the urologist. Medical control in locally advanced or metastatic prostate cancer is usually performed with LHRH analogues and/or antiandrogens. Different treatments have been proposed when there is biochemical and clinical progression of the disease and other new ones have changed the patients' perspective and life expectancy. OBJECTIVE This review has aimed to establish the current role of Abiraterone Acetate in the treatment of castration-resistant prostate cancer and facilitate decision-making by the Urologist by means of a Treatment Algorithm. ACQUISITION OF THE EVIDENCE A search of current evidence on Abiraterone treatment in patients with castration- resistant metastatic prostate cancer was performed in PubMed, mainly analyzing those studies designed as clinical trials. In addition, we reviewed and updated the role of hormone therapy and androgen receptors in prostate cancer. EVIDENCE SYNTHESIS There are currently basically two clinical trials that demonstrate the effectiveness of Abiraterone in metastatic prostate cancer compared to placebo. The study COU-AA 302 shows a clear benefit with Abiraterone prior to chemotherapy in patients with castration-resistant prostate cancer, this making it possible to establish an algorithm for initial treatment that facilitates decision-making by the urologist. CONCLUSION Abiraterone is a pre-chemotherapy treatment option in selected patients with castration resistant metastatic prostate cancer, although it is necessary to improve the cost and to design more multicenter clinical trials to optimize the cost/benefit ratio.
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104
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Heemers HV. Targeting androgen receptor action for prostate cancer treatment: does the post-receptor level provide novel opportunities? Int J Biol Sci 2014; 10:576-87. [PMID: 24948870 PMCID: PMC4062950 DOI: 10.7150/ijbs.8479] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 01/23/2014] [Indexed: 12/11/2022] Open
Abstract
The standard of care for patients who suffer from non-organ confined prostate cancer (CaP) is androgen deprivation therapy (ADT). ADT exploits the reliance of CaP cells on androgen receptor (AR) signaling throughout CaP progression from androgen-stimulated (AS) to castration-recurrent (CR) disease. AR is a member of the nuclear receptor family of ligand-activated transcription factors. Ligand-activated AR relocates from the cytoplasm to the nucleus, where it binds to Androgen Response Elements (AREs) to regulate transcription of target genes that control CaP cell behavior and progression. Current forms of ADT interfere at 2 levels along the AR signaling axis. At the pre-receptor level, ADT limits the availability of ligand for AR, while at the receptor level, ADT interrupts AR-ligand interactions. Both forms of ADT induce remission, but are not curative and, because of extraprostatic actions, are associated with severe side effects. Here, the potential of interference with the molecular regulation of AR-dependent transcription and the action of AR target genes, at the post receptor level, as the foundation for the development of novel, more CaP- specific selective forms of ADT is explored.
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Affiliation(s)
- Hannelore V. Heemers
- Departments of Urology and Cancer Genetics, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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105
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Yuan X, Cai C, Chen S, Chen S, Yu Z, Balk SP. Androgen receptor functions in castration-resistant prostate cancer and mechanisms of resistance to new agents targeting the androgen axis. Oncogene 2014; 33:2815-25. [PMID: 23752196 PMCID: PMC4890635 DOI: 10.1038/onc.2013.235] [Citation(s) in RCA: 261] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 04/30/2013] [Accepted: 05/06/2013] [Indexed: 12/17/2022]
Abstract
The metabolic functions of androgen receptor (AR) in normal prostate are circumvented in prostate cancer (PCa) to drive tumor growth, and the AR also can acquire new growth-promoting functions during PCa development and progression through genetic and epigenetic mechanisms. Androgen deprivation therapy (ADT, surgical or medical castration) is the standard treatment for metastatic PCa, but patients invariably relapse despite castrate androgen levels (castration-resistant PCa, CRPC). Early studies from many groups had shown that AR was highly expressed and transcriptionally active in CRPC, and indicated that steroids from the adrenal glands were contributing to this AR activity. More recent studies showed that CRPC cells had increased expression of enzymes mediating androgen synthesis from adrenal steroids, and could synthesize androgens de novo from cholesterol. Phase III clinical trials showing a survival advantage in CRPC for treatment with abiraterone (inhibitor of the enzyme CYP17A1 required for androgen synthesis that markedly reduces androgens and precursor steroids) and for enzalutamide (new AR antagonist) have now confirmed that AR activity driven by residual androgens makes a major contribution to CRPC, and led to the recent Food and Drug Administration approval of both agents. Unfortunately, patients treated with these agents for advanced CRPC generally relapse within a year and AR appears to be active in the relapsed tumors, but the molecular mechanisms mediating intrinsic or acquired resistance to these AR-targeted therapies remain to be defined. This review outlines AR functions that contribute to PCa development and progression, the roles of intratumoral androgen synthesis and AR structural alterations in driving AR activity in CRPC, mechanisms of action for abiraterone and enzalutamide, and possible mechanisms of resistance to these agents.
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MESH Headings
- Androgen Receptor Antagonists/therapeutic use
- Androgens/metabolism
- Animals
- Cell Transformation, Neoplastic/genetics
- Cell Transformation, Neoplastic/metabolism
- Disease Progression
- Drug Resistance, Neoplasm
- Gene Expression Regulation, Neoplastic
- Humans
- Male
- Prostatic Neoplasms, Castration-Resistant/drug therapy
- Prostatic Neoplasms, Castration-Resistant/genetics
- Prostatic Neoplasms, Castration-Resistant/metabolism
- Receptors, Androgen/chemistry
- Receptors, Androgen/metabolism
- Repressor Proteins/metabolism
- Steroid 17-alpha-Hydroxylase/antagonists & inhibitors
- Steroid 17-alpha-Hydroxylase/metabolism
- Trans-Activators/metabolism
- Transcription, Genetic
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Affiliation(s)
- X Yuan
- Hematology Oncology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - C Cai
- Hematology Oncology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - S Chen
- Hematology Oncology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - S Chen
- Hematology Oncology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Z Yu
- Hematology Oncology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - S P Balk
- Hematology Oncology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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106
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Abstract
The discovery of androgen dependence in prostate cancer in 1941 by Huggins and colleagues has remained the backbone for the treatment of this disease. However, although many patients initially respond to androgen depletion therapy, they almost invariably relapse and develop resistance with transition of the disease to a castration-resistant state. Over the past decade, the better understanding of the mechanisms that drive resistance to castration has led to the development of next-generation androgen receptor targeting agents such as abiraterone acetate and enzalutamide. This Review aims to revisit the discovery and evolution of androgen receptor targeting therapeutics for the treatment of advanced-stage prostate cancer over the years and to discuss the upcoming future and challenges in the treatment of this common cancer.
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107
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Stein MN, Patel N, Bershadskiy A, Sokoloff A, Singer EA. Androgen synthesis inhibitors in the treatment of castration-resistant prostate cancer. Asian J Androl 2014; 16:387-400. [PMID: 24759590 PMCID: PMC4023364 DOI: 10.4103/1008-682x.129133] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/11/2014] [Accepted: 03/14/2014] [Indexed: 01/01/2023] Open
Abstract
Suppression of gonadal testosterone synthesis represents the standard first line therapy for treatment of metastatic prostate cancer. However, in the majority of patients who develop castration-resistant prostate cancer (CRPC), it is possible to detect persistent activation of the androgen receptor (AR) through androgens produced in the adrenal gland or within the tumor itself. Abiraterone acetate was developed as an irreversible inhibitor of the dual functional cytochrome P450 enzyme CYP17 with activity as a 17α-hydroxylase and 17,20-lyase. CYP17 is necessary for production of nongonadal androgens from cholesterol. Regulatory approval of abiraterone in 2011, based on a phase III trial showing a significant improvement in overall survival (OS) with abiraterone and prednisone versus prednisone, represented proof of principle that targeting AR is essential for improving outcomes in men with CRPC. Inhibition of 17α-hydroxylase by abiraterone results in accumulation of upstream mineralocorticoids due to loss of cortisol-mediated suppression of pituitary adrenocorticotropic hormone (ACTH), providing a rationale for development of CYP17 inhibitors with increased specificity for 17,20-lyase (orteronel, galeterone and VT-464) that can potentially be administered without exogenous corticosteroids. In this article, we review the development of abiraterone and other CYP17 inhibitors; recent studies with abiraterone that inform our understanding of clinical parameters such as drug effects on quality-of-life, potential early predictors of response, and optimal sequencing of abiraterone with respect to other agents; and results of translational studies providing insights into resistance mechanisms to CYP17 inhibitors leading to clinical trials with drug combinations designed to prolong abiraterone benefit or restore abiraterone activity.
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Affiliation(s)
- Mark N Stein
- Rutgers Cancer Institute of New Jersey, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Neal Patel
- Rutgers Cancer Institute of New Jersey, USA
- Section of Urologic Oncology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Alexander Bershadskiy
- Rutgers Cancer Institute of New Jersey, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Alisa Sokoloff
- Rutgers Cancer Institute of New Jersey, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Eric A Singer
- Rutgers Cancer Institute of New Jersey, USA
- Section of Urologic Oncology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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108
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Thomas LN, Merrimen J, Bell DG, Rendon R, Goffin V, Too CKL. Carboxypeptidase-D is elevated in prostate cancer and its anti-apoptotic activity is abolished by combined androgen and prolactin receptor targeting. Prostate 2014; 74:732-42. [PMID: 24615730 DOI: 10.1002/pros.22793] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 01/28/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Carboxypeptidase-D (CPD) cleaves C-terminal arginine for nitric oxide (NO) production. CPD and NO levels are upregulated by testosterone (T) and prolactin (PRL) to promote survival of prostate cancer (pCa) cells. This study evaluated CPD immunostaining and T/PRL regulation of CPD and NO levels in benign and malignant prostate tissues/cells to determine the role of CPD in pCa. METHODS Immunohistochemistry (IHC) and tissue microarrays (TMA) were used to determine CPD immunostaining in prostate specimens. QPCR and immunoblotting were used to quantify CPD mRNA/protein expression in prostate cells. NO production was measured using 4,5-diaminofluorescein diacetate assay. RESULTS CPD staining increased from 8.9 ± 3.8% (Mean ± SEM, n = 15) of benign epithelial cell area to 30.9 ± 2.9% (n = 30) of tumor cell area in one set of TMAs (P = 0.0008) and from 5.9 ± 0.9% (n = 45) of benign epithelial cell area to 18.8 ± 1.9% (n = 55) of tumor area in another (P < 0.0001). IHC of prostate tissues (≥50 mm(2)) confirmed increased CPD staining, from 13.1 ± 2.9% in benign (n = 16) to 29.5 ± 4.4% in pCa (n = 31, P = 0.0095). T and/or PRL increased CPD expression in several pCa but not benign cell lines. T and PRL acted synergistically to increase NO production, which was abolished only when receptor antagonists flutamide and Δ1-9-G129R-hPRL were used together. CONCLUSIONS CPD immunostaining and T/PRL-stimulated CPD expression were higher in pCa than benign tissues/cells. Elevated CPD increased NO production, which was abolished when both AR and PRLR were inhibited. Our study implicates a critical role for the T/PRL-stimulated CPD-Arg-NO pathway in pCa progression, and suggests that AR+PRLR inhibition is a more effective treatment for pCa.
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Affiliation(s)
- Lynn N Thomas
- Departments of Biochemistry & Molecular Biology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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109
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de Liaño AG, Reig O, Mellado B, Martin C, Rull EU, Maroto JP. Prognostic and predictive value of plasma testosterone levels in patients receiving first-line chemotherapy for metastatic castrate-resistant prostate cancer. Br J Cancer 2014; 110:2201-8. [PMID: 24722180 PMCID: PMC4007243 DOI: 10.1038/bjc.2014.189] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 03/12/2014] [Accepted: 03/15/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Biomarkers for metastatic castration-resistant prostatic cancer (mCRPC) are an unmet medical need. METHODS The prognostic and predictive value for survival and response to salvage hormonal therapy (SHT) of baseline testosterone level (TL) was analysed in a cohort of 101 mCRPC patients participating in 9 non-hormonal first-line chemotherapy phase II-III trials. Inclusion criteria in all trials required a TL of <50 ng dl(-1). RESULTS Median age: 70 years; visceral metastases: 19.8%; median prostate-specific antigen (PSA): 50.7 ng ml(-1); median TL: 11.5 ng dl(-1). Median overall survival (OS; 24.5 months) was significantly longer if baseline TL was above (High TL; n=52) than under (Low TL; n=49) the TL median value (32.7 vs 22.4 months, respectively; P=0.0162, hazard ratio (HR)=0.6). The presence of anaemia was an unfavourable prognostic factor (median OS: 20.6 vs 28.4 months; P=0.0025, HR=1.88 (CI95%: 1.01-3.48)). Patients presenting both anaemia and low testosterone had a worse outcome compared to those with one or none of them (median OS: 17.9 vs 22.4 vs 38.1 months; P=0.0024). High vs Low TL was associated with PSA response rate (55.6% vs 21.7%) in 41 patients receiving SHT. CONCLUSION Testosterone level under castration range was a prognostic factor for survival mCRPC patients. The PSA response to SHT differed depending on TLs. Testosterone levels might help in treatment decision.
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Affiliation(s)
- A G de Liaño
- Medical Oncology and Biochemistry Departments, Hospital de la Santa Creu i Sant Pau, Mas Casanovas s/n, 08025 Barcelona, Spain
| | - O Reig
- Medical Oncology Department, Hospital Clinic, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - B Mellado
- Medical Oncology Department, Hospital Clinic, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - C Martin
- Medical Oncology and Biochemistry Departments, Hospital de la Santa Creu i Sant Pau, Mas Casanovas s/n, 08025 Barcelona, Spain
| | - E U Rull
- Medical Oncology and Biochemistry Departments, Hospital de la Santa Creu i Sant Pau, Mas Casanovas s/n, 08025 Barcelona, Spain
| | - J P Maroto
- Medical Oncology and Biochemistry Departments, Hospital de la Santa Creu i Sant Pau, Mas Casanovas s/n, 08025 Barcelona, Spain
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110
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Affiliation(s)
- Sham Mailankody
- From the Medical Oncology Service, National Cancer Institute, Bethesda, MD
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111
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Peer A, Gottfried M, Sinibaldi V, Carducci MA, Eisenberger MA, Sella A, Leibowitz-Amit R, Berger R, Keizman D. Comparison of abiraterone acetate versus ketoconazole in patients with metastatic castration resistant prostate cancer refractory to docetaxel. Prostate 2014; 74:433-40. [PMID: 24338986 PMCID: PMC4696030 DOI: 10.1002/pros.22765] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 11/25/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Abiraterone, a potent CYP 17 inhibitor, is standard treatment in docetaxel refractory, metastatic castrate resistant prostate cancer (mCRPC). However, in countries where abiraterone has not been approved yet, or for patients who cannot afford it, ketoconazole is used as an alternative CYP 17 inhibitor. Although preclinical data suggests that ketoconazole is a less potent inhibitor of CYP 17, there are limited clinical data comparing both agents. We aimed to compare the clinical effectiveness of abiraterone versus ketoconazole in docetaxel refractory mCRPC. METHODS Records from mCRPC patients treated with ketoconazole (international multicenter database, n = 162) were reviewed retrospectively. Twenty-six patients treated post docetaxel were individually matched by clinicopathologic factors to patients treated with abiraterone (national multicenter database, n = 140). We compared the PSA response, biochemical and radiological progression free survival (PFS), and overall survival (OS) between the groups. PFS and OS were determined by Cox regression. RESULTS The groups were matched by Gleason score, pre-treatment disease extent, ECOG PS, pre-treatment risk category (Keizman, Oncologist 2012). Furthermore, they were balanced regarding other known confounding risk factors. In the groups of abiraterone versus ketoconazole, PSA response was 46% versus 19% (OR 4.3, P = 0.04), median biochemical PFS 7 versus 2 months (HR 1.54, P = 0.02), median radiological PFS 8 versus 2.5 months (HR 1.8, P = 0.043), median OS 19 versus 11 months (HR 0.53, P = 0.79), and treatment interruption d/t severe adverse events 8% (n = 2) versus 31% (n = 8) (0R 0.6, P = 0.023). CONCLUSIONS In docetaxel refractory mCRPC, the outcome of abiraterone treatment may be superior to ketoconazole.
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Affiliation(s)
- Avivit Peer
- Departmentof Oncology, Rambam Medical Center, Haifa, Israel
| | - Maya Gottfried
- Departmentof Oncology, Meir Medical Center, Kfar Saba, Israel
| | - Victoria Sinibaldi
- Sidney Kimmel Comprehensive Cancer Centerat Johns Hopkins, Baltimore, MD
| | | | | | - Avishay Sella
- Departmentof Oncology, Asaf Harofe Medical Center, Zerif|n, Israel
| | | | - Raanan Berger
- Department of Oncology, Sheba Medical Center,Tel Hashomer, Israel
| | - Daniel Keizman
- Departmentof Oncology, Meir Medical Center, Kfar Saba, Israel
- Correspondence to: Daniel Keizman, Department of Oncology, Meir Medical Center, Kfar Saba, Israel.
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112
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Bazarbashi S, Bachour M, Bulbul M, Alotaibi M, Jaloudi M, Jaafar H, Mukherji D, Farah N, Alrubai T, Shamseddine A. Metastatic castration resistant prostate cancer: current strategies of management in the Middle East. Crit Rev Oncol Hematol 2014; 90:36-48. [PMID: 24289901 DOI: 10.1016/j.critrevonc.2013.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 09/27/2013] [Accepted: 11/01/2013] [Indexed: 02/08/2023] Open
Abstract
Although most patients with prostate cancer respond to initial androgen-deprivation therapy, progression to castration-resistant prostate cancer (CRPC) is almost inevitable. In 2004, the docetaxel/prednisone regimen was approved for the management of patients with metastatic CRPC, becoming the standard first-line therapy. Recent advances have also led to an unprecedented number of approved new drugs; thus, providing several treatment options for patients with metastatic CRPC. Five new drugs have received US Food and Drug Administration-approval between 2010 and 2012: sipuleucel-T, an immunotherapeutic agent; cabazitaxel, a novel microtubule inhibitor; abiraterone acetate, a new androgen biosynthesis inhibitor; enzalutamide, a novel androgen receptor inhibitor; and denosumab, a bone-targeting agent. Such drugs are either already marketed or about to be marketed in the Middle East. Data supporting the approval of each of these agents are described in this review, as are recent approaches to the treatment of metastatic CRPC.
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Affiliation(s)
- Shouki Bazarbashi
- Section of Medical Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Marwan Bachour
- Department of Medical Oncology, El Beyrouni University Hospital, Damascus, Syria
| | - Muhammad Bulbul
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohammed Alotaibi
- Department of Urology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mohamed Jaloudi
- Department of Oncology, Tawam Hospital/Johns Hopkin Medicine, Al Ain, United Arab Emirates
| | - Hassan Jaafar
- Department of Oncology, Tawam Hospital/Johns Hopkin Medicine, Al Ain, United Arab Emirates
| | - Deborah Mukherji
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Naim Farah
- Division of Uro-Oncology, King Hussein Cancer Center, Amman, Jordan
| | | | - Ali Shamseddine
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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113
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Chaturvedi S, Garcia JA. Novel agents in the management of castration resistant prostate cancer. J Carcinog 2014; 13:5. [PMID: 24799832 PMCID: PMC4007389 DOI: 10.4103/1477-3163.128185] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 12/15/2013] [Indexed: 11/14/2022] Open
Abstract
Prostate cancer (PCa) is a leading cause of cancer mortality in men and despite high cure rates with surgery and/or radiation, 30-40% of patients will eventually develop advanced disease. Androgen deprivation is the first line therapy for standard of care for men with advanced disease. Eventually however all men will progress to castration-resistant prostate cancer (CRPC). Insight into the molecular mechanisms of androgen resistance has led to the development of alternative novel hormonal agents. Newer hormonal agents such as abiraterone, enzalutamide and TOK-001; and the first cancer vaccine, Sipuleucel T have been approved for use in men with CRPC. The recognition of the importance of bone health and morbidity associated with skeletal related events has led to the introduction of the receptor activator of nuclear factor kappa-B-ligand inhibitor denosumab. Other molecularly targeted therapies have shown promise in pre-clinical studies, but this has not consistently translated into clinical efficacy. It is increasingly evident that CRPC is a heterogeneous disease and an individualized approach directed at identifying primary involvement of specific pathways could maximize the benefit from targeted therapies. This review focuses on targeted therapy for PCa with special emphasis on therapies that have been Food and Drug Administration approved for use in men with CRPC.
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Affiliation(s)
- Shruti Chaturvedi
- Department of Internal Medicine, Cleveland Clinic, Taussig Cancer Institute and Glickman Urological and Kidney Institute, Cleveland, Ohio 44195, USA
| | - Jorge A Garcia
- Department of Solid Tumor Oncology, Cleveland Clinic, Taussig Cancer Institute and Glickman Urological and Kidney Institute, Cleveland, Ohio 44195, USA ; Department of Urology, Cleveland Clinic, Taussig Cancer Institute and Glickman Urological and Kidney Institute, Cleveland, Ohio 44195, USA
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Goodman OB, Flaig TW, Molina A, Mulders PFA, Fizazi K, Suttmann H, Li J, Kheoh T, de Bono JS, Scher HI. Exploratory analysis of the visceral disease subgroup in a phase III study of abiraterone acetate in metastatic castration-resistant prostate cancer. Prostate Cancer Prostatic Dis 2014; 17:34-9. [PMID: 24080993 PMCID: PMC3921671 DOI: 10.1038/pcan.2013.41] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 07/26/2013] [Accepted: 08/22/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Visceral disease, non-nodal soft-tissue metastases predominantly involving the lung and liver, is a negative prognostic factor in patients with metastatic castration-resistant prostate cancer (mCRPC). An exploratory analysis of COU-AA-301 assessed whether abiraterone acetate (AA) improved overall survival (OS) in mCRPC patients with visceral disease progressing post docetaxel. METHODS In COU-AA-301, post-docetaxel mCRPC patients were randomized 2:1 to AA 1000 mg (n=797) or placebo (n=398) once daily, each with prednisone 5 mg b.i.d. The primary end point was OS; secondary end points included radiographic progression-free survival (rPFS), PSA response rate and objective response rate (ORR). Treatment effects in visceral disease (n=352) and non-visceral disease (n=843) subsets were examined using final data (775 OS events). RESULTS AA plus prednisone produced similar absolute improvement in median OS in patients with (4.6 months) and without (4.8 months) visceral disease versus prednisone; hazard ratios (HRs) were 0.79 (95% confidence interval (CI): 0.60-1.05; P=0.102) and 0.69 (95% CI: 0.58-0.83; P<0.0001), respectively. Treatment with AA plus prednisone significantly and comparably improved secondary endpoint outcomes versus prednisone in both the subsets: the HRs for rPFS were 0.60 (95% CI: 0.46-0.78; P=0.0002) and 0.68 (95% CI: 0.58-0.80; P<0.0001) in visceral and non-visceral disease subsets, respectively. PSA response rates were 28% versus 7% in the visceral disease subsets and 30% versus 5% in the non-visceral disease subsets (both P<0.0001), and ORRs were 11% versus 0% (P=0.0058) and 19% versus 5% (P=0.0010), respectively. The incidence of grade 3/4 adverse events was similar between the subsets and between the treatment arms in each subset. Adverse events related to CYP17 blockade were increased in the AA arms and were similar in patients with or without visceral disease. CONCLUSIONS AA plus prednisone provides significant clinical benefit, including improvements in OS and secondary end points, in post-docetaxel mCRPC patients with or without baseline visceral disease. The presence of visceral disease does not preclude clinical benefit from abiraterone.
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Affiliation(s)
- O B Goodman
- Department of Medical Oncology, Comprehensive Cancer Centers of Nevada, Las Vegas, NV, USA
| | - T W Flaig
- University of Colorado Cancer Center, Aurora, CO, USA
| | - A Molina
- Janssen Research & Development, Los Angeles, CA, USA
| | - P F A Mulders
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - K Fizazi
- Institut Gustave Roussy, University of Paris Sud, Villejuif, France
| | | | - J Li
- Janssen Research & Development, Raritan, NJ, USA
| | - T Kheoh
- Janssen Research & Development, Los Angeles, CA, USA
| | - J S de Bono
- The Institute of Cancer Research and The Royal Marsden Hospital, Sutton, UK
| | - H I Scher
- Memorial Sloan-Kettering Cancer Center and Weill-Cornell Medical College, New York, NY, USA
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Bennett LL, Ingason A. Enzalutamide (Xtandi) for patients with metastatic, resistant prostate cancer. Ann Pharmacother 2014; 48:530-7. [PMID: 24458946 DOI: 10.1177/1060028013518899] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To review the pharmacology and pharmacokinetics, and to evaluate the clinical efficacy, safety, and place in therapy of enzalutamide for the treatment of castration-resistant prostate cancer (CRPC). DATA SOURCES A literature search through PubMed (1984 to November 2013; English language) was performed using the following keywords: MDV3100, androgen deprivation therapy, enzalutamide, CRPC, and androgen receptor antagonist. Searches were limited to published studies in humans. STUDY SELECTION AND DATA EXTRACTION All articles in English identified from reviews, abstracts, presentations, and clinical trials of enzalutamide in humans were selected and included. DATA SYNTHESIS Enzalutamide is an oral, nonsteroidal second-generation androgen receptor antagonist that is Food and Drug Administration-approved for the treatment of metastatic CRPC in men who were previously treated with docetaxel. Enzalutamide was superior to placebo for increasing median survival from 13.6 months to 18.4 months. Enzalutamide was well tolerated at a dose of 160 mg, with minor adverse events such as fatigue, diarrhea, musculoskeletal pain, and hot flashes. Patients with increased risk of seizure should not take enzalutamide. CONCLUSIONS Enzalutamide is effective to slow progression of metastatic CRPC, to reduce prostate-specific antigen (PSA) levels, to decrease time to progression of PSA, to increase time to first skeletal-related events, and to increase quality of response rate. Enzalutamide was given at 160 mg/d for a median of 8 cycles of administration. Clinical trials are currently being conducted to observe if enzalutamide will be useful for treatment of other cancers and for early administration in prostate cancer.
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Dorff TB, Quek ML, Daneshmand S, Pinski J. Evolving treatment paradigms for locally advanced and metastatic prostate cancer. Expert Rev Anticancer Ther 2014; 6:1639-51. [PMID: 17134367 DOI: 10.1586/14737140.6.11.1639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While men with early stage prostate cancer typically enjoy long-term survival after definitive management, for those who present with locally advanced or metastatic disease, survival is compromised. Multimodality therapy can prolong survival in these patients, with state-of-the-art options including intensity-modulated radiation or brachytherapy in conjunction with androgen ablation, adjuvant androgen ablation and/or chemotherapy with radical retropubic prostatectomy. In addition, novel biological therapies are being explored to target the unique molecular changes in prostate cancer cells and their interactions with the microenvironment. With these advances the outlook will undoubtedly improve, even for patients presenting with advanced disease. Careful application of these emerging therapies to a select group of prostate cancer patients most likely to obtain benefit from them is the challenge for urologists, medical oncologists and radiation oncologists for the future.
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Affiliation(s)
- Tanya B Dorff
- University of Southern California, Norris Comprehensive Cancer Center, Division of Medical Oncology, Los Angeles, CA, USA.
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117
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Yap TA, Pezaro CJ, de Bono JS. Cabazitaxel in metastatic castration-resistant prostate cancer. Expert Rev Anticancer Ther 2014; 12:1129-36. [DOI: 10.1586/era.12.88] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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118
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Shah S, Small E. Emerging biological observations in prostate cancer. Expert Rev Anticancer Ther 2014; 10:89-101. [DOI: 10.1586/era.09.161] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Chadha KC, Miller A, Nair BB, Schwartz SA, Trump DL, Underwood W. New serum biomarkers for prostate cancer diagnosis. CLINICAL CANCER INVESTIGATION JOURNAL 2014; 3:72-79. [PMID: 25593898 DOI: 10.4103/2278-0513.125802] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Prostate-specific antigen (PSA) is currently used as a biomarker for diagnosis and management of prostate cancer (CaP). However, PSA typically lacks the sensitivity and specificity desired of a diagnostic marker. OBJECTIVE The goal of this study was to identify an additional biomarker or a panel of biomarkers that is more sensitive and specific than PSA in differentiating benign versus malignant prostate disease and/or localized CaP versus metastatic CaP. METHODS Concurrent measurements of circulating interleukin-8 (IL-8), Tumor necrosis factor-α (TNF-α) and soluble tumor necrosis factor-α receptors 1 (sTNFR1) were obtained from four groups of men: (1) Controls (2) with elevated prostate-specific antigen with a negative prostate biopsy (elPSA_negBx) (3) with clinically localized CaP and (4) with castration resistant prostate cancer. RESULTS TNF-α Area under the receiver operating characteristic curve (AUC = 0.93) and sTNFR1 (AUC = 0.97) were strong predictors of elPSA_negBx (vs. CaP). The best predictor of elPSA_negBx vs CaP was sTNFR1 and IL-8 combined (AUC = 0.997). The strongest single predictors of localized versus metastatic CaP were TNF-α (AUC = 0.992) and PSA (AUC = 0.963) levels. CONCLUSIONS The specificity and sensitivity of a PSA-based CaP diagnosis can be significantly enhanced by concurrent serum measurements of IL-8, TNF-α and sTNFR1. In view of the concerns about the ability of PSA to distinguish clinically relevant CaP from indolent disease, assessment of these biomarkers in the larger cohort is warranted.
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Affiliation(s)
- Kailash C Chadha
- Department of Molecular and Cellular Biology, Roswell Park Cancer Institute, University at Buffalo, Buffalo, NY, USA
| | - Austin Miller
- Department of Biostatistics and Bioinformatics, Roswell Park Cancer Institute, University at Buffalo, Buffalo, NY, USA
| | - Bindukumar B Nair
- Department of Molecular and Cellular Biology, Roswell Park Cancer Institute, University at Buffalo, Buffalo, NY, USA ; Department of Medicine, Division of Allergy/Immunology and Rheumatology, University at Buffalo, Buffalo, NY, USA
| | - Stanley A Schwartz
- Department of Medicine, Division of Allergy/Immunology and Rheumatology, University at Buffalo, Buffalo, NY, USA
| | - Donald L Trump
- Department of Medicine, Roswell Park Cancer Institute, University at Buffalo, Buffalo, NY, USA
| | - Willie Underwood
- Department of Urologic Oncology, Roswell Park Cancer Institute, University at Buffalo, Buffalo, NY, USA
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Sternberg CN, Petrylak DP, Madan RA, Parker C. Progress in the treatment of advanced prostate cancer. Am Soc Clin Oncol Educ Book 2014:117-131. [PMID: 24857068 DOI: 10.14694/edbook_am.2014.34.117] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The androgen receptor (AR) is the most significant target for patients with metastatic castration-resistant prostate cancer (mCRPC). There is now irrefutable evidence that the AR axis is functional in most patients throughout the history of prostate cancer, is crucial from diagnosis to death, even in patients who have received hormonal manipulation, and represents a relevant therapeutic target in all phases of the disease. The potential mechanisms of tumor escape after castration are multifold, with each mechanism today representing a therapeutic opportunity. Phase III trials have been able to demonstrate improved overall survival (OS), improved quality of life, decreased skeletal-related events, and other important clinical benefits in young and elderly patients. After the initial positive results with docetaxel chemotherapy in improving OS, further research has resulted in five new treatments in the past few years. Immunotherapy with sipuleucel-T, cabazitaxel chemotherapy, the androgen biosynthesis inhibitor abiraterone acetate, the antiandrogen enzalutamide, and the radioisotope radium-223 have all been shown to improve OS in large-scale, well-conducted clinical trials. Proper understanding of mechanisms of resistance and of cross-resistance among these agents, sequencing, and combinations is now a priority.
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MESH Headings
- Androgen Antagonists/adverse effects
- Androgen Antagonists/therapeutic use
- Antineoplastic Agents, Hormonal/adverse effects
- Antineoplastic Agents, Hormonal/therapeutic use
- Drug Resistance, Neoplasm
- Humans
- Immunotherapy/adverse effects
- Immunotherapy/methods
- Male
- Neoplasms, Hormone-Dependent/immunology
- Neoplasms, Hormone-Dependent/metabolism
- Neoplasms, Hormone-Dependent/mortality
- Neoplasms, Hormone-Dependent/pathology
- Neoplasms, Hormone-Dependent/therapy
- Orchiectomy/adverse effects
- Prostatic Neoplasms/immunology
- Prostatic Neoplasms/metabolism
- Prostatic Neoplasms/mortality
- Prostatic Neoplasms/pathology
- Prostatic Neoplasms/therapy
- Prostatic Neoplasms, Castration-Resistant/immunology
- Prostatic Neoplasms, Castration-Resistant/metabolism
- Prostatic Neoplasms, Castration-Resistant/mortality
- Prostatic Neoplasms, Castration-Resistant/pathology
- Prostatic Neoplasms, Castration-Resistant/therapy
- Radiopharmaceuticals/adverse effects
- Radiopharmaceuticals/therapeutic use
- Receptors, Androgen/drug effects
- Receptors, Androgen/metabolism
- Signal Transduction/drug effects
- Treatment Outcome
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Affiliation(s)
- Cora N Sternberg
- From the San Camillo Forlanini Hospital, Rome, Italy; Yale University Cancer Center, New Haven, CT; Center for Cancer Research, National Cancer Institute, Bethesda, MD; The Royal Marsden Hospital, London, United Kingdom
| | - Daniel P Petrylak
- From the San Camillo Forlanini Hospital, Rome, Italy; Yale University Cancer Center, New Haven, CT; Center for Cancer Research, National Cancer Institute, Bethesda, MD; The Royal Marsden Hospital, London, United Kingdom
| | - Ravi A Madan
- From the San Camillo Forlanini Hospital, Rome, Italy; Yale University Cancer Center, New Haven, CT; Center for Cancer Research, National Cancer Institute, Bethesda, MD; The Royal Marsden Hospital, London, United Kingdom
| | - Chris Parker
- From the San Camillo Forlanini Hospital, Rome, Italy; Yale University Cancer Center, New Haven, CT; Center for Cancer Research, National Cancer Institute, Bethesda, MD; The Royal Marsden Hospital, London, United Kingdom
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Williams S, Chiong E, Lojanapiwat B, Umbas R, Akaza H. Management of prostate cancer in Asia: resource-stratified guidelines from the Asian Oncology Summit 2013. Lancet Oncol 2013; 14:e524-34. [PMID: 24176571 DOI: 10.1016/s1470-2045(13)70451-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Many local and systemic options for prostate cancer have emerged in recent years, but existing management guidelines do not account for diversity in health resources between different countries. We present recommendations for the management of prostate cancer, stratified according to the extent of resource availability-based on a four-tier system of basic, limited, enhanced, and maximum resources-to enable applicability to Asian countries with differing levels of health-care resources. This statement of recommendations was formulated by a multidisciplinary panel from Asia-Pacific countries, at a consensus session on prostate cancer that was held as part of the 2013 Asian Oncology Summit in Bangkok, Thailand.
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Affiliation(s)
- Scott Williams
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
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Abstract
Prior to 2010, the treatment options for castrate-resistant prostate cancer (CRPC) were limited. In the past 3 years, four new agents have been approved by the US Food and Drug Administration for use in CRPC. These four agents differ in their mechanisms of action and highlight the progress made in our understanding of CRPC, and more importantly, provide options with proven clinical benefit. This review examines the development, investigational evolution, adverse events, and future direction of: 1) the androgen receptor inhibitor, enzalutamide, 2) androgen biosynthesis inhibitor, abiraterone, 3) novel taxane chemotherapy, cabazitaxel, and 4) autologous immunotherapeutic agent, sipuleucel-T.
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Caffo O, Palermo A, Veccia A, Maines F, Chierichetti F, Galligioni E. Metabolic and Prostate-Specific Antigen Response After Abiraterone Acetate Withdrawal: A New Clinical Scenario for Castration-Resistant Prostate Cancer? Clin Genitourin Cancer 2013; 11:e10-4. [DOI: 10.1016/j.clgc.2013.04.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 04/03/2013] [Accepted: 04/17/2013] [Indexed: 11/27/2022]
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Abstract
As the first in class steroid 17α-hydroxylase/C17,20-lyase (CYP17) inhibitor, abiraterone acetate (of which the active metabolite is abiraterone) has been shown to improve overall survival in patients with castration-resistant prostate cancer (CRPC)--in those who are chemotherapy-naive and those previously treated with docetaxel. Furthermore, the clinical success of abiraterone demonstrated that CRPC, which has previously been regarded as an androgen-independent disease, is still driven, at least in part, by androgens. More importantly, abiraterone is a 'promiscuous' drug that interacts with a number of targets, which dictate its clinical benefits and adverse effects profile. Besides CYP17 inhibition, abiraterone acts as an antagonist to the androgen receptor and inhibits 3β-hydroxysteroid dehydrogenase--two effects that potentially contribute to its antitumour effects. However, the inhibition of the 17α-hydroxylase activity of CYP17, CYP11B1 and a panel of hepatic CYP enzymes leads to adverse effects and toxicities that include secondary mineralocorticoid excess. Abiraterone is also associated with increased incidence of cardiac disorders. Under such circumstances, development of new CYP17 inhibitors as an additional line of defence is urgently needed. To achieve enhanced clinical benefits, new strategies are being explored that include selective inhibition of the C17,20-lyase activity of CYP17 and multi-targeting strategies that affect androgen synthesis and signalling at different points. Some of these strategies-including the drugs orteronel, VT-464 and galeterone--are supported by preclinical data and are being explored in the clinic.
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125
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Deshmukh RR, Schmitt SM, Hwang C, Dou QP. Chemotherapeutic inhibitors in the treatment of prostate cancer. Expert Opin Pharmacother 2013; 15:11-22. [PMID: 24156780 DOI: 10.1517/14656566.2014.852184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Prostate cancer being the second leading cause of death in men in Western countries remains a major challenge in healthcare. Several novel agents targeting signaling pathways in prostate cancer have recently been approved by the US Food and Drug Administration (FDA) but there is still an unmet need for new treatment strategies for castration-resistant prostate cancer (CRPC). AREAS COVERED This review provides a broad overview of prostate cancer therapeutics and highlights key players in the biology of prostate cancer as well as first- and second-line treatments for CRPC. Keywords 'chemotherapeutic agents', 'prostate cancer', 'Phase III clinical trials' and 'US FDA approval' were used for search in PubMed and clinicalTrials.gov databases and the obtained literature was reviewed and summarized. EXPERT OPINION Owing to the advances in screening and diagnostic techniques, the majority of prostate cancer cases are diagnosed at an early stage resulting in an almost 100% 5-year survival rate. Recently FDA-approved novel agents (e.g., abiraterone acetate and enzalutamide) have provided new hope in the fight against prostate cancer. However, CRPC remains an incurable disease. Identification of mechanisms of resistance, new biomarkers, appropriate clinical trial end points and novel treatments holds the key for the future of prostate cancer therapy.
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Affiliation(s)
- Rahul R Deshmukh
- Wayne state University, Karmanos Cancer Institute, School of Medicine, Department of Pathology , 540.1 HWCRC, 4100 John R Road, Detroit, MI 48201 , USA
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Abstract
PURPOSE OF REVIEW Prior to 2010, docetaxel was the only treatment shown to prolong survival in metastatic castrate-resistant prostate cancer (CRPC). In the past 3 years, several therapeutic agents have demonstrated survival improvements for CRPC after the receipt of prior docetaxel, leading to multiple approvals by the US Food and Drug Administration. RECENT FINDINGS The development of these novel agents, each with a distinct mechanism of action, is the fruition of sedulous preclinical research and well designed clinical trials. Cabazitaxel, a next generation taxane, was the first Food and Drug Administration-approved drug for the postdocetaxel setting. The recognition of sustained androgen dependence of CRPC has led to the identification of more potent and selective inhibitors of androgen synthesis and androgen-receptor signaling, such as abiraterone and enzalutamide, respectively. Radium-223, an α-emitting radionuclide still under regulatory review, recently showed a significant survival benefit for CRPC. Finally, sipuleucel-T, a form of immunotherapy, may benefit a subset of patients in the postdocetaxel setting. SUMMARY Post-docetaxel management of CRPC has undergone a dramatic yet welcome paradigm change in the past 3 years. With multiple life-prolonging agents available, it now becomes imperative to coordinate how and when these new therapies should be used and sequenced to achieve optimal patient outcomes.
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127
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Agarwal N, Hussain M. Management of hormone-sensitive metastatic prostate cancer. Hematol Oncol Clin North Am 2013; 27:1221-41, viii. [PMID: 24188260 DOI: 10.1016/j.hoc.2013.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Targeting gonadal androgen synthesis (often in conjunction with blockade of androgen receptor) is the cornerstone of treatment of hormone-sensitive metastatic prostate cancer (HSPC). Despite the failure of androgen deprivation therapy, most tumors maintain some dependence on androgen or androgen receptor signaling for proliferation. This article reviews the current standard of care for metastatic HSPC, mechanisms of treatment resistance, novel drugs targeting the androgen signaling pathway, biomarkers predicting response to treatment and survival, future directions, and ongoing clinical trials in HSPC.
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Affiliation(s)
- Neeraj Agarwal
- Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Suite 2123, Salt Lake City, UT 84112, USA
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Zhu H, Garcia JA. Targeting the adrenal gland in castration-resistant prostate cancer: a case for orteronel, a selective CYP-17 17,20-lyase inhibitor. Curr Oncol Rep 2013; 15:105-12. [PMID: 23371447 DOI: 10.1007/s11912-013-0300-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Androgen and the androgen receptor (AR) pathway remain the key targets for emerging new therapies against castration-resistant prostate cancer (CRPC). Adrenal androgens and intratumoral testosterone production appear to be sufficient to activate AR in the castration-resistant setting. This process re-engages AR and allows it to continue to be the primary target responsible for prostate cancer progression. Adrenal androgen production can be blocked by inhibiting cytochrome P450 17α-hydroxylase/17,20-lyase (CYP17), a key enzyme for androgen synthesis in adrenal glands and peripheral tissues. Therapeutic CYP17 inhibition by ketoconazole or by the recently approved adrenal inhibitor abiraterone acetate is the only available choice to target this pathway in CRPC. A new CYP17 inhibitor, with more selective inhibition of 17,20-lyase over 17α-hydroxylase, orteronel (TAK-700), is currently undergoing phase III clinical trials in pre- and postchemotherapy CRPC. In a completed phase II trial in CRPC patients, orteronel demonstrated its efficacy by lowering the levels of circulating androgens, reducing prostate-specific antigen (PSA) levels, and decreasing the levels of circulating tumor cells. Ongoing studies evaluating orteronel in CRPC will further define its safety and role in the management of this disease.
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Affiliation(s)
- Hui Zhu
- Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA.
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Saad F, Hotte S, Catton C, Drachenberg D, Finelli A, Fleshner N, Gleave M, Kapoor A, Kassouf W, Loblaw A, North S, Usmani N, Chi KN. CUA-CUOG guidelines for the management of castration-resistant prostate cancer (CRPC): 2013 update. Can Urol Assoc J 2013; 7:231-7. [PMID: 24032056 DOI: 10.5489/cuaj.1542] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Fred Saad
- Division of Urologic Oncology Centre Hospitalier de l'Université de Montréal, Montréal, QC
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Gravanis I, Lopez AS, Hemmings RJ, Jiménez JC, Garcia-Carbonero R, Gallego IG, Giménez EV, O'Connor D, Giuliani R, Salmonson T, Pignatti F. The European medicines agency review of abiraterone for the treatment of metastatic castration-resistant prostate cancer in adult men after docetaxel chemotherapy and in chemotherapy-naive disease: summary of the scientific assessment of the committee for medicinal products for human use. Oncologist 2013; 18:1032-42. [PMID: 23966222 DOI: 10.1634/theoncologist.2013-0092] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
On September 5, 2011, abiraterone was approved in the European Union in combination with prednisone or prednisolone for the treatment of metastatic castration-resistant prostate cancer (CRPC) in adult men whose disease has progressed on or after a docetaxel-based chemotherapy regimen. On December 18, 2012, the therapeutic indication was extended to include the use of abiraterone in combination with prednisone or prednisolone for the treatment of metastatic CRPC in adult men who are asymptomatic or mildly symptomatic after failure of androgen deprivation therapy in whom chemotherapy is not yet clinically indicated. Abiraterone is a selective, irreversible inhibitor of cytochrome P450 17α, an enzyme that is key in the production of androgens. Inhibition of androgen biosynthesis deprives prostate cancer cells from important signals for growth, even in cases of resistance to castration. At the time of European Union approval and in a phase III trial in CRPC patients who had failed at least one docetaxel-based chemotherapy regimen, median overall survival for patients treated with abiraterone was 14.8 months versus 10.9 months for those receiving placebo (hazard ratio, 0.65; 95% confidence interval 0.54-0.77; p < .0001). In a subsequent phase III trial in a similar but chemotherapy-naïve patient population, median radiographic progression-free survival was 16.5 months for patients in the abiraterone treatment arm versus 8.3 months for patients in the placebo arm (hazard ratio, 0.53; 95% confidence interval, 0.45-0.62; p < .0001). Abiraterone was most commonly associated with adverse reactions resulting from increased or excessive mineralocorticoid activity. These were generally manageable with basic medical interventions. The most common side effects (affecting more than 10% of patients) were urinary tract infection, hypokalemia, hypertension, and peripheral edema.
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Madan RA, Arlen PM. Recent advances revolutionize treatment of metastatic prostate cancer. Future Oncol 2013; 9:1133-44. [DOI: 10.2217/fon.13.65] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In 2004, the chemotherapy agent docetaxel was approved for the treatment of metastatic prostate cancer. Although it has taken almost a decade, significant new advances have been made in this area, including the clinical development of modern hormonal therapies, such as abiraterone and enzalutamide, and immunotherapies, such as sipuleucel-T, all of which have improved survival in metastatic prostate cancer. These agents have not only provided new therapeutic options for patients with advanced disease, they have also spurred research in both androgen receptor-targeting therapy and immunotherapy. Future trials will focus on the optimal sequence of these and other emerging therapies, with the aim of using these treatments earlier in the disease course (including the adjuvant setting) to enhance clinical benefit and potentially increase the cure rate for prostate cancer.
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Affiliation(s)
- Ravi A Madan
- Medical Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institute of Health, Bethesda, MD, USA
| | - Philip M Arlen
- Medical Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institute of Health, Bethesda, MD, USA.
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132
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Abiraterone acetate: targeting persistent androgen dependence in castration-resistant prostate cancer. Adv Ther 2013; 30:727-47. [PMID: 23979793 PMCID: PMC3778906 DOI: 10.1007/s12325-013-0050-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Indexed: 12/15/2022]
Abstract
Abiraterone acetate is the first second-line hormonal agent proven to improve survival in metastatic castration-resistant prostate cancer. It selectively inhibits cytochrome P450 17 (CYP17) α-hydroxylase and cytochrome17,20 (C17,20)-lyase, which are enzymes critical for androgen synthesis. Abiraterone acetate was initially approved in the United States in 2011 after demonstrating a 4-month survival benefit in docetaxel-refractory metastatic prostate cancer. The FDA recently expanded its indication for use in the pre-chemotherapy setting after it elicited significant delays in disease progression and a strong trend for increased overall survival in phase III studies. Ongoing investigations of abiraterone are evaluating its efficacy in earlier disease states, exploring its synergy in combination with other therapeutic agents, and assessing the necessity for administration of concurrent steroids and gonadal suppression. The identification and development of predictive biomarkers will optimize the incorporation of abiraterone into the management of advanced prostate cancer.
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133
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Aggarwal R, Halabi S, Kelly WK, George D, Mahoney JF, Millard F, Stadler WM, Morris MJ, Kantoff P, Monk JP, Carducci M, Small EJ. The effect of prior androgen synthesis inhibition on outcomes of subsequent therapy with docetaxel in patients with metastatic castrate-resistant prostate cancer: results from a retrospective analysis of a randomized phase 3 clinical trial (CALGB 90401) (Alliance). Cancer 2013; 119:3636-43. [PMID: 23913744 DOI: 10.1002/cncr.28285] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/27/2013] [Accepted: 06/03/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Preliminary data suggest a potential decreased benefit of docetaxel in patients with metastatic, castration-resistant prostate cancer (mCRPC) who previously received abiraterone acetate, a novel androgen synthesis inhibitor (ASI). Cancer and Leukemia Group B (CALGB) trial 90401 (Alliance), a phase 3 trial in patients with mCRPC who received docetaxel-based chemotherapy, offered the opportunity to evaluate effect of prior ketoconazole, an earlier generation ASI, on clinical outcomes after docetaxel. METHODS In CALGB trial 90401, 1050 men with chemotherapy-naive mCRPC were randomized to receive treatment with docetaxel and prednisone that included either bevacizumab or placebo. In total, 1005 men (96%) had data available regarding prior ketoconazole therapy. The observed effects of prior ketoconazole on overall survival (OS), progression-free survival (PFS), prostate-specific antigen (PSA) decline, and the objective response rate (ORR) were assessed using proportional hazards and Poisson regression methods adjusted for validated prognostic factors and treatment arm. RESULTS Baseline characteristics between patients who did (N=277) and did not (N=728) receive prior ketoconazole therapy were similar. There were no statistically significant differences between patients who did and those who did not receive prior ketoconazole therapy with respect to OS (median OS, 21.1 months vs 22.3 months, respectively; stratified log-rank P=.635), PFS (median PFS, 8.1 months vs 8.6 months, respectively; stratified log-rank P=.342), the proportion achieving a decline ≥ 50% in PSA (61% vs 66%, respectively; relative risk, 1.09; adjusted P=.129), or ORR (39% vs 43%, respectively; relative risk, 1.11; adjusted P=.366). CONCLUSIONS As measured by OS, PFS, PSA, and the ORR, there was no evidence that prior treatment with ketoconazole had an impact on the clinical outcomes of patients with mCRPC who received subsequent docetaxel-based therapy. The current results highlight the need for prospective studies to assess for potential cross-resistance with novel ASIs and to define the optimal sequence of therapy in mCRPC.
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Affiliation(s)
- Rahul Aggarwal
- Division of Hematology/Oncology, University of California San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, California
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134
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Goyal J, Antonarakis ES. Clinical Evaluation of Abiraterone in the Treatment of Metastatic Prostate Cancer. ACTA ACUST UNITED AC 2013; 2013:1-14. [PMID: 24482578 PMCID: PMC3904375 DOI: 10.4137/cmu.s8337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Treatment of castration-resistant prostate cancer remains an area of unmet medical need. Evidence suggests that this entity continues to be driven by androgens and androgen receptor (AR) signaling. Abiraterone acetate, a pregnenolone derivative, is an oral selective and irreversible inhibitor of the key steroidogenic enzyme CYP17. It possesses dual 17-α hydroxylase and C17,20-lyase blocking activity, the result of which is decreased gonadal and extra-gonadal androgen synthesis. Abiraterone was first approved by the US Food and Drug Administration (FDA) in 2011 following the demonstration of superior survival compared with placebo in the post-docetaxel population. Since that time, more evidence has been generated from preclinical studies and clinical trials which have considerably enhanced our understanding of this complex disease. In this paper, we review the development of abiraterone acetate, its pharmacological characteristics, and its effects on the androgen-AR signaling axis, along with the combined experience from clinical trials. We also discuss some of the ongoing trials using this agent, as well as potential mechanisms of abiraterone resistance, novel bio-marker development, and future directions using AR-directed therapies.
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Affiliation(s)
- Jatinder Goyal
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Emmanuel S Antonarakis
- Assistant Professor of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore MD
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135
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Abstract
Since 1941, the understanding of prostate cancer pathogenesis and therapy has undergone a significant transformation. Rigorous translational research has identified multiple mechanisms underlying castration resistance, the fatal clinical state of the disease. Therapeutic approaches targeting these mechanisms in metastatic castration-resistant prostate cancer have now been clinically validated in the clinic including high-potency androgen signaling inhibition, novel cytotoxic chemotherapy, and bone-targeted therapies. Despite these advances, cure remains an elusive goal. The natural history of metastatic prostate cancer has evolved particularly in the last 2 decades in step with improved management of age-associated comorbidities, improved imaging, and the expansion of novel therapies, thus providing new opportunities and challenges. It is also important to note that the advent of prostate-specific antigen testing caused a stage shift in the disease spectrum, thus leading to earlier interventions and potentially positively impacting survival. The optimal sequencing and combinations of available therapies, predictive biomarkers, and better understanding of mechanisms of resistance remain high priority. Further refinement of the clinical niche for novel therapies in hormone-sensitive and castration-resistant disease through rationally designed clinical trials incorporating molecular, clinical, and imaging biomarkers and quality-of-life correlatives is of paramount importance.
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136
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Hendrix LN, Hamilton DA, Kyprianou N. Emerging therapeutics targeting castration-resistant prostate cancer: the AR-mageddon of tumor epithelial-mesenchymal transition. Expert Rev Endocrinol Metab 2013; 8:403-416. [PMID: 30736155 DOI: 10.1586/17446651.2013.811914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Advanced prostate cancer will claim nearly 30,000 lives among men in the USA in the year 2013. Most of these will be castration-resistant prostate cancers that are not responsive to traditional therapeutic modalities, and there is no available regimen that fully eradicates metastatic disease. This poses a significant clinical challenge for practitioners and has stimulated the development of novel agents that target these castration-resistant tumor cells. Development of metastatic prostate cancer is orchestrated by multiple signaling pathways that regulate cell survival, apoptosis, anoikis, epithelial-mesenchymal transition (EMT), invasion, the androgen signaling axis and angiogenesis. Disruption of the mechanisms underlying these processes is critical for development of agents that can target otherwise resistant tumor cells. Insights into the mechanisms by which rounds of EMT/mesenchymal-epithelial transition conversions facilitate the progression of localized prostate carcinomas to advanced metastatic and castration-resistant disease emerge as attractive targets for drug development. In this review, the authors discuss the current understanding of therapeutic resistance in castration-resistant prostate cancer with focus on the androgen receptor signaling axis and EMT. Novel therapeutic approaches targeting critical players of both pathways as well as the results from ongoing clinical trials will be discussed in this review.
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Affiliation(s)
- Lauren N Hendrix
- a Division of Urology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - David A Hamilton
- a Division of Urology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Natasha Kyprianou
- b Department of Molecular and Cellular Biochemistry, University of Kentucky College of Medicine, Lexington, KY, USA
- c Department of Pathology, University of Kentucky College of Medicine, Lexington, KY, USA
- d Division of Urology, University of Kentucky College of Medicine, Lexington, KY, USA.
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137
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Ryan CJ, Molina A, Li J, Kheoh T, Small EJ, Haqq CM, Grant RP, de Bono JS, Scher HI. Serum androgens as prognostic biomarkers in castration-resistant prostate cancer: results from an analysis of a randomized phase III trial. J Clin Oncol 2013; 31:2791-8. [PMID: 23816964 DOI: 10.1200/jco.2012.45.4595] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE In the phase III study COU-AA-301, abiraterone acetate (AA) plus prednisone (P) prolonged overall survival (OS) in patients with metastatic castration-resistant prostate cancer (mCRPC) after docetaxel administration. In this article, we investigate the relationship between baseline serum androgen (SA) levels and OS. PATIENTS AND METHODS COU-AA-301 is a randomized, double-blind study of AA (1,000 mg every day) plus P (5 mg by mouth twice daily; n = 797) versus P alone (n = 398). Randomization was stratified by Eastern Cooperative Oncology Group performance status (0 to 1 v 2), pain (Brief Pain Inventory-Short Form over past 24 hours: 4 to 10, present; v 0 to 3, absent), prior chemotherapy (1 v 2), and progression (prostate-specific antigen v radiographic). Association of baseline SA (testosterone, androstenedione, dehydroepiandrosterone sulfate), was measured by ultrasensitive liquid-liquid extraction or protein precipitation and two-dimensional liquid chromatography coupled to mass spectrometry, with OS determined by bivariate and multivariable Cox models. OS was examined with SA as greater than median and less than or equal to the median. RESULTS Median survival increased with each quartile increase in testosterone level regardless of treatment arm. SA levels at baseline strongly associated with survival (P < .0001) in bivariate and multivariable analyses. Longer survival was observed for patients with SA above median compared with below median in both the AA and P arms (eg, testosterone, AA; hazard ratio, 0.64; 95% CI, 0.53 to 0.77; P < .0001). Treatment with AA led to longer survival versus P alone in the above- or below-median group for all androgens. CONCLUSION SA, measured with a novel ultrasensitive assay in COU-AA-301, is prognostic for OS and may be useful for risk stratification in mCRPC clinical trials.
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Affiliation(s)
- Charles J Ryan
- University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA 94115, USA.
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138
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Ferraldeschi R, Sharifi N, Auchus RJ, Attard G. Molecular pathways: Inhibiting steroid biosynthesis in prostate cancer. Clin Cancer Res 2013; 19:3353-9. [PMID: 23470964 PMCID: PMC3736095 DOI: 10.1158/1078-0432.ccr-12-0931] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A significant proportion of castration-resistant prostate cancers (CRPC) remains driven by ligand activation of the androgen receptor. Although the testes are the primary source of testosterone, testosterone can also be produced from peripheral conversion of adrenal sex hormone precursors DHEA and androstenedione in the prostate and other tissues. CYP17A1 catalyzes two essential reactions in the production of DHEA and androstenedione: the hydroxylation (hydroxylase activity) and the subsequent cleavage of the C17-20 side chain (lyase activity). Potent and selective inhibition of CYP17A1 by abiraterone depletes residual nongonadal androgens and is an effective treatment for CRPC. Elucidation of the mechanisms that underlie resistance to abiraterone will inform the development of novel therapeutic strategies post-abiraterone. Preclinical evidence that androgen biosynthesis in prostate cancer cells does not necessarily follow a single dominant pathway, and residual androgens or alternative ligands (including administered glucocorticoids) can reactivate androgen receptor signaling, supports cotargeting of more than one enzyme involved in steroidogenesis and combining a CYP17A1 inhibitor with an antiandrogen. Furthermore, given the drawbacks of 17α-hydroxylase inhibition, there is considerable interest in developing new CYP17A1 inhibitors that more specifically inhibit lyase activity and are therefore less likely to require glucocorticoid coadministration.
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Affiliation(s)
- Roberta Ferraldeschi
- Prostate Cancer Targeted Therapy Group and Drug Development Unit, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Downs Road, Sutton, Surrey, UK
| | - Nima Sharifi
- Division of Hematology/Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Richard J. Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gerhardt Attard
- Prostate Cancer Targeted Therapy Group and Drug Development Unit, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Downs Road, Sutton, Surrey, UK
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139
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Abstract
Over the past few years, we have developed an increased understanding of the molecular mechanisms that underlie prostate cancer progression and castration resistance and expanded our repertoire of therapeutic options for castration-resistant prostate cancer (CRPC). Four new agents (cabazitaxel, abiraterone acetate, enzalutamide, and radium-233) have been shown to prolong overall survival in patients with CRPC in the postchemotherapy setting. Targeting the androgen receptor pathway continues to have an important role in the treatment of CRPC, with abiraterone acetate and enzalutamide being the most exciting developments. Cabazitaxel is now considered the standard-of-care second-line chemotherapy for men with metastatic CRPC (mCRPC). Bone-targeted therapy is an active area of research, with denosumab being the first bone-targeted agent able to significantly delay the appearance of bone metastases in patients with CRPC and radium-223 being the first radiopharmaceutical agent to improve survival in patients with mCRPC.
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140
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The type of patients who would benefit from anti-androgen withdrawal therapy: could it be performed safely for aggressive prostate cancer? Med Oncol 2013; 30:647. [PMID: 23797774 DOI: 10.1007/s12032-013-0647-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 06/14/2013] [Indexed: 10/26/2022]
Abstract
This study was designed to detect the factors that were significantly associated with the results of anti-androgen withdrawal (AAWD) therapy, and to examine whether patients with aggressive prostate cancer demonstrating a short prostate-specific antigen (PSA)-doubling time (DT) could benefit from it without even greater exacerbation of the disease. We conducted a retrospective chart review study of 121 patients who received AAWD therapy due to failed combined androgen blockade (CAB) therapy. A reduction in the serum PSA level after AAWD was observed in 35 patients (28.9 %), and a greater than 50 % decrease from the baseline serum PSA level was observed in 16 patients (13.2 %). Shortening of PSA-DT after AAWD was observed in 48 patients (39.7 %). Univariate and multivariate analyses demonstrated that only a long duration of prior anti-androgen treatment was selected as a significant predictor for a good response to AAWD therapy. With respect to exacerbation after AAWD, we found that patients with a short baseline PSA-DT conversely had a low risk of subsequent shortening of PSA-DT. Using these two factors, we could stratify the patients into four groups, and patients with prior duration of anti-androgen >18 months and PSA-DT ≤3 months demonstrated the best results with a good response rate (67.9 %) and a low risk for a worsening of the disease (14.3 %). We conclude that AAWD would be effective especially for patients whose cancer progressed rapidly (short PSA-DT) after a long stable period under CAB and should be recommended before embarking on the next therapeutic maneuver.
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141
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Cookson MS, Roth BJ, Dahm P, Engstrom C, Freedland SJ, Hussain M, Lin DW, Lowrance WT, Murad MH, Oh WK, Penson DF, Kibel AS. Castration-resistant prostate cancer: AUA Guideline. J Urol 2013; 190:429-38. [PMID: 23665272 DOI: 10.1016/j.juro.2013.05.005] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2013] [Indexed: 11/16/2022]
Abstract
PURPOSE This Guideline is intended to provide a rational basis for the management of patients with castration-resistant prostate cancer based on currently available published data. MATERIALS AND METHODS A systematic review and meta-analysis of the published literature was conducted using controlled vocabulary supplemented with keywords relating to the relevant concepts of prostate cancer and castration resistance. The search strategy was developed and executed by reference librarians and methodologists to create an evidence report limited to English-language, published peer-reviewed literature. This review yielded 303 articles published from 1996 through 2013 that were used to form a majority of the guideline statements. Clinical Principles and Expert Opinions were used for guideline statements lacking sufficient evidence-based data. RESULTS Guideline statements were created to inform clinicians on the appropriate use of observation, androgen-deprivation and antiandrogen therapy, androgen synthesis inhibitors, immunotherapy, radionuclide therapy, systemic chemotherapy, palliative care and bone health. These were based on six index patients developed to represent the most common scenarios encountered in clinical practice. CONCLUSIONS As a direct result of the significant increase in FDA-approved therapeutic agents for use in patients with metastatic CRPC, clinicians are challenged with a multitude of treatment options and potential sequencing of these agents that, consequently, make clinical decision-making more complex. Given the rapidly evolving nature of this field, this guideline should be used in conjunction with recent systematic literature reviews and an understanding of the individual patient's treatment goals. In all cases, patients' preferences and personal goals should be considered when choosing management strategies.
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Affiliation(s)
- Michael S Cookson
- American Urological Association Education and Research, Inc., Linthicum, Maryland, USA
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142
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Tesei A, Leonetti C, Di Donato M, Gabucci E, Porru M, Varchi G, Guerrini A, Amadori D, Arienti C, Pignatta S, Paganelli G, Caraglia M, Castoria G, Zoli W. Effect of small molecules modulating androgen receptor (SARMs) in human prostate cancer models. PLoS One 2013; 8:e62657. [PMID: 23667504 PMCID: PMC3648536 DOI: 10.1371/journal.pone.0062657] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 03/25/2013] [Indexed: 01/03/2023] Open
Abstract
The management of hormone-refractory prostate cancer represents a major challenge in the therapy of this tumor, and identification of novel androgen receptor antagonists is needed to render treatment more effective. We analyzed the activity of two novel androgen receptor antagonists, (S)-11 and (R)-9, in in vitro and in vivo experimental models of hormone-sensitive or castration-resistant prostate cancer (CRPC). In vitro experiments were performed on LNCaP, LNCaP-AR, LNCaP-Rbic and VCaP human prostate cancer cells. Cytotoxic activity was assessed by SRB and BrdU uptake, AR transactivation by luciferase reporter assay and PSA levels by Real Time RT-PCR and ELISA assays. Cell cycle progression-related markers were evaluated by western blot. In vivo experiments were performed on SCID mice xenografted with cells with different sensitivity to hormonal treatment. In hormone-sensitive LNCaP and LNCaP-AR cells, the latter expressing high androgen receptor levels, (R)-9 and (S)-11 exhibited a higher cytotoxic effect compared to that of the reference compound ((R)-bicalutamide), also in the presence of the synthetic androgen R1881. Furthermore, the cytotoxic effect produced by (R)-9 was higher than that of (S)-11 in the two hormone-resistant LNCaP-AR and VCaP cells. A significant reduction in PSA levels was observed after exposure to both molecules. Moreover, (S)-11 and (R)-9 inhibited DNA synthesis by blocking the androgen-induced increase in cyclin D1 protein levels. In vivo studies on the toxicological profile of (R)-9 did not reveal the presence of adverse events. Furthermore, (R)-9 inhibited tumor growth in various in vivo models, especially LNCaP-Rbic xenografts, representative of recurrent disease. Our in vitro results highlight the antitumor activity of the two novel molecules (R)-9 and (S)-11, making them a potentially attractive option for the treatment of CRPC.
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Affiliation(s)
- Anna Tesei
- Biosciences Laboratory, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
- * E-mail: (AT); (CL)
| | - Carlo Leonetti
- Department of Experimental Oncology, Laboratory of Experimental Preclinical Chemotherapy, National Cancer Institute “Regina Elena”, Rome, Italy
- * E-mail: (AT); (CL)
| | - Marzia Di Donato
- Department of General Pathology, II University of Naples, Naples, Italy
| | - Elisa Gabucci
- Biosciences Laboratory, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
| | - Manuela Porru
- Department of Experimental Oncology, Laboratory of Experimental Preclinical Chemotherapy, National Cancer Institute “Regina Elena”, Rome, Italy
| | - Greta Varchi
- Italian National Research Council, Institute for Organic Chemistry and Photoreactivity, Bologna, Italy
| | - Andrea Guerrini
- Italian National Research Council, Institute for Organic Chemistry and Photoreactivity, Bologna, Italy
| | - Dino Amadori
- Department of Medical Oncology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
| | - Chiara Arienti
- Biosciences Laboratory, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
| | - Sara Pignatta
- Biosciences Laboratory, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
| | - Giulia Paganelli
- Biosciences Laboratory, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
| | - Michele Caraglia
- Department of Biochemistry and Biophysics, Second University of Naples, Naples, Italy
| | | | - Wainer Zoli
- Biosciences Laboratory, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
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143
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Tombal B. Non-metastatic CRPC and asymptomatic metastatic CRPC: which treatment for which patient? Ann Oncol 2013; 23 Suppl 10:x251-8. [PMID: 22987972 DOI: 10.1093/annonc/mds325] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The introduction of early PSa-based diagnosis has profoundly impacted the epidemiology of castration-resistant prostate cancer (CRPC). Many patients enter the disease at an early stage when the only sign of resistance to androgen deprivation therapy (ADT) is a progressive elevation of prostate-specific antigen (PSA). This created a very heterogeneous population of non-metastatic (M0) CRPC. PSa kinetics is the most powerful indicator of aggressiveness in that population and can be used to trigger imaging investigation and enrollment in clinical trials. Several registered and near to come treatments have not been tested in that population but in men with more advanced metastatic and often symptomatic disease. Several agents have been investigated to delay the onset of the first bone metastasis but only one, denosumab, has reached its end-point. Because CRPC remains largely driven by the androgen receptor (AR), physicians have relied on second-line hormonal manipulations to delay the progression of the disease, including first generation antiandrogens, adrenal synthesis inhibitors, steroids and estrogens. The data however are mostly limited to phase II trials.
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Affiliation(s)
- B Tombal
- Cliniques universitaires Saint Luc, Université catholique de Louvain, Brussels, Belgium.
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144
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Abstract
With a large, aging population in the USA and continued prolongation of life expectancy, treatment of cancer in the elderly will continue to be of importance. The most common cancer in men is prostate cancer, which is most often diagnosed in those over the age of 65 years. Initial therapies for prostate cancer are local treatments in those with localized disease and for whom definitive therapy is appropriate. Optimal treatment of an older patient with recurrent prostate cancer now involves more of a decision process than treatment has in the past, with the recent approval of several new medical agents for advanced prostate cancer. Through this article we will focus on treatment options for recurrent prostate cancer, keeping in mind the unique characteristics of the elderly population. A majority of the discussion will focus on many of the newly approved agents used to treat castration-resistant prostate cancer, and exciting agents currently under investigation. Improved androgen blockade has improved overall survival in patients with metastatic disease but carries many of the same adverse effects as previous agents. Newer approaches with immunotherapy, radiopharmaceuticals, or second-generation androgen receptor blockers introduce a different adverse-effect profile for older patients. As data matures, these too may improve survival for patients with metastatic disease. Throughout all stages of disease, one must keep in mind the unique needs of an older patient population.
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145
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Abstract
The landscape of treatment for advanced prostate cancer is continually evolving as new therapies are developed and guidelines are constantly updated. However, the management of older men with advanced disease is not optimal. Many men are denied chemotherapy based on their chronological age, not their health status. Androgen-deprivation therapy (ADT) remains the mainstay of first-line treatment of advanced disease. Once the disease becomes resistant to castration, docetaxel-based chemotherapy is the regulatory-approved standard of care, irrespective of age. The place of weekly docetaxel in patients with poor performance status and signs of frailty has to be further evaluated in clinical studies. New treatments are now available, or on the horizon, for disease that progresses during or after docetaxel therapy. Cabazitaxel and abiraterone have been shown to prolong survival, irrespective of age, and are already in clinical use having received regulatory approval. The optimal sequence for these two agents is still unknown, although there is some indication that in patients predicted to be poor responders to abiraterone (high Gleason score, progression during docetaxel therapy, rapid progression to castrate-resistant prostate cancer with ADT) cabazitaxel should be the preferred choice. Further advances are being investigated, with promising data reported from phase III trials.
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Affiliation(s)
- Matti S Aapro
- Multidisciplinary Oncology Institute, Genolier, Switzerland.
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146
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New players for advanced prostate cancer and the rationalisation of insulin-sensitising medication. Int J Cell Biol 2013; 2013:834684. [PMID: 23573093 PMCID: PMC3614121 DOI: 10.1155/2013/834684] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 01/29/2013] [Indexed: 12/13/2022] Open
Abstract
Obesity and type 2 diabetes are recognised risk factors for the development of some cancers and, increasingly, predict more aggressive disease, treatment failure, and cancer-specific mortality. Many factors may contribute to this clinical observation. Hyperinsulinaemia, dyslipidaemia, hypoxia, ER stress, and inflammation associated with expanded adipose tissue are thought to be among the main culprits driving malignant growth and cancer advancement. This observation has led to the proposal of the potential utility of "old players" for the treatment of type 2 diabetes and metabolic syndrome as new cancer adjuvant therapeutics. Androgen-regulated pathways drive proliferation, differentiation, and survival of benign and malignant prostate tissue. Androgen deprivation therapy (ADT) exploits this dependence to systemically treat advanced prostate cancer resulting in anticancer response and improvement of cancer symptoms. However, the initial therapeutic response from ADT eventually progresses to castrate resistant prostate cancer (CRPC) which is currently incurable. ADT rapidly induces hyperinsulinaemia which is associated with more rapid treatment failure. We discuss current observations of cancer in the context of obesity, diabetes, and insulin-lowering medication. We provide an update on current treatments for advanced prostate cancer and discuss whether metabolic dysfunction, developed during ADT, provides a unique therapeutic window for rapid translation of insulin-sensitising medication as combination therapy with antiandrogen targeting agents for the management of advanced prostate cancer.
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147
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Abstract
To improve future drug development and patient management for patients with castration-resistant prostate cancer (CRPC), surrogate biomarkers that are linked to relevant outcomes are urgently needed. A biomarker must be measurable, reproducible, linked to relevant clinical outcomes, and demonstrate clinical utility. This area is rapidly evolving, with recent trials in patients with CRPC incorporating the detection of circulating tumour cells (CTCs), imaging, and patient-reported outcome biomarkers. We discuss the framework for the development of biomarkers for CRPC, including different categories and contexts of use. We also highlight the requirements of analytical validation, the sequence of trials needed for clinical validation and regulatory approval, and the future outlook for imaging and CTC biomarkers.
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148
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Shibata Y, Suzuki K, Arai S, Miyoshi Y, Umemoto S, Masumori N, Kamiya N, Ichikawa T, Kitagawa Y, Mizokami A, Sugimura Y, Nonomura N, Sakai H, Honma S, Kubota Y. Impact of pre-treatment prostate tissue androgen content on the prediction of castration-resistant prostate cancer development in patients treated with primary androgen deprivation therapy. Andrology 2013; 1:505-11. [DOI: 10.1111/j.2047-2927.2013.00068.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 01/04/2013] [Accepted: 01/07/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Y. Shibata
- Department of Urology; Gunma University Graduate School of Medicine; Maebashi; Japan
| | - K. Suzuki
- Department of Urology; Gunma University Graduate School of Medicine; Maebashi; Japan
| | - S. Arai
- Department of Urology; Gunma University Graduate School of Medicine; Maebashi; Japan
| | - Y. Miyoshi
- Department of Urology; Yokohama City University Graduate School of Medicine; Yokohama; Japan
| | - S. Umemoto
- Department of Urology; Yokohama City University Graduate School of Medicine; Yokohama; Japan
| | - N. Masumori
- Department of Urologic Surgery and Andrology; Sapporo Medical University School of Medicine; Sapporo; Japan
| | - N. Kamiya
- Department of Urology; Chiba University Graduate School of Medicine; Chiba; Japan
| | - T. Ichikawa
- Department of Urology; Chiba University Graduate School of Medicine; Chiba; Japan
| | - Y. Kitagawa
- Department of Integrative Cancer Therapy and Urology; Kanazawa University Graduate School of Medical Science; Kanazawa; Japan
| | - A. Mizokami
- Department of Integrative Cancer Therapy and Urology; Kanazawa University Graduate School of Medical Science; Kanazawa; Japan
| | - Y. Sugimura
- Department of Nephro-Urologic Surgery and Andrology; Mie University Graduate School of Medicine; Tsu; Japan
| | - N. Nonomura
- Department of Urology; Osaka University Graduate School of Medicine; Osaka; Japan
| | - H. Sakai
- Department of nephro-urology; Nagasaki University Graduate School of Biomedical Sciences; Nagasaki; Japan
| | - S. Honma
- ASKA Pharma Medical Co., Ltd; Kawasaki; Japan
| | - Y. Kubota
- Department of Urology; Yokohama City University Graduate School of Medicine; Yokohama; Japan
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Monteiro C, Sousa MV, Ribeiro R, Maurício J, Fraga A, Medeiros R. Genetic variants in AR and SHBG and resistance to hormonal castration in prostate cancer. Med Oncol 2013; 30:490. [DOI: 10.1007/s12032-013-0490-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 01/30/2013] [Indexed: 12/18/2022]
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150
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Clemons J, Glodé LM, Gao D, Flaig TW. Low-dose diethylstilbestrol for the treatment of advanced prostate cancer. Urol Oncol 2013; 31:198-204. [PMID: 21795073 PMCID: PMC3229833 DOI: 10.1016/j.urolonc.2010.12.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 12/06/2010] [Accepted: 12/07/2010] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the efficacy and safety of low-dose (1 mg) daily diethylstilbestrol (DES) for the treatment of castrate-resistant prostate cancer (CRPC). MATERIALS AND METHODS A retrospective chart review was performed on patients treated with low-dose DES who had CRPC despite anti-androgen withdrawal. The study population consists of 63 patients treated in the pre- and post-chemotherapy settings based on a database review; 58 had sufficient data for efficacy, all were analyzed for safety. RESULTS A PSA decrease of ≥50% was observed in 19 of 49 pre-chemotherapy patients (39%) with a median time to progression (TTP) of 30 weeks (95% CI, 21.9, 68.7). A PSA decrease of <50% was seen in another 16 patients (33%) with a median TTP of 16.4 weeks (95% CI, 13.0, 37.6). Fourteen patients (29%) had progressive disease by PSA testing; their median TTP was 6.9 weeks (95% CI, 5.6, 12.9). Thromboembolic events included 2 patients with DVTs and 1 patient who developed primary fibrinolysis syndrome. Additional adverse events included gynecomastia in 37 of 63 patients (59%). Secondary observations included PSA responses in 3 of 9 patients treated with DES after chemotherapy progression and a high rate of PSA responses in patients re-treated with DES after a drug holiday. CONCLUSIONS Low-dose DES is safe and effective in a modern cohort of men with CRPC despite anti-androgen treatment. Its potential role in the post-chemotherapy setting and the suggestion of efficacy on re-challenge merits additional consideration.
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Affiliation(s)
- Julia Clemons
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, School of Medicine, Aurora, CO
| | - L. Michael Glodé
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, School of Medicine, Aurora, CO
| | - Dexiang Gao
- Research Institute, The Children’s Hospital, Aurora, CO
| | - Thomas W. Flaig
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, School of Medicine, Aurora, CO
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