Nomogram for overall survival of patients with progressive metastatic prostate cancer after castration

Sipuleucel-T (APC8015) for prostate cancer

Sipuleucel-T (Provenge; APC8015; Dendreon Corp, WA, USA) is a novel immunotherapeutic cellular product, which includes autologous dendritic cells pulsed ex vivo with a recombinant fusion protein (PA2024) consisting of granulocyte macrophage colony-stimulating factor and prostatic acid phosphatase. Two Phase II trials in men with androgen-dependent biochemically relapsed prostate cancer have demonstrated a decrease in prostate-specific antigen and prolongation in prostate-specific antigen doubling time. In men with hormone-refractory prostate cancer, clinical trials have demonstrated both biological activity and clinical response to sipuleucel-T. Data from two Phase III trials in men with asymptomatic, metastatic hormone-refractory prostate cancer demonstrated an improved median overall survival in men who received sipuleucel-T compared with placebo. Clinical trials are ongoing or are being developed to evaluate sipuleucel-T in various prostate cancer disease states and in combination with other treatment modalities.

Use of nomograms as predictive tools in bladder cancer

Bladder cancer is a common genitourinary malignancy that demonstrates a great variation in risk of tumor recurrence and progression following treatment. The dramatic differences in clinical behavior dictate vastly differing treatments, which may range from simple surveillance to combination radical surgery with systemic chemotherapy. For non-muscle invasive bladder cancer prediction of the risk of recurrence and progression is necessary to assess the need for intravesical therapy and possible early cystectomy. In contrast, prediction of advanced disease response to primary treatment such as cystectomy and the response to systemic chemotherapy plays an important role in treatment assignment for patients with muscle invasive disease. To estimate these risk traditional risk grouping schemes such as the present TNM staging system has been used to guide patient treatment. More recently, improved prognostic tools such as nomograms have been developed to provide a more accurate assessment of outcomes. Clinicians are enthusiastically working to utilize these statistical methods in bladder cancer. We summarize the current status of outcome predictive models for bladder cancer; and focus particularly on the ability of nomograms to predict disease recurrence, progression, and patient survival.

Preliminary evidence that the allogeneic response might trigger antitumour immunity in patients with advanced prostate cancer

OBJECTIVE

To explore the possibility that allogeneic responses might, by chance, encompass cross-reactive T cell clones specific for neo-antigenic tumour determinants, and thereby activate antitumour immunity; such cross-reactions are well documented for antiviral immunity, and genetic instability in developing cancers generates many neo-antigenic determinants as potential targets for immune responses, but the biology inevitably favours tumour progression.

PATIENTS AND METHODS

Fourteen patients with hormone-refractory prostate cancer received full-thickness skin allografts from different, unrelated donors (fellow patients) until each had received six grafts. Serum prostate-specific antigen (PSA) level was used as a surrogate for tumour mass.

RESULTS

One patient had a remarkable decline in PSA level, with levels at 1 year lower than before grafting. A second patient had stable PSA levels for almost 2 years. A third patient had stable PSA levels for 10-12 months before they resumed an exponential rise. Of four patients with PSA levels of > 10 ng/mL, three required surgery or radiotherapy for obstructive symptoms during or shortly after grafting.

CONCLUSION

Transplant rejection involves mechanistically atypical T cell recognition of allogeneic major histocompatibility complex antigens, with massive polyclonal T cell activation. This unique aspect of T cell biology might represent a novel approach for initiating cross-reactive antitumour responses.

Vaccination of advanced prostate cancer patients with PSCA and PSA peptide-loaded dendritic cells induces DTH responses that correlate with superior overall survival

Prostate stem cell antigen (PSCA) and prostate-specific antigen (PSA) are overexpressed in most prostate cancers. PSCA- and PSA-derived, HLA-A2 binding peptides are specific targets for T-cell responses in vitro. A phase I/II trial was performed to demonstrate feasibility, safety and induction of antigen-specific immunity by vaccination with dendritic cells (DC) presenting PSCA and PSA peptides in patients with hormone- and chemotherapy-refractory prostate cancer. Patients received 4 vaccinations with a median of 2.7 x 10(7) peptide-loaded mature DC s.c. in biweekly intervals. Clinical responses were assessed 2 weeks after the 4th vaccination. Immune monitoring was performed by DTH and HLA multimer analysis. Twelve patients completed vaccination without relevant toxicities. Six patients had stable disease after 4 vaccinations. One patient had a complete disappearance of lymphadenopathy despite rising PSA. Four patients with SD and 1 progressor developed a positive DTH after the 4th vaccination. With a median survival of all patients of 13.4 months, DTH-positivity was associated with significantly superior survival (p = 0.003). HLA tetramer analysis detected high frequencies of peptide-specific T cells after 2 vaccinations in 1 patient who was also the sole responder to concomitant hepatitis B vaccination as an indicator of immune competence and survived 27 months after start of vaccination. Vaccination with PSA/PSCA peptide-loaded, autologous DCs may induce cellular responses primarily in immunocompetent patients, which appear to be associated with clinical benefit. Testing of DC-based vaccination is warranted for patients at earlier stages of prostate cancer.

Management of the Spectrum of Hormone Refractory Prostate Cancer

INTRODUCTION

In its advanced stages, hormone refractory prostate cancer (HRPC) is an incurable condition which consists of a spectrum of disease. This requires an integrated multidisciplinary approach by an uro-oncologic team supported by radiologists, skeletal surgeons and palliative care. Aim of this review was to critically evaluate the current and potential approaches to patients affected by HRPC.

MATERIALS AND METHODS

A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1981 to January 2006. Official proceedings of internationally known scientific societies held in the same time period were also assessed.

RESULTS

Most men with hormone refractory prostate cancer will die of their disease in the absence of intercurrent illness, and the various conditions arising as a consequence of local and distal cancer progression commonly lead to a spectrum of morbidity requiring treatment. Recent data regarding docetaxel-based chemotherapy have shown small but significant improvements in survival and improvement in quality of life in men receiving treatment. However, this therapy may not be suitable for all patients. New agents used alone or in combination with docetaxel currently are under trial in an attempt to provide much needed improvements in outcome. Bone-targeted treatments, particularly late-generation bisphosphonates, have added to the range of options, reducing the incidence of skeletal complications in some men. Further work is needed to target their use more effectively, to explore their efficacy in combination with existing proven therapies and to develop new approaches to treat bone metastases. Complications arising as a consequence of upper and lower tract dysfunction, haematologic, neurologic and psychologic disorders are common. These complications often are amenable to effective treatment, but interventions may engender difficult clinical and ethical decisions.

CONCLUSIONS

Although HRPC is incurable, it is not untreatable, and that the clinical management embraces not just chemotherapy, but many interventional and supportive therapies. A holistic and supportive approach to patient care is vital for optimal management, and is best provided by a coordinated, multidisciplinary team including urologists and oncologists.

Immunotherapy for prostate cancer using prostatic acid phosphatase loaded antigen presenting cells

Dendritic cells from patients with cancer are deficient in number and functional activity, leading to inadequate tumor immunosurveillance as a result of poor induction of T-cell antitumor responses. Loaded dendritic cell therapy is a vaccination strategy aimed at eliciting tumor antigen-specific, T-cell immune responses. Loaded dendritic cell therapy using prostatic acid phosphatase (APC8015; Provenge, Dendreon Corp., Seattle, WA) as an immunogen has shown a survival benefit in patients with metastatic hormone-refractory prostate cancer in a randomized phase III trial. This review will summarize the prostate cancer clinical trials using APC8015 and discuss the potential future role of APC8015 in prostate cancer treatment.

Prostate cancer nomograms: an update

OBJECTIVE

Several nomograms have been developed to predict outcomes related to prostate cancer (PCa).

METHODS

We provide a descriptive and an analytic comparison of nomograms. Further, we report a set of recent PCa nomograms, in which we recorded predictor variables, number of patients used to develop each nomogram, and nomogram-specific features. Moreover, accuracy estimates and type of validation are considered.

RESULTS

Our findings suggest a demand for updated nomograms in selected fields of PCa outcomes. Moreover, an increasing number of nomograms address important end points such as prostate-specific antigen recurrence, distant metastases, or androgen-independent PCa-specific survival.

CONCLUSION

Our results suggest that nomograms are available for many PCa-related outcomes. They represent a valid methodologic approach if correct criteria are met.

Placebo-controlled phase III trial of immunologic therapy with sipuleucel-T (APC8015) in patients with metastatic, asymptomatic hormone refractory prostate cancer

PURPOSE

Sipuleucel-T (APC8015) is an investigational immunotherapy product designed to stimulate T-cell immunity against prostatic acid phosphatase. A phase III study was undertaken to evaluate the safety and efficacy of sipuleucel-T in a placebo-controlled study.

PATIENTS AND METHODS

A total of 127 patients with asymptomatic metastatic hormone refractory prostate cancer (HRPC) were randomly assigned in a 2:1 ratio to receive three infusions of sipuleucel-T (n = 82) or placebo (n = 45) every 2 weeks. On disease progression, placebo patients could receive APC8015F, a product made with frozen leukapheresis cells.

RESULTS

Of the 127 patients, 115 patients had progressive disease at the time of data analysis, and all patients were followed for survival for 36 months. The median for time to disease progression (TTP) for sipuleucel-T was 11.7 weeks compared with 10.0 weeks for placebo (P = .052, log-rank; hazard ratio [HR], 1.45; 95%CI, 0.99 to 2.11). Median survival was 25.9 months for sipuleucel-T and 21.4 months for placebo (P = .01, log-rank; HR, 1.70; 95%CI, 1.13 to 2.56). Treatment remained a strong independent predictor of overall survival after adjusting for prognostic factors using a Cox multivariable regression model (P = .002, Wald test; HR, 2.12; 95%CI, 1.31 to 3.44). The median ratio of T-cell stimulation at 8 weeks to pretreatment was eight-fold higher in sipuleucel-T-treated patients (16.9 v 1.99; P < .001). Sipuleucel-T therapy was well tolerated.

CONCLUSION

While the improvement in the primary end point TTP did not achieve statistical significance, this study suggests that sipuleucel-T may provide a survival advantage to asymptomatic HRPC patients. Supportive studies are underway.

Using prostate-specific antigen screening and nomograms to assess risk and predict outcomes in the management of prostate cancer

We review the role of prostate-specific antigen (PSA) and the importance of patient education in the management of prostate cancer, based on discussions held at a European symposium on managing prostate cancer. Although PSA is the most widely used serum marker for detecting prostate cancer and for monitoring treatment responses, its use as a diagnostic marker is controversial due to concerns of over-diagnosis and low specificity. PSA isoforms, as well as PSA doubling time, might improve the specificity for earlier prostate cancer detection and can be used as surrogate markers for treatment efficacy. Patients can differ considerably in the importance they place on health-related quality of life aspects and fear of cancer progression. Consequently, there needs to be active, educated discussion of risk and outcomes between physicians and patients. Risk assessment tools, e.g. validated nomograms, enable clinicians to improve their decision analysis and form the basis for subsequent discussion of treatment options between the physician and patient, thereby enabling informed consent and appropriate decision-making.

Markers of Bone Metabolism and Survival in Men with Hormone-Refractory Metastatic Prostate Cancer

PURPOSE

To evaluate the relative prognostic value for specific markers of osteoblast and osteoclast activity while controlling for previously reported prognostic variables among men with hormone-refractory metastatic prostate cancer.

EXPERIMENTAL DESIGN

The 643 subjects in this report were participants in multicenter randomized controlled trial of zoledronic acid in men with metastatic prostate cancer. All subjects had bone metastases and disease progression despite medical or surgical castration. Relationships between baseline covariates and overall survival were examined by Cox proportional hazard model. Serum bone-specific alkaline phosphatase (BAP) and urinary N-telopeptide were assessed as representative specific markers of osteoblast and osteoclast activity, respectively. Other covariates in the model were age, log prostate-specific antigen, hemoglobin, lactate dehydrogenase, albumin, analgesic use, and Eastern Cooperative Oncology Group performance status.

RESULTS

Serum BAP was significantly correlated with urinary N-telopeptide (correlation coefficient = 0.674; 95% confidence interval, 0.628-0.715; P < 0.0001). In univariate analyses, higher levels of serum BAP and urinary N-telopeptide levels were significantly associated with shorter overall survival. After controlling for the other variables, including N-telopeptide, in multivariate models, higher serum BAP levels were consistently associated with shorter survival. In contrast, urinary N-telopeptide levels were not significantly associated with survival in multivariate analyses. Variables retained in the reduced multivariate model were age, log prostate-specific antigen, hemoglobin, lactate dehydrogenase, analgesic use, and BAP.

CONCLUSIONS

Serum BAP significantly correlates with urinary N-telopeptide in men with androgen-independent prostate cancer and bone metastases. In multivariate models, higher levels of serum BAP but not urinary N-telopeptide are associated with shorter overall survival.

Markers of bone metabolism in prostate cancer

Although bone metastases from prostate cancer are described as osteoblastic, markers of both osteoblastic and osteoclastic activity are strikingly elevated in men with metastatic prostate cancer. Elevated markers of osteoblastic and osteoclastic activity are associated with adverse clinical outcomes in men with prostate cancer--outcomes including shorter time to skeletal complications, disease progression, and death. Bone marker measurement appears to be a promising method for monitoring the efficacy of bone-targeted therapy. Additional studies are needed to assess the potential role of bone markers in identifying men at highest risk for development of bone metastases.

Transcript quantification of Dresden G protein-coupled receptor (D-GPCR) in primary prostate cancer tissue pairs

Recently, we identified the novel protein D-GPCR (Dresden G protein-coupled receptor) which is selectively overexpressed in human prostate cancer (PCa) and belongs to the subfamily of odorant-like orphan GPCRs. Quantification of D-GPCR transcripts in paired malignant and non-malignant prostate tissues of 106 patients with primary PCa by real-time PCR demonstrated a significant up-regulation of this gene in tumor samples. Furthermore, its expression increases with higher tumor stages and grades. The evaluation of D-GPCR expression as a potential molecular tumor marker was performed by receiver-operating characteristic curve (ROC) analysis resulting in an area under the curve (AUC) value of 0.6452. Hence, the evaluation of D-GPCR as possible additive diagnostic tool and putative therapy target appears promising.

Chemotherapy for prostate cancer: implementing early systemic therapy to improve outcomes

Prostate cancer remains a significant health concern for men in the USA as it is a leading cancer diagnosis and a cause of death. With the use of prostate-specific antigen or screening, a stage migration has occurred with an increase in the number of men diagnosed with early-stage disease. The optimal primary management of these men is evolving, but despite adequate local treatment a significant percentage will develop either biochemical or clinical evidence of recurrent disease. Several criteria for risk stratification have been developed, thus, improving the ability to identify a high-risk population. Small studies have been reported demonstrating the feasibility of neoadjuvant or adjuvant chemotherapy in conjunction with either radiation or radical prostatectomy in this high-risk population, and large phase III studies are ongoing. With the advent of life-prolonging chemotherapy in the hormone-refractory setting, attention must now also be given to early-stage disease so as to develop multi-modality approaches with the hope of increasing survival and ultimately providing a cure.

Second-line chemotherapy for prostate cancer: patient characteristics and survival

PURPOSE

First-line chemotherapy with docetaxel in patients with progressive castrate metastatic prostate cancer has been shown to improve overall survival compared with mitoxantrone-based therapies. The use and outcomes of chemotherapy after first-line antimicrotubule-based therapy have not been well described.

PATIENTS AND METHODS

Patients with progressive castrate metastatic prostate cancer enrolled on an antimicrotubule-based protocol for treatment were followed to determine their baseline characteristics and outcomes with second- or third-line systemic therapy.

RESULTS

Of 108 patients treated with antimicrotubule-based therapy, 81% received second-line therapy, and 40% received third-line therapies. Corresponding prostate-specific antigen (PSA) decreases > or = 50% were observed in 72%, 15%, and 22% of patients. Median survival times from the start of first-, second-, and third-line therapy were 21 months (95% confidence interval [CI], 18-25 months), 13 months (95% CI, 10-15 months) and 12 months (95% CI, 9-19 months). Significant prognostic indicators for survival in the second-line setting include pretreatment PSA level, alkaline phosphatase level, and performance status. Patients not fit to receive second-line therapy were more symptomatic with first-line therapy, as illustrated by a greater need for narcotic therapy (67% vs. 15%) and palliative radiation therapy after first-line therapy (57% vs. 10%) in lieu of second-line systemic therapy.

CONCLUSION

Eighty percent of patients received second-line chemotherapy, with a median survival of 12 months from the start of second-line treatment. Although only 40% received third-line chemotherapy, median survival was similar to that of patients in the second-line setting. Our data show that patients who initiate chemotherapy with symptoms are more likely to require palliative radiation therapy rather than chemotherapy as second-line therapy. A sequential or continuous administration of therapy may optimize the care of this subset of symptomatic patients.

Pre-treatment nomogram for disease-specific survival of patients with chemotherapy-naive androgen independent prostate cancer

OBJECTIVE

Our objective was to develop a nomogram that predicts the probability of cancer-specific survival in men with untreated androgen-independent prostate cancer (AIPC).

METHODS

AIPC was diagnosed in 129 consecutive patients between 1989 and 2002. No patient received cytotoxic chemotherapy. Univariate and multivariate Cox regression models were used to test the association between prostate-specific antigen (PSA) level at initiation of androgen deprivation, PSA doubling time (PSADT), PSA nadir on androgen deprivation therapy (ADT), time from ADT to AIPC, and AIPC-specific mortality. Multivariate regression coefficients were then used to develop a nomogram predicting AIPC-specific survival at 12-60 mo after AIPC diagnosis. Two-hundred bootstrap resamples were used to internally validate the nomogram.

RESULTS

AIPC-specific mortality was recorded in 74 of 129 patients (57.4%). Other-cause mortality was recorded in 7 men (5.4%). Median overall survival was 52.0 mo (mean, 36.0 mo) and median AIPC-specific survival was 54.0 mo (mean, 35.0 mo). In univariate regression models, all variables were significant predictors of AIPC-specific survival (p < or = 0.02). In multivariate models, PSADT and time from androgen deprivation to AIPC remained statistically significant (p < or = 0.004). Bootstrap-corrected predictive accuracy of the nomogram was 80.9% versus 74.9% for our previous model.

CONCLUSIONS

A nomogram predicting AIPC-specific survival is between 13% and 14% more accurate than previous nomograms and 6% more accurate than tree regression-based predictions obtained from the same data. Moreover, a nomogram approach combines several advantages, such as user-friendly interface and precise estimation of individual recurrence probability at several time points after AIPC diagnosis, which all patients deserve to know and all treating physicians need to know.

Secondary Hormonal Therapy for Advanced Prostate Cancer

PURPOSE

Androgen ablation remains the cornerstone of management for advanced prostate cancer. Therapeutic options in patients with progressive disease following androgen deprivation include antiandrogen withdrawal, secondary hormonal agents and chemotherapy. Multiple secondary hormonal agents have clinical activity and the sequential use of these agents may lead to prolonged periods of clinical response. We provide a state-of-the-art review of the various agents currently used for secondary hormonal manipulation and discusses their role in the systemic treatment of patients with prostate cancer.

MATERIALS AND METHODS

A comprehensive review of the peer reviewed literature was performed on the topic of secondary hormonal therapies, including oral antiandrogens, adrenal androgen inhibitors, corticosteroids, estrogenic compounds, gonadotropin-releasing hormone antagonists and alternative hormonal therapies for advanced prostate cancer.

RESULTS

Secondary hormonal therapies can provide a safe and effective treatment option in patients with AIPC. The use of steroids and adrenolytics, such as ketoconazole and aminoglutethimide, has resulted in symptomatic improvement and a greater than 50% prostate specific antigen decrease in a substantial percent of patients with AIPC. A similar clinical benefit has been demonstrated with estrogen based therapies. Furthermore, these therapies have demonstrated a decrease in metastatic disease burden. Other novel hormonal therapies are currently under investigation and they may also show promise as secondary hormonal therapies. Finally, guidelines from the United States Food and Drug Administration Prostate Cancer Endpoints Workshop were reviewed in the context of developing new agents.

CONCLUSIONS

Secondary hormonal therapy serves as an excellent therapeutic option in patients with AIPC in whom primary hormonal therapy has failed. Practicing urologists should familiarize themselves with these oral medications, their indications and their potential side effects.

First- and second-line chemotherapy with docetaxel or mitoxantrone in patients with hormone-refractory prostate cancer

BACKGROUND

Docetaxel and mitoxantrone are considered first-line chemotherapeutic options in patients with hormone-refractory prostate cancer (HRPC), but their clinical effectiveness in a second-line setting is unknown. Therefore, the authors conducted a population-based retrospective study to establish activity and tolerability of second-line docetaxel or mitoxantrone in HRPC.

METHODS

The study included 68 patients who had failed androgen ablation therapy and who received docetaxel and mitoxantrone in either sequence. Clinical efficacy in terms of median overall survival (OS), progression-free survival (PFS), posttreatment prostate-specific antigen (PSA) decline of > or = 50% and treatment-related toxicity were evaluated.

RESULTS

Of 68 patients, 35 received docetaxel followed by mitoxantrone, and 33 received mitoxantrone followed by docetaxel. Both groups were comparable for recognized pretreatment prognostic factors. Patients who received docetaxel first-line had a trend toward longer median OS compared with patients treated with second-line docetaxel after mitoxantrone failure (22 mos, 95% confidence interval [CI], 17.2-26.8 mos vs. 15 mos, 95% CI, 10.4-19.6 mos). Median number of second-line chemotherapy cycles was 3 and median PFS survival was 2-3 months in both groups. Second-line docetaxel produced a higher PSA response compared with mitoxantrone (38% vs. 12%, P = 0.012), but this did not translate to a survival benefit. Both second-line docetaxel and mitoxantrone were associated with a high frequency of treatment-related adverse events that resulted in dose reduction, delay, or discontinuation (64% and 46% of patients, respectively).

CONCLUSIONS

Study results favored docetaxel given up-front for patients with HRPC considered suitable for further chemotherapy. Second-line docetaxel or mitoxantrone had limited efficacy and tolerability. Patients who are candidates for second-line chemotherapy, should be enrolled into clinical trials.

A retrospective study of the time to clinical endpoints for advanced prostate cancer

OBJECTIVE

To determine the natural history of patients with prostate cancer who start initial androgen-deprivation therapy (ADT) for biochemical failure with no radiographic evidence of disease (D0) or with radiographic metastatic disease (D2), as the history is either not well-defined or is changing, and such data are critical for guiding therapy after prostate cancer recurrence.

PATIENTS AND METHODS

We retrospectively assessed the time to androgen-independence (AI), defined as the first sustained rise in prostate-specific antigen (PSA) level on ADT, time to metastatic disease and overall survival for 80 patients with metastatic prostate cancer in clinical trials at the National Cancer Institute.

RESULTS

ADT was initiated after metastatic disease in 37 patients and before metastatic disease in 43 patients; in these 43 patients, the median time to developing metastatic disease on ADT was 37.8 months. The median time to AI from the initiation of ADT was 19.3 and 13.1 months in D0 and D2 patients, respectively. The median overall survival from the start of ADT was 89.0 and 63.0 months, and the median overall survival from the time of AI was 63.1 and 44.2 months in D0 and D2 patients, respectively. These 80 patients, which included 43 who had no metastatic disease when starting ADT, had a median survival of 54.8 months after AI prostate cancer.

CONCLUSIONS

We describe the natural history of AI prostate cancer in D0 patients who eventually developed metastasis, and in D2 patients. The results suggest a longer than expected survival with AI prostate cancer, and to our knowledge this is the first study to report the time to metastatic disease for D0 patients from ADT and from AI. These results can be used to help design clinical trials in patients with D0 prostate cancer.

Chemotherapy for Hormone-Refractory Prostate Cancer: Now It's a Question of “When?”

Recently, data from two randomized phase III studies that compared docetaxel-based chemotherapy to mitoxantrone-based therapy demonstrated that treatment with docetaxel can prolong life in a significant way for patients with hormone-refractory prostate cancer. For many patients who experience disease progression after androgen-deprivation therapy, however, chemotherapy may not be immediately indicated. Such cases include those individuals with hormone-refractory disease in the absence of clinical metastases, and those with asymptomatic metastatic disease, for example. As a result, clinicians treating patients with hormone-refractory disease must weigh the benefits of earlier chemotherapy against its risks, and may consider other therapies such as secondary hormonal approaches before initiating chemotherapy. This decision is further complicated by the fact that a phase III study designed to compare secondary hormonal therapy with chemotherapy has failed due to lack of accrual. Furthermore, the limitations of chemotherapy for prostate cancer are being clarified and include a lack of standard second-line therapy as well as uncertain benefits for those with nonmetastatic disease. In this review, we will highlight some of the issues that impact on the decision of when to start chemotherapy and in whom as well as the potential benefits of secondary hormonal approaches.

Predictive factors for skeletal complications in hormone-refractory prostate cancer patients with metastatic bone disease

Factors predictive of skeletal-related events (SREs) in bone metastatic prostate cancer patients with hormone-refractory disease were investigated. We evaluated the frequency of SREs in 200 hormone-refractory patients consecutively observed at our Institution and followed until death or the last follow-up. Baseline parameters were evaluated in univariate and multivariate analysis as potential predictive factors of SREs. Skeletal-related events were observed in 86 patients (43.0%), 10 of which (5.0%) occurred before the onset of hormone-refractory disease. In univariate analysis, patient performance status (P=0.002), disease extent (DE) in bone (P=0.0001), bone pain (P=0.0001), serum alkaline phosphatase (P=0.0001) and urinary N-telopeptide of type one collagen (P=0.0001) directly correlated with a greater risk to develop SREs, whereas Gleason score at diagnosis, serum PSA, Hb, serum albumin, serum calcium, types of bone lesions and duration of androgen deprivation therapy did not. Both DE in bone (hazard ratio (HR): 1.16, 95% confidence interval (CI): 1.07-1.25, P=0.000) and pain score (HR: 1.13, 95% CI: 1.06-1.20, P=0.000) were independent variables predicting for the onset of SREs in multivariate analysis. In patients with heavy tumour load in bone and great bone pain, the percentage of SREs was almost twice as high as (26 vs 52%, P<0.02) and occurred significantly earlier (P=0.000) than SREs in patients with limited DE in bone and low pain. Bone pain and DE in bone independently predict the occurrence of SREs in bone metastatic prostate cancer patients with hormone-refractory disease. These findings could help physicians in tailoring the skeletal follow-up most appropriate to individual patients and may prove useful for stratifying patients enrolled in bisphosphonate clinical trials.

Racial disparity in clinical course and outcome of metastatic androgen-independent prostate cancer

OBJECTIVES

To perform a review of patient and disease characteristics and response and survival outcomes of patients with metastatic androgen-independent prostate cancer. Racial differences in prostate cancer have usually been attributed to socioeconomic status, quality of care, comorbidities, and dietary factors. In a clinical trial population, some of these factors, such as access to care and performance status, are likely to be relatively uniform.

METHODS

The patients included in the review had been registered in clinical trials between 1991 and 2001 at Wayne State University.

RESULTS

Of 145 patients, 90 (62%) were white Americans and 55 (38%) were black Americans, 27% were 70 years or older, and 34% had minimal metastatic disease (axial bony involvement and/or lymph node involvement) and 66% had extensive disease (appendicular skeleton and/or visceral involvement). The chi-square test demonstrated no statistically significant difference by race in the distribution of the patient and disease characteristics. The prostate-specific antigen response rate was 41% in whites and 29% in blacks (P = 0.12). Log-rank analysis revealed race to be the only statistically significant factor predictive of the time to prostate-specific antigen progression (P = 0.02, median 4.6 months in whites and 2.3 months in blacks). No statistically significant difference by race was found in overall survival. Poor performance status, extensive disease, elevated alkaline phosphatase and lactate dehydrogenase levels, and a lack of prostate-specific antigen response were statistically significant predictors of worse overall survival.

CONCLUSIONS

In patients with androgen-independent metastatic prostate cancer studied in clinical trials, race was an independent predictor of therapeutic outcome. Additional investigation of the biologic and genetic differences underlying this clinical disparity is warranted.

Chemotherapy agents and timing of chemotherapy in prostate cancer management

In 2005, it is estimated that more than 30,000 men will die from metastatic hormone-refractory prostate cancer. For decades, no chemotherapeutic agent demonstrated a survival benefit in these patients, although two randomized clinical trials demonstrated a clear palliative benefit using mitoxantrone combined with a corticosteroid. However, beginning in 1999, a series of phase-2 trials were performed using docetaxel, either as a single agent or in combination with estramustine. Preliminary data implied a survival improvement, with median survivals reported to be 14 to 23 months. Prostate-specific antigen levels dropped by more than 50% in 38% to 48% of patients treated with docetaxel. These findings were confirmed in two phase-3 randomized trials in which docetaxel with and without estramustine have demonstrated a survival benefit using chemotherapy in the treatment of hormone-refractory prostate cancer.

When and how to use informatics tools in caring for urologic patients

Making predictions is an essential part of any medical decision. It is particularly crucial when considering treatment of clinically localized prostate cancer. Nomograms and prediction model software typically provide the most accurate predictions. Many nomograms have been developed, for all prostate cancer clinical states. Some of these are discussed in this review, as is their utility in facilitating decision making and informed consent.

Angiogenesis-targeted therapies in prostate cancer

Most patients with metastatic prostate cancer will respond initially to ablation of gonadal androgen production. Eventually, all patients will develop progressive disease despite continued androgen suppression, a condition called androgen-independent or hormone-refractory prostate cancer. Hormone-refractory prostate cancer is characterized by virulent biologic and clinical behavior. Recently, docetaxel-based chemotherapy has been shown to improve survival and quality of life in this disease when compared with mitoxantrone-based therapy. However, results remain suboptimal. Recently, there have been remarkable advances in the delineation of the mechanisms of cancer growth, metastasis, and the intricate interactions between tumor cells and the surrounding normal tissues. The accumulated evidence has confirmed the importance of angiogenesis in these processes and validated the theory that inhibition of neovascularization is a promising therapeutic anticancer strategy. Currently, dozens of compounds that interfere with different steps of the angiogenic cascade are in preclinical and clinical development. Some of these agents have exhibited promising antitumor activity in hormone-refractory prostate cancer. This review summarizes the molecular mechanisms implicating angiogenesis in the development and progression of advanced-stage prostate cancer, as well as the drug development efforts that are targeting this process.

Prediction of recurrence after radical surgery for gastric cancer: a scoring system obtained from a prospective multicenter study

OBJECTIVE

The aim of this prospective multicenter study was to define a scoring system for the prediction of tumor recurrence after potentially curative surgery for gastric cancer.

SUMMARY BACKGROUND DATA

The estimation of the risk of recurrence in individual patient may be relevant in clinical practice, to apply adjuvant therapies after surgery, and plan an adequate follow-up program. Only a few studies, most of which were retrospective or performed on a limited number of patients, have developed a prognostic score in patients with gastric cancer.

METHODS

A total of 536 patients who underwent UICC R0 resection between 1988 and 1998 at 3 surgical departments in Italy were considered. All patients were followed up using a standard protocol after discharge from the hospital. The mean follow-up period was 56 +/- 44 months, and 94 +/- 29 months for surviving patients. The scoring system was calculated on the basis of a logistic regression model, where the presence of the recurrence was the dependent variable, and clinicopathologic variables were the covariates.

RESULTS

Recurrence occurred in 272 of 536 patients (50.7%). The scoring system for the prediction of the risk in individual cases gave values ranging from 1.4 to 99.9; the model distributed most cases in the extremes of the range. The risk of recurrence increased remarkably with score values; it was only 5% in patients with a score below 10, up to 95.4% in patients with a score of 91 to 100. No recurrence was observed in 43 patients with a score below 4, whereas all of the 56 patients with a score over 97 presented a recurrence. The model correctly predicted recurrence in 227 of 272 patients (sensitivity, 83.5%), whereas the absence of recurrence was correctly predicted in 214 of 264 patients (specificity, 81.1%); the overall accuracy was 82.2%. Prognostic score was clearly superior to UICC tumor stage in predicting recurrence. The high effectiveness of the score was confirmed in preliminary data of a validation study.

CONCLUSIONS

The scoring system obtained with a regression model on the basis of our follow-up data is useful for defining subgroups of patients at a very low or very high risk of tumor recurrence after radical surgery for gastric cancer. Final results of the validation study are essential for a clinical application of the model.

Clinical model to predict survival in chemonaive patients with advanced non-small-cell lung cancer treated with third-generation chemotherapy regimens based on eastern cooperative oncology group data

PURPOSE

(1) Identify clinical factors that can be used to predict survival in chemotherapy-naive patients with advanced non-small-cell lung cancer (NSCLC) treated with third-generation chemotherapy regimens, and (2) build a clinical model to predict survival in this patient population.

PATIENTS AND METHODS

Using data from two randomized, phase III Eastern Cooperative Oncology Group (ECOG) trials (E5592/E1594), we performed univariate and multivariate stepwise Cox regression analyses to identify survival prognostic factors. We used 75% of randomly sampled data to build a prediction model for survival, and the remaining 25% of data to validate the model.

RESULTS

From 1993 to 1999, 1,436 patients with stage IV or IIIB NSCLC with effusion were treated with platinum-based doublets (involving either paclitaxel, docetaxel, or gemcitabine). The response rate and median survival time were 20% and 8.2 months, respectively. One- and 2-year survivals were 33% and 11%, respectively. In multivariate analysis, six independent poor prognostic factors were identified: skin metastasis (hazard ratio [HR], 1.88), lower performance status (ECOG 1 or 2; HR, 1.46), loss of appetite (HR, 1.62), liver metastasis (HR, 1.32), >/= four metastatic sites (HR, 1.20), and no prior surgery (HR, 1.16). A nomogram using six pretreatment prognostic factors was built to predict 1- and 2-year survival.

CONCLUSION

Six pretreatment factors can be used to predict survival in chemotherapy-naive NSCLC patients treated with standard chemotherapy. Using our prognostic nomogram, 1- and 2-year survival probability of NSCLC patients can be estimated before treatment. This prognostic model may help clinicians and patients in clinical decision making, as well as investigators in research planning.

Diagnostic accuracy of the palliative prognostic score in hospitalized patients with advanced cancer

PURPOSE

To evaluate the predictive accuracy of the Palliative Prognostic (PaP) score in patients with advanced cancer under the care of an oncologist.

PATIENTS AND METHODS

The PaP score was calculated in 100 consecutive patients with advanced cancer hospitalized under the care of a medical or radiation oncologist at a university teaching hospital in Australia. The attending oncologist predicted the survival duration for the purpose of the scoring. The positive predictive value of the PaP score was evaluated. Survival analysis was performed to compare the survival of the three prognostic groups.

RESULTS

Assessable survival data were available for 98 patients. The overall median survival was 12 weeks (interquartile range, 7 to 25 weeks). The PaP score divided the heterogeneous patient sample into three isoprognostic groups related to the chance of surviving 1 month, with 64 patients in group A (> 70% chance), 32 patients in group B (30% to 70% chance), and four patients in group C (< 30% chance). The estimated median survival of the three groups was 17 weeks (95% CI, 12 to 26 weeks), 7 weeks (95% CI, 4 to 12 weeks), and less than 1 week (95% CI, < 1 to 3 weeks), respectively. These survival differences were highly significant (log-rank test of trend, chi1(2) = 25.65; P < .0001). The 1-month survival of the groups was 97%, 59%, and 25%, respectively.

CONCLUSION

When oncologists' survival estimates are used, the PaP score is able to identify accurately three isoprognostic patient groups, irrespective of the cancer type. The PaP score may help reduce the uncertainty of formulating a prognosis in patients with advanced cancer.

Newer Therapies in Advanced Prostate Cancer

Prostate cancer is a leading cause of morbidity and mortality among males. Androgen ablation as initial therapy for advanced prostate cancer provides high response rates but does not cure disease, as nearly all men with metastases will eventually progress to hormone-refractory prostate cancer (HRPC). Present chemotherapy regimens for HRPC can provide palliation and have recently demonstrated an increase in overall survival. Over the past 2 decades, these regimens represent clear advances in the treatment of metastatic prostate cancer but also demonstrate that newer therapies are needed. Studies are ongoing to provide viable alternatives among traditional cytotoxic therapies as well as among novel agents targeting specific molecular pathways. This article reviews some of the newer therapies being developed and evaluated, including the epothilone analogues, human epidermal growth factor receptor pathway inhibitors, angiogenesis inhibitors, and endothelin receptor antagonists.

A simple and accurate prediction model to estimate the intrahospital mortality risk of hospitalised cancer patients

We aimed to form a risk prediction model to assess the probability of intrahospital death in cancer patients at the time of hospitalisation. The medical records and the relevant clinical parameters of cancer patients who died in or who were discharged from a teaching hospital between 1997 and 2000 (n = 334) were reviewed to explore the determinants of intrahospital death, which later were verified prospectively (n = 131). Eastern Cooperative Oncology Group (ECOG) performance status of four, short duration of disease (on a logarithmic scale), emergency admission, low haemoglobin (Hb) value (on a linear scale) and lactate dehydrogenase (LDH) value greater than 378 micro/ml were significantly and independently associated with the risk of intrahospital death. This model had a receiver operating characteristic area of 0.88 in the derivation cohort and 0.82 in the validation cohort. Using readily available clinical parameters, it is possible to devise an accurate and applicable risk prediction model for the hospitalised cancer patients.

Is baseline quality of life useful for predicting survival with hormone-refractory prostate cancer? A pooled analysis of three studies of the European Organisation for Research and Treatment of Cancer Genitourinary Group

PURPOSE

Patients with symptomatic metastatic hormone-resistant prostate cancer (HRPC) survive a median of 10 months and are often regarded as a homogeneous group. Few prognostic factors have been identified so far. We examined whether baseline health-related quality of life (HRQOL) parameters assessed by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) were independent prognostic factors of survival and whether they bring extra precision to the predictions achievable with models based on clinical and biochemical factors only.

PATIENTS AND METHODS

Data of 391 symptomatic (bone) metastatic HRPC patients from three randomized EORTC trials were used in multivariate Cox proportional hazards models. The significance level was set at alpha =.05.

RESULTS

Of the 391 patients, 371 died, most of prostate cancer. Bone scan result, performance status, hemoglobin level, and insomnia and appetite loss as measured by the EORTC QLQ-C30 were independent predictors of survival. This model's area under the receiver operating curve was 0.65 compared with 0.63 without the two HRQOL factors.

CONCLUSION

Certain HRQOL sores, at baseline, seem to be predictors for duration of survival in HRPC. However, such measurements do not add to the predictive ability of models based only on clinical and biochemical factors.

THE NATURAL HISTORY OF ANDROGEN INDEPENDENT PROSTATE CANCER

PURPOSE

We describe the natural history of androgen independent prostate cancer (AIPC) in the modern prostate specific antigen (PSA) era.

MATERIALS AND METHODS

Data from 160 patients diagnosed with AIPC between 1989 and 2002 were reviewed. No patient had received cytotoxic chemotherapy. Univariate and multivariate proportional hazards models were constructed to identify significant risk factors for cancer specific survival. Recursive partitioning analysis stratified patients into prognostic risk groupings. The types and frequencies of cancer specific complications per risk grouping were compared.

RESULTS

The final prognostic risk model included nadir PSA on androgen deprivation therapy (p = 0.023), time to PSA recurrence (p = 0.006) and prostate specific antigen doubling time (p <0.01). Three highly independent risk groupings were identified. The observed median cancer specific survivals were 14.0 months (95% CI, 8.3-19.8), 38.4 months (95% CI, 26.9-49.9) and 89.1 months (95% CI, 69.0-109.2) for low, intermediate and high risk groupings, respectively (p <0.001). Patients in the low risk grouping experienced significantly fewer cancer specific complications (p = 0.003).

CONCLUSIONS

This prognostic model stratified patients into 3 highly significant and independent risk groupings. A detailed PSA history alone is sufficient to risk stratify patients with AIPC.

Analysis of biochemical bone markers as prognostic factors for survival in patients with hormone-resistant prostate cancer and bone metastases

OBJECTIVES

To investigate the prognostic value of some conventional bone markers and a number of other factors in terms of the survival of patients with hormone-resistant prostate cancer and bone metastases treated with chemotherapy.

METHODS

The data of 141 patients were analyzed to verify the influence of the following factors on survival: bone-alkaline phosphatase, type I collagen propeptide, the carboxyterminal telopeptide of type I collagen, the urinary calcium/creatinine ratio, patient age, Karnofsky performance status, pathologic grade, duration of response to primary hormonal therapy, prostate-specific antigen, hemoglobin, lactate dehydrogenase, and extent of bone disease.

RESULTS

When all the variables were simultaneously analyzed using the multivariate proportional hazard model, only Karnofsky performance status (P <0.005) and duration of response to primary hormonal therapy (P <0.0001) remained statistically significant.

CONCLUSIONS

The results of this study suggest that bone-alkaline phosphatase, type I collagen propeptide, the carboxyterminal telopeptide of type I collagen, and the urinary calcium/creatinine ratio are not prognostic of survival in patients with hormone-resistant prostate cancer and bone metastases treated with chemotherapy.

Survival of patients with hormone refractory prostate cancer in the prostate specific antigen era

PURPOSE

The historically reported 12 to 18-month duration of survival of patients with hormone refractory prostate cancer is not consistent with current clinical experience. Furthermore, to our knowledge patient survival after serum prostate specific antigen (PSA) progressively increases from a nadir despite castrate testosterone has not been previously reported. For this reason we studied overall survival and the clinical variables that influence survival in patients with hormone refractory prostate cancer.

MATERIALS AND METHODS

The study focused on 254 patients with prostate cancer on androgen deprivation therapy. Hormone refractory prostate cancer was defined as the first in a series of PSA elevations despite castrate levels of testosterone. The duration of survival in the hormone refractory phase was calculated from the date of the first PSA elevation to the date of death.

RESULTS

Median survival after hormone refractory prostate cancer developed in patients initially staged with and without skeletal metastasis was 40 and 68 months, respectively. Six of more than 25 input variables were retained as significant in the final Cox model. Variables associated with longer survival were lower nadir PSA, younger age, higher pretreatment testosterone, no history of obstructive uropathy, no history of tobacco use (past or current) and lower alkaline phosphatase.

CONCLUSIONS

Historical reports of survival in hormone refractory prostate cancer underestimate current survival observations. The likely explanations of this observation include delayed enrollment in clinical trials from which most survival data are derived, PSA lead time in staging and improved supportive care. Models predicting survival in patients with hormone refractory prostate cancer should consider multiple variables.

Novel approaches to treating the asymptomatic hormone-refractory prostate cancer patient

For >50 years, the standard treatment for advanced prostate cancer has been hormonal therapy. However, all such treated patients eventually develop disease refractory to androgen suppression as manifested by increasing prostate-specific antigen (PSA) levels, progressive disease on radiographic imaging, and ultimately, symptomatic deterioration. Historical perceptions that treatment of hormone-refractory prostate cancer was a largely futile venture have faded over the past decade with the advances in new therapeutic strategies. With the use of PSA values to follow the progress of patients after definitive therapy, physicians are seeing more patients who have failed hormonal therapy yet have no symptoms from their disease. There are standard therapies available for patients who require palliation for symptoms, but there is no consensus on treatment for asymptomatic patients. To date, there has been no definitive increase in survival with any therapy in this group of patients. In addition, several novel drugs have advanced through preclinical testing into early clinical trials. It is these drugs--alone or in combination--that are designed to target strategic tumor pathways in these patients. This article will review a selection of agents that may be potentially useful in this population.

Ten-year survival in patients with metastatic prostate cancer

The objective of this analysis is to identify baseline covariates that predict which patients will be long-term survivors with metastatic prostate cancer. We analyzed data from Southwest Oncology Group (SWOG) S8894, a clinical trial in men with newly diagnosed metastatic prostate cancer, to evaluate pretreatment characteristics associated with 10-year survival. There were 1286 eligible patients randomized to this study. Of these, 794 have been followed for > or = 10.5 years and are included in the analyses. Proportional odds models were used to predict 3 survival categories (survival for < 5 years, 5 up to 10 years, and > or = 10 years). Baseline patient and disease characteristics investigated were protocol treatment (flutamide vs. placebo), severity of disease, SWOG performance status (PS), bone pain, Gleason score, race, age, and prostate-specific antigen (PSA) level at study entry. Of the 794 evaluable patients, 77% lived < 5 years, 16% lived 5 up to 10 years, and 7% lived > or = 10 years. Factors predicting a statistical significant association with longer survival (P < 0.05) included minimal disease, better PS, no bone pain, lower Gleason score, and lower PSA level. All but PS were also significant in multivariate analyses. However, only 13% of patients (5 of 38) who lived > or = 10 years were correctly predicted in their survival category based on the model, whereas 98% (405 of 414) who died within the first 5 years were correctly predicted. Although statistically significant baseline characteristics were identified in this clinical trial, they did not accurately predict the survival interval to which a patient belonged.

DC therapy for prostate cancer

The wide range of currently available treatments for metastatic prostate cancer have demonstrated a modest palliative effect, but none to date has shown an increase in overall survival. The immune system has evolved to protect against infection, however, the modulation of this system represents the possibility of allowing it to identify and destroy cancer cells. The immune system is capable of inciting a powerful immune response against tissues, in the form of transplant rejection, and the potential exists to harness these powers to fight against tumors. Modest clinical responses have been seen in patients with metastatic prostate cancer treated with DC therapies; however, no increase in overall survival has been demonstrated. The current state of DC immunotherapy for prostate cancer is reviewed.

Use of nomograms to predict the risk of disease recurrence after definitive local therapy for prostate cancer

The generally indolent nature of prostate cancer, as well as the impact that treatment can have on quality of life (QOL) and cancer control, makes the decision analysis difficult for patients facing the task of selecting a treatment for clinically localized disease. Instruments to aid patients and their physicians in this decision analysis are needed. Nomograms are instruments that predict outcomes using specific clinical parameters. Nomograms use algorithms that incorporate several variables to calculate the predicted probability that a patient will achieve a particular clinical end point. Nomograms tend to outperform both clinical experts and predictive models using methods of risk grouping. We briefly outline the uses and limitations of nomograms, principles of nomogram construction, and the available models for predicting the progression-free probability after local definitive therapy with radical prostatectomy, external-beam radiotherapy, or brachytherapy. There is a need for additional nomograms that predict outcomes after salvage therapy, as well other clinical end points, including QOL-adjusted survival.

The patient with hormone-refractory prostate cancer: determining who, when, and how to treat

Hormone-refractory prostate cancer (HRPC) encompasses a wide spectrum of patients, including patients with prostate-specific antigen (PSA)--only disease, those with increasing PSA levels yet stable metastatic disease, and those with increasing PSA levels and objective evidence of progressive metastases. Unfortunately, with the historical lack of effective therapy in this population, the oncologist is faced with few data with which to make difficult clinical decisions. Although our understanding of the biology of androgen independence continues to improve, and our fund of potential therapeutic agents has widened, multiple trial-specific and patient-specific obstacles have contributed to the difficulty in demonstrating clear benefit to therapy. Herein, we will review the biology of androgen-independent prostate cancer, the historical impediments to clinical trials in this population, and the reasons to treat, or not to treat, the patient with HRPC.

Use of nomograms for predicting survival in patients with castrate prostate cancer

Given the heterogeneity of prognoses in patients with castrate metastatic prostate cancer, the ability to accurately predict survival is vital for optimal patient counseling, selection of treatments, clinical trial design, and interpretation of clinical data. Over the past 20 years, several prognostic models have been developed in an attempt to refine the clinician's predictive ability. Early models were based on patients with more advanced disease. They included variables that are no longer regularly encountered today and involved cumbersome calculations that were not practical for everyday use in the clinic. Recently, 2 point-based nomograms have been developed based on pretreatment variables measured on a routine basis. These models provide a user-friendly format in which to make sophisticated predictions of survival. These models have improved our ability to predict the outcomes of patients with castrate metastatic disease. However, further work to identify novel prognostic markers to improve the accuracy of these predictions is needed.

Clinical experience with intravenous estramustine phosphate, paclitaxel, and carboplatin in patients with castrate, metastatic prostate adenocarcinoma

BACKGROUND

The combination of paclitaxel, oral estramustine phosphate (EMP), and carboplatin (TEC) has shown antitumor activity in patients with castrate, metastatic prostate carcinoma. To improve the therapeutic efficacy and reduce the toxicity of TEC, the authors substituted intravenous (i.v.) EMP for oral EMP based on single-agent studies demonstrating an improved safety profile with i.v. EMP.

METHODS

Patients with progressive, castrate, metastatic prostate carcinoma were treated with up to 6 4-week cycles of i.v. EMP (500-1500 mg/m(2) per week), paclitaxel (100 mg/m(2) per week), and carboplatin (target area under the curve = 6 mg/mL every 4 weeks).

RESULTS

Thirty patients were treated in 6 dose cohorts. Deep venous thrombosis occurred in 5 of 30 patients (17%). Other common Grade 3/4 (according to National Cancer Institute Common Toxicity Criteria) toxicities included hepatic toxicity (23%) and leukopenia (24%). Posttherapy prostate specific antigen declines > 50% were seen in 18 of 30 patients (60%), and declines > 80% were seen in 15 of 30 patients (50%). Eleven of 17 patients (65%) with measurable soft tissue disease achieved a partial response. Four of 27 patients (15%) with osseous metastases demonstrated improvement on bone scan.

CONCLUSIONS

Intravenous EMP was administered safely with paclitaxel and carboplatin and produced clinical outcomes similar to the outcomes achieved with the TEC regimen. Substitution of i.v. EMP for the oral formulation was found to result in a lower incidence of severe nausea but increased hepatic toxicity.

Clinical approaches to osseous metastases in prostate cancer

BACKGROUND

Prostate cancer is unique among solid tumors in its proclivity to metastasize primarily to bone. Osseous metastases pose a formidable health threat to patients with metastatic disease, putting them at risk for pain, marrow crowding, fracture, and other sequelae. Treatments directed against bone disease have the potential both to palliate pain and to increase survival.

CONCLUSIONS

A number of agents exist that have the potential to palliate the effects of osseous metastases and should be routinely applied in the clinical care of the patient with advanced prostate cancer. These include hormones, bone-seeking radiopharmaceuticals, chemotherapy, and bisphosphonates. Strategies under investigation aim to eradicate bone disease, and not merely palliate symptoms. These approaches combine those listed above with tumor-directed targeting of osseous disease and manipulation of the biology that underlies the cancer's relationship to bone.

Prognostic factors for survival in patients with hormone-refractory prostate cancer (HRPC) after initial androgen deprivation therapy (ADT)

Androgen deprivation therapy (ADT) is a standard mode of therapy for patients with metastatic prostate cancer. Controversy exists, however, as to the optimal timing of initiation of ADT, as well as whether this form of therapy imparts a survival benefit to patients with advanced disease. Side effects of ADT are not minimal and can seriously compromise a patient's quality of life. Additionally, ADT eventually results in hormone-refractory prostate cancer (HRPC). Despite new chemotherapeutic regimens and hormonal agents, overall survival in these patients remains universally low. Nonetheless, it is valuable to gauge a patient's prognosis to assist in decision making when considering treatment options. Contemporary series analyzing patients with HRPC have identified several factors prognostic of survival outcomes, such as lactate dehydrogenase (LDH), alkaline phosphatase (ALK), hemoglobin (Hgb), and serum prostate specific antigen (PSA) level. Nomograms have been developed that utilize these pretreatment clinical variables to predict clinical outcomes, including 1-year, 2-year, and median survival times in patients with HRPC. These instruments are capable of more accurately predicting survival outcomes than traditional tables of multivariate results or simple analysis of prognostic factors. We believe these nomograms will become indispensable tools for patient counseling and clinical trial design in patients with HRPC.

Prostate cancer update

Research has yielded important insights into the impact of radical prostatectomy in patients with localized prostate cancer. Other recent research has focused on the role of nutrition in prostate cancer development and progression, improved prognostication for patients with both early and advanced prostate cancer, efficacy of adjuvant and neoadjuvant hormonal therapy, and development of novel agents. In addition, the role of bisphosphonates in patients with bone metastasis was established.

Prognostic model for predicting survival in men with hormone-refractory metastatic prostate cancer

PURPOSE

To develop and validate a model that can be used to predict the overall survival probability among metastatic hormone-refractory prostate cancer patients (HRPC).

PATIENTS AND METHODS

Data from six Cancer and Leukemia Group B protocols that enrolled 1,101 patients with metastatic hormone-refractory adenocarcinoma of the prostate during the study period from 1991 to 2001 were pooled. The proportional hazards model was used to develop a multivariable model on the basis of pretreatment factors and to construct a prognostic model. The area under the receiver operating characteristic curve (ROC) was calculated as a measure of predictive discrimination. Calibration of the model predictions was assessed by comparing the predicted probability with the actual survival probability. An independent data set was used to validate the fitted model.

RESULTS

The final model included the following factors: lactate dehydrogenase, prostate-specific antigen, alkaline phosphatase, Gleason sum, Eastern Cooperative Oncology Group performance status, hemoglobin, and the presence of visceral disease. The area under the ROC curve was 0.68. Patients were classified into one of four risk groups. We observed a good agreement between the observed and predicted survival probabilities for the four risk groups. The observed median survival durations were 7.5 (95% confidence interval [CI], 6.2 to 10.9), 13.4 (95% CI, 9.7 to 26.3), 18.9 (95% CI, 16.2 to 26.3), and 27.2 (95% CI, 21.9 to 42.8) months for the first, second, third, and fourth risk groups, respectively. The corresponding median predicted survival times were 8.8, 13.4, 17.4, and 22.80 for the four risk groups.

CONCLUSION

This model could be used to predict individual survival probabilities and to stratify metastatic HRPC patients in randomized phase III trials.