Inverse correlation between body mass index and clinical outcomes in men with advanced castration–recurrent prostate cancer

Adiposity assessed close to diagnosis and prostate cancer prognosis in the EPIC study

BACKGROUND

Adiposity has been characterized as a modifiable risk factor for prostate cancer. Its association with outcomes after prostate cancer diagnosis, however, must be better understood, and more evidence is needed to facilitate the development of lifestyle guidance for patients with prostate cancer.

METHODS

We investigated the associations between adiposity indices close to prostate cancer diagnosis (up to 2 years before or up to 5 years after diagnosis) and mortality in 1968 men of the European Prospective Investigation into Cancer and Nutrition cohort. Men were followed up for a median of 9.5 years. Cox proportional hazards models were adjusted for age and year of diagnosis, disease stage and grade, and smoking history and stratified by country.

RESULTS

Each 5-unit increment in prediagnosis or postdiagnosis body mass index combined was associated with a 30% higher rate of all-cause mortality and a 49% higher rate of prostate cancer-specific mortality. Similarly, each 5-unit increment in prediagnosis body mass index was associated with a 35% higher rate of all-cause mortality and a 51% higher rate of prostate cancer-specific mortality. The associations were less strong for postdiagnosis body mass index, with a lower number of men in analyses. Less clear positive associations were shown for waist circumference, hip circumference, and waist to hip ratio, but data were limited.

CONCLUSIONS

Elevated levels of adiposity close to prostate cancer diagnosis could lead to higher risk of mortality; therefore, men are encouraged to maintain a healthy weight. Additional research is needed to confirm whether excessive adiposity after prostate cancer diagnosis could worsen prognosis.

Effect of BMI and hemoglobin A1c on survival of veterans with metastatic castration-resistant prostate cancer treated with abiraterone or enzalutamide

BACKGROUND

Abiraterone acetate and enzalutamide are two common therapies for metastatic castration-resistant prostate cancer (mCRPC) that have shown improved overall survival (OS). The drugs have different mechanisms of action with limited comparative trials to evaluate treatment in patients with comorbidities such as obesity and diabetes. This is important since abiraterone requires the co-administration of prednisone. We assessed the relationship between body mass index (BMI), hemoglobin A1c (HbA1c), treatment, and survival in mCRPC.

METHODS

Veterans treated with abiraterone or enzalutamide within the Veterans Health Administration between September 10, 2014 and June 2, 2017 with BMI and HbA1c were identified. Additional variables included age, baseline prostate-specific antigen at first treatment for mCRPC, race, and the Charlson comorbidity index. Differences in survival were compared using the Kaplan-Meier method. Cox proportional hazards regression modeling was used to assess the association between initial treatment, BMI, and HbA1c while adjusting for confounding variables.

RESULTS

A total of 5231 patients were identified with a mean age of 75.2 years and 1241 (23.7%) were of black race. BMI was associated with OS with longest median survival of 29.8 months in BMI ≥ 30 (n = 1903), 23.9 months in BMI 25-30 (n = 1879), 15.9 months in BMI 18.5-25 (n = 1336), and 9.2 months in BMI < 18.5 (n = 113, p < 0.001). In a multivariable model compared to normal BMI, increased mortality was observed in BMI < 18.5 (adjusted hazard ratio (aHR) = 1.583, 95% confidence interval [CI]: 1.29-1.94) and a decreased mortality in BMI 25-30 (aHR = 0.751, 95% CI: 0.69-0.81) and BMI > 30 (aHR = 0.644, 95% CI: 0.59-0.70). In 3761 patients with BMI > 25, there was longer OS in patients treated with enzalutamide (28.4 months, n = 1615) compared to abiraterone (25.8 months, n = 2146, p = 0.002). In 1470 patients with BMI < 25, there was no difference in OS between patients treated with enzalutamide (16.0 months, n = 597, p = 0.513) or abiraterone (16.1 months, n = 873). In 1333 veterans with HbA1c ≥ 6.5%, initial prescription of enzalutamide was associated with longer OS compared with abiraterone (24.4 vs. 20.5 months, p = 0.0005). In 2088 patients with HbA1c < 6.5%, there was no difference in OS in patients who were initially prescribed enzalutamide versus abiraterone (25.7 vs. 23.5 months, p = 0.334).

CONCLUSIONS

In veterans with mCRPC, increased BMI was associated with longer survival. Veterans with BMI > 25 had longer survival with enzalutamide compared to abiraterone. In patients with HbA1c ≥ 6.5%, enzalutamide was associated with longer survival compared to abiraterone. These results may facilitate prognostication of survival and improve treatment selection based on patient comorbidities.

Survival of veterans treated with enzalutamide and abiraterone for metastatic castrate resistant prostate cancer based on comorbid diseases

BACKGROUND

Comorbid diseases influence patient outcomes, yet little is known about how comorbidities interact with treatments for metastatic castrate-resistant prostate cancer (mCRPC). No head-to-head trials have compared the efficacy of abiraterone and enzalutamide - oral androgen-receptor targeted agents (ARTAs) for mCRPC. In patients with comorbid disease, outcomes with ARTAs may differ due to disparate mechanisms of action, adverse events, and drug interactions.

METHODS

Retrospective observational study of US veterans initiating treatment for mCRPC with abiraterone or enzalutamide between September 2014 and June 2017. Treatment duration and overall survival (OS) was compared based on age and comorbid diseases. The association between ARTA and OS was assessed using Cox proportional hazards and propensity-score matched modeling while adjusting for potential confounders. Sensitivity analyses were performed based on patient age, comorbidities, and subsequent treatments for mCRPC.

RESULTS

Of 5822 veterans treated for mCRPC, 43.0% initially received enzalutamide and 57.0% abiraterone. Veterans initially treated with enzalutamide versus abiraterone were older (mean 75.8 vs. 75.0 years) with higher mean Charlson comorbidity index (4.4 vs. 4.1), and higher rates of cardiovascular disease or diabetes (74.2% vs. 70.6%). In the entire population, veterans initially treated with enzalutamide had longer median OS compared to those initially treated with abiraterone (24.2 vs. 22.1 months, p = 0.001). In veterans with cardiovascular disease or diabetes, median treatment duration with enzalutamide was longer (11.4 vs. 8.6 months, p < 0.001) with longer median OS compared to abiraterone (23.2 vs. 20.5 months, p < 0.001). In a propensity score matched cohort, enzalutamide was associated with decreased mortality compared to abiraterone (HR 0.90, 95% CI 0.84-0.96).

CONCLUSIONS

Veterans with cardiovascular disease or diabetes had longer treatment duration and OS with enzalutamide compared to abiraterone. Further study of ARTA selection may benefit men with metastatic castrate resistant prostate cancer and likely hormone sensitive prostate cancer, especially among patients with comorbid diseases.

Association between adiposity after diagnosis of prostate cancer and mortality: systematic review and meta-analysis

Objective

To explore the associations between adiposity indices, assessed at or after a diagnosis of prostate cancer, and mortality.

Design

Systematic review and meta-analysis.

Data sources

PubMed and Embase, from inception to 16 November 2022.

Eligibility criteria for selecting studies

Cohort studies or randomised controlled trials of men with a diagnosis of prostate cancer that investigated the associations between adiposity (body mass index, waist and hip circumference, waist-to-hip ratio, and subcutaneous and visceral adipose tissue) after diagnosis and mortality outcomes. A modified version of the risk of bias for nutrition observational studies tool was used to assess risk of bias.

Results

79 studies were identified that investigated adiposity indices after a diagnosis of prostate cancer in relation to mortality. No randomised controlled trials were found. A non-linear dose-response meta-analysis indicated a J shaped association between body mass index and all cause mortality (33 910 men, 11 095 deaths, 17 studies). The highest rate of all cause mortality was found at the lowest and upper range of the distribution: 11-23% higher rate for a body mass index of 17-21 and 4-43% higher rate for a body mass index of 30-40. The association between body mass index and mortality specific to prostate cancer was flat until body mass index reached 26-27, and then increased linearly by 8-66% for a body mass index of 30-40 (33 137 men, 2947 deaths, 13 studies), but the 95% confidence intervals were wide. These associations did not differ in most predefined subgroups by study design, number of deaths, anthropometric assessment, follow-up time, geographical location, prostate cancer risk group, and adjustment variables. No associations were found in meta-analyses between 10 cm increases in waist circumference and all cause mortality or mortality specific to prostate cancer, but only three studies were available. The few studies with data on change in weight, waist-to-hip ratio, and subcutaneous and visceral adipose tissue reported conflicting results.

Conclusions

This review suggests that patients with prostate cancer might benefit from maintaining a healthy weight and avoiding obesity. Future studies should investigate adiposity across different stages of cancer survivorship and use various parameters for distribution of adipose tissue.

Systematic review registration

Open Science Framework https://osf.io/qp3c4.

Elevated Body Mass Index Is Associated with Improved Overall Survival in Castration-Resistant Prostate Cancer Patients Undergoing Prostate-Specific Membrane Antigen-Directed Radioligand Therapy

In patients with prostate cancer scheduled for systemic treatment, being overweight is linked to prolonged overall survival (OS), whereas sarcopenia is associated with shorter OS. We investigated fat-related and body composition parameters in patients undergoing prostate-specific membrane antigen (PSMA)-directed radioligand therapy (RLT) to assess their predictive value for OS. Methods: Body mass index (BMI, in kg/m²) and CT-derived body composition parameters (total, subcutaneous, visceral fat area, and psoas muscle area at the L3-L4 level) were determined for 171 patients scheduled for PSMA-directed RLT. After normalization for stature, the psoas muscle index was used to define sarcopenia. Outcome analysis was performed using Kaplan-Meier curves and Cox regression including fat-related and other clinical parameters (Gleason score, C-reactive protein [CRP], lactate dehydrogenase [LDH], hemoglobin, and prostate-specific antigen levels). The Harrell C-index was used for goodness-of-fit analysis. Results: Sixty-five patients (38%) had sarcopenia, and 98 patients (57.3%) had increased BMI. Relative to the 8-mo OS in normal-weight men (BMI < 25), overweight men (25 ≥ BMI > 30) and obese men (BMI ≥ 30) achieved a longer OS of 14 mo (hazard ratio [HR], 0.63; 95% CI, 0.40-0.99; P = 0.03) and 13 mo (HR, 0.47; 95% CI, 0.29-0.77; P = 0.004), respectively. Sarcopenia showed no impact on OS (11 vs. 12 mo; HR, 1.4; 95% CI, 0.91-2.1; P = 0.09). Most of the body composition parameters were tightly linked to OS on univariable analyses, with the highest C-index for BMI. In multivariable analysis, a higher BMI (HR, 0.91; 95% CI, 0.86-0.97; P = 0.006), lower CRP (HR, 1.09; 95% CI, 1.03-1.14; P < 0.001), lower LDH (HR, 1.08; 95% CI, 1.03-1.14; P < 0.001), and longer interval between initial diagnosis and RLT (HR, 0.95; 95% CI, 0.91-0.99; P = 0.02) were significant predictors of OS. Conclusion: Increased fat reserves assessed by BMI, CRP, LDH, and interval between initial diagnosis and RLT, but not CT-derived body composition parameters, were relevant predictors for OS. As BMI can be altered, future research should investigate whether a high-calorie diet before or during PSMA RLT may improve OS.

Frailty and survival among veterans treated with abiraterone or enzalutamide for metastatic castration-resistant prostate cancer

INTRODUCTION

Abiraterone and enzalutamide are treatments for metastatic castration-resistant prostate cancer (mCRPC). Due to a lack of head-to-head trials, they are prescribed interchangeably. However, the drugs have different pharmacokinetics and thus may have differing efficacy and adverse effects influenced by patient functional status and comorbid diseases. Additionally, mCRPC mainly affects older adults and since the prevalence of frailty increases with age, frailty is an important patient factor to consider in personalizing drug selection.

MATERIALS AND METHODS

We conducted a retrospective observational study of US veterans treated with abiraterone or enzalutamide for mCRPC from September 2014 to June 2017. Frailty was assessed using the Veterans Affairs Frailty Index (VA-FI), which utilizes administrative codes to assign a standardized frailty score. Patients were categorized as frail if VA-FI scores were > 0.2. The primary outcome was difference in overall survival (OS) between the two treatment groups. Cox regression modeling and propensity score matching was used to compare between abiraterone and enzalutamide treatments.

RESULTS

We identified 5,822 veterans, 57% of whom were initially treated with abiraterone and 43% with enzalutamide. Frail patients (n = 2,314; 39.7%) were older, with a mean age of 76.1 versus 74.9 years in the non-frail group (n = 3,508; 60.3%, p < 0.001) and had shorter OS compared to non-frail patients regardless of treatment group (18.5 vs. 26.6 months, p < 0.001). Among non-frail patients there was no significant difference in OS between abiraterone and enzalutamide treatment (27.7 vs 26.1 months, p = 0.07). However, frail patients treated with enzalutamide versus abiraterone had improved OS (20.7 vs 17.2 months, p < 0.001). In a propensity score matched analysis of frail patients (n = 2,070), enzalutamide was associated with greater median OS (24.1 vs 20.9 months, p < 0.001). In patients with dementia, enzalutamide was associated with longer OS (19.4 vs. 16.6 months, p = 0.003).

DISCUSSION

In this study of 5822 US veterans with mCRPC, treatment with enzalutamide was associated with improved OS compared to abiraterone among frail veterans and veterans with dementia, but not among non-frail veterans. Future studies should evaluate interactions between frailty and cancer treatments to optimize selection of therapy among frail adults.

Adipose Tissue-Derived Extracellular Vesicles Contribute to Phenotypic Plasticity of Prostate Cancer Cells

Metastatic prostate cancer is one of the leading causes of male cancer deaths in the western world. Obesity significantly increases the risk of metastatic disease and is associated with a higher mortality rate. Systemic chronic inflammation can result from a variety of conditions, including obesity, where adipose tissue inflammation is a major contributor. Adipose tissue endothelial cells (EC) exposed to inflammation become dysfunctional and produce a secretome, including extracellular vesicles (EV), that can impact function of cells in distant tissues, including malignant cells. The aim of this study was to explore the potential role of EVs produced by obese adipose tissue and the ECs exposed to pro-inflammatory cytokines on prostate cancer phenotypic plasticity in vitro. We demonstrate that PC3ML metastatic prostate cancer cells exposed to EVs from adipose tissue ECs and to EVs from human adipose tissue total explants display reduced invasion and increased proliferation. The latter functional changes could be attributed to the EV miRNA cargo. We also show that the functional shift is TWIST1-dependent and is consistent with mesenchymal-to-epithelial transition, which is key to establishment of secondary tumor growth. Understanding the complex effects of EVs on prostate cancer cells of different phenotypes is key before their intended use as therapeutics.

A novel prognostic model predicting overall survival in patients with metastatic castration-resistant prostate cancer receiving standard chemotherapy: A multi-trial cohort analysis

PURPOSE

Generalizable, updated, and easy-to-use prognostic models for patients with metastatic castration-resistant prostate cancer (mCRPC) are lacking. We developed a nomogram predicting the overall survival (OS) of mCRPC patients receiving standard chemotherapy using data from five randomized clinical trials (RCTs).

METHODS

Patients enrolled in the control arm of five RCTs (ASCENT 2, VENICE, CELGENE/MAINSAIL, ENTHUSE 14, and ENTHUSE 33) were randomly split between training (n = 1636, 70%) and validation cohorts (n = 700, 30%). In the training cohort, Cox regression tested the prognostic significance of all available variables as a predictor of OS. Independent predictors of OS on multivariable analysis were used to construct a novel multivariable model (nomogram). The accuracy of this model was tested in the validation cohort using time-dependent area under the curve (tAUC) and calibration curves.

RESULTS

Most of the patients were aged 65-74 years (44.5%) and the median (interquartile range) follow-up time was 13.9 (8.9-20.2) months. At multivariable analysis, the following were independent predictors of OS in mCRPC patients: sites of metastasis (visceral vs. bone metastasis, hazard ratio [HR]: 1.24), prostate-specific antigen (HR: 1.00), aspartate transaminase (HR: 1.01), alkaline phosphatase (HR: 1.00), body mass index (HR: 0.97), and hemoglobin (≥13 g/dl vs. <11 g/dl, HR: 0.41; all p < 0.05). A nomogram based on these variables was developed and showed favorable discrimination (tAUC at 12 and 24 months: 73% and 72%, respectively) and calibration characteristics on external validation.

CONCLUSION

A new prognostic model to predict OS of patients with mCRPC undergoing first line chemotherapy was developed. This can help urologists/oncologists in counseling patients and might be useful to better stratify patients for future clinical trials.

Help or hindrance: The obesity paradox in cancer treatment response

Obesity is a rising epidemic, the influence of which on cancer development, progression as well as its impact on current standard of care cancer treatments is profound with many facets. Obesity is emerging as a modulating factor in many cancer therapies, such as chemotherapy, radiotherapy, immunotherapy and combination therapies. It has been reported to diminish the efficacy of some treatments but has also been alluded to being protective in terms of reduced treatment toxicities, thus the evolution of the obesity paradox. The obese tumour microenvironment influences treatment response through modulation of a series of aspects, including altered adipocyte secretome, angiogenesis, hypoxia, fibrosis, free fatty acid uptake as well as a modulated immune landscape. However, the influence of these underlying mechanisms on cancer treatment response and the biological action of adipose tissue is still largely unknown. Elucidation of these facets may lead to the enhanced efficacy of current treatment options or the identification of novel methods to combat cancer in the obese tumour microenvironment.

Combination of body mass index and albumin predicts the survival in metastatic castration-resistant prostate cancer patients treated with abiraterone: A post hoc analysis of two randomized trials

Background

Low body mass index (BMI) and low serum albumin levels are suggested indicators of malnutrition and are associated with poor outcomes in cancer patients. Decreasing androgen can alter lipid metabolism, so the prognostic value of BMI may change in metastatic castration‐resistant prostate cancer (mCRPC) patients receiving abiraterone. We aimed to delineate the prognostic value of BMI, serum albumin, and BMI and serum albumin (ALB) combined.

Materials and methods

A post hoc analysis was performed on data from two randomized clinical trials evaluating the efficacy of abiraterone in chemotherapy‐pretreated and ‐naïve mCRPC patients. Survival analysis was conducted using Kaplan–Meier and Cox proportional hazard methods.

Results

A total of 2,205 mCRPC patients were included in this study. Low ALB independently predicted the OS in both cohorts (HR, 1.54; 95%CI, 1.34–1.78 and HR, 1.40; 95%CI, 1.21–1.64, respectively), while low BMI independently predicted the OS only in the post‐chemotherapy cohort (HR, 1.30; 95%CI, 1.12–1.50) but not in the pre‐chemotherapy cohort (HR, 1.19; 95%CI, 0.98–1.43). By combining BMI (<25 kg/m² or ≥30 kg/m²) and ALB (<4 g/dl or >4 g/dl), the four groups were characterized and their HRs were 1, 0.60 (95%CI, 0.47–0.76, p < 0.001), 0.75 (95%CI,0.61–0.92 p = 0.006), and 0.49 (95%CI, 0.41–0.60, p < 0.001) in post‐chemotherapy patients and 1, 0.64 (95%CI, 0.46–0.89, p = 0.008), 0.75 (95%CI,0.58–0.98 p = 0.034), and 0.55 (95%CI, 0.42–0.72, p < 0.001) in chemotherapy‐naïve patients, respectively.

Conclusions

Our results demonstrate that the combination of BMI and ALB better characterizes the risk groups irrespective of previous chemotherapy. Patients with high BMI but low ALB have higher risk of death than patients with low BMI but high ALB.

Obesity as a Risk Factor for Prostate Cancer Mortality: A Systematic Review and Dose-Response Meta-Analysis of 280,199 Patients

Simple Summary

Results from individual studies on the association between obesity and prostate cancer mortality remain inconclusive; additionally, several large cohort studies have recently been conducted. We aimed to systematically review all available evidence and synthetize it using meta-analytic techniques. The results of our study showed that obesity was associated with prostate cancer specific mortality and all-cause mortality. The temporal association was consistent with a dose-response relationship. Our results demonstrated that obesity, a potentially modifiable prognostic factor, was associated with higher prostate cancer mortality. This study improved the evidence regarding the potential impact of lifestyle on improving prostate cancer prognosis. Strategies aimed at maintaining normal, or reducing abnormal, body mass index in diagnosed prostate cancer patients might improve survival. These results should guide urologists, oncologists, patients, policy-makers and primary care providers with respect to evidence-based practice and counselling concerning lifestyle changes after prostate cancer diagnosis.

Abstract

The aim of this study was to systematically review all evidence evaluating obesity as a prognostic factor for PC mortality. Cohort and case-control studies reporting mortality among PC patients stratified by body mass index (BMI) were included. The risk of mortality among obese patients (BMI ≥ 30) was compared with the risk for normal weight (BMI < 25) patients, pooling individual hazard ratios (HR) in random-effects meta-analyses. Reasons for heterogeneity were assessed in subgroup analyses. Dose-response associations for BMI per 5 kg/m² change were assessed. Among 7278 citations, 59 studies (280,199 patients) met inclusion criteria. Obesity was associated with increased PC-specific mortality (HR: 1.19, 95% CI: 1.10–1.28, I²: 44.4%) and all-cause mortality (HR: 1.09, 95% CI: 1.00–1.18, I²: 43.9%). There was a 9% increase (95% CI: 5–12%, I²: 39.4%) in PC-specific mortality and 3% increase (95% CI: 1–5%, I²: 24.3%) in all-cause mortality per 5 kg/m² increase in BMI. In analyses restricted to the higher quality subgroup (NOS ≥ 8), obesity was associated with increased PC-specific mortality (HR: 1.24, 95% CI: 1.14–1.35, I²: 0.0%) and maintained the dose-response relationship (HR: 1.11 per 5 kg/m² increase in BMI, 95% CI: 1.07–1.15, I²: 26.6%). Obesity had a moderate, consistent, temporal, and dose-response association with PC mortality. Weight control programs may have a role in improving PC survival.

Combined Longitudinal Clinical and Autopsy Phenomic Assessment in Lethal Metastatic Prostate Cancer: Recommendations for Advancing Precision Medicine

BACKGROUND

Systematic identification of data essential for outcome prediction in metastatic prostate cancer (mPC) would accelerate development of precision oncology.

OBJECTIVE

To identify novel phenotypes and features associated with mPC outcome, and to identify biomarker and data requirements to be tested in future precision oncology trials.

DESIGN SETTING AND PARTICIPANTS

We analyzed deep longitudinal clinical, neuroendocrine expression, and autopsy data of 33 men who died from mPC between 1995 and 2004 (PELICAN33), and related findings to mPC biomarkers reported in the literature.

INTERVENTION

Thirty-three men prospectively consented to participate in an integrated clinical-molecular rapid autopsy study of mPC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Data exploration with correction for multiple testing and survival analysis from the time of diagnosis to time to death and time to first occurrence of severe pain as outcomes were carried out. The effect of seven complications on the modeled probability of dying within 2 yr after presenting with the complication was evaluated using logistic regression.

RESULTS AND LIMITATIONS

Feature exploration revealed novel phenotypes related to mPC outcome. Four complications (pleural effusion, severe anemia, severe or controlled pain, and bone fracture) predict the likelihood of death within 2 yr. Men with Gleason grade group 5 cancers developed severe pain sooner than those with lower-grade tumors. Surprisingly, neuroendocrine (NE) differentiation was frequently observed in the setting of high serum prostate-specific antigen (PSA) levels (≥30 ng/ml). In 4/33 patients, no controlled (requiring analgesics) or severe pain was detected, and strikingly, 14/15 metastatic sites studied in these men did not express NE markers, suggesting an inverse relationship between NE differentiation and pain in mPC. Intracranial subdural metastasis is common (36%) and is usually clinically undetected. Categorization of "skeletal-related events" complications used in recent studies likely obscures the understanding of spinal cord compression and fracture. Early death from prostate cancer was identified in a subgroup of men with a low longitudinal PSA bandwidth. Cachexia is common (body mass index <0.89 in 24/31 patients) but limited to the last year of life. Biomarker review identified 30 categories of mPC biomarkers in need of winnowing in future trials. All findings require validation in larger cohorts, preferably alongside data from this study.

CONCLUSIONS

The study identified novel outcome subgroups for future validation and provides "vision for mPC precision oncology 2020-2050" draft recommendations for future data collection and biomarker studies.

PATIENT SUMMARY

To better understand variation in metastatic prostate cancer behavior, we assembled and analyzed longitudinal clinical and autopsy records in 33 men. We identified novel outcomes, phenotypes, and aspects of disease burden to be tested and refined in future trials.

The obesity paradox in metastatic castration-resistant prostate cancer

OBJECTIVE

To test whether body mass index (BMI) amongst patients with metastatic castration-resistant prostate cancer (mCRPC) is associated with overall survival (OS) and cancer-specific survival.

METHODS

Individual patient data from 1577 men with mCRPC treated with docetaxel and prednisone from the control arms of ASCENT2, VENICE, and MAINSAIL were considered. The role of BMI on survival outcomes was investigated both as a continuous and categorical variable (≤24.9 vs. 25-29.9 vs. ≥30 km/m²). BMI ≥ 30 kg/m² was considered obese. Analyses were adjusted for age, PSA, ECOG performance status, number of metastases and prior treatment. The Cox semi-proportional hazard model was used to predict OS, whereas competing risks regression was used for predicting cancer-specific mortality (CSM). To exclude any possible effect attributable to higher doses of chemotherapy (titrated according to body-surface area), we checked for eventual interactions between BMI and chemotherapy dose (both as continuous-continuous and categorical-continuous interactions).

RESULTS

The median (IQR) age for the patient population was 69 (63,74) years with a median (IQR) BMI of 28 (25-31) kg/m². Median follow-up for survivors was 12 months. Of the 1577 patients included, 655 were deceased by the end of the studies. Regarding OS, BMI emerged as a protective factor both as a continuous variable (HR: 0.96; 95% CI: 0.94, 0.99; p = 0.015) and as a categorical variable (obesity: HR: 0.71, 95% CI: 0.53, 0.96; p = 0.027, relatively to normal weight). The protective effect of high BMI on CSM was confirmed both as a continuous (SHR: 0.94; 95% CI: 0.91, 0.98; p = 0.002) and as a categorical variable (obesity SHR: 0.65; 95% CI: 0.45, 0.93; p = 0.018). No interaction was detected between the BMI categories and the docetaxel dose at any level in our analyses (all p » 0.05).

CONCLUSIONS

Obese patients with mCRPC had better cancer-specific and overall survival as compared to overweight and normal weight patients. The protective effect of BMI was not related to receiving higher chemotherapy doses. Further studies aimed at elucidating the biological mechanism behind this effect are warranted.

Association of Obesity With Survival Outcomes in Patients With Cancer: A Systematic Review and Meta-analysis

Importance

Obesity, defined as a body mass index (BMI) greater than 30, is associated with a significant increase in the risk of many cancers and in overall mortality. However, various studies have suggested that patients with cancer and no obesity (ie, BMI 20-25) have worse outcomes than patients with obesity.

Objective

To assess the association between obesity and outcomes after a diagnosis of cancer.

Data Sources

PubMed, the Cochrane Library, and EMBASE were searched from inception to January 2020.

Study Selection

Studies reporting prognosis of patients with obesity using standard BMI categories and cancer were included. Studies that used nonstandard BMI categories, that were limited to children, or that were limited to patients with hematological malignant neoplasms were excluded. Screening was performed independently by multiple reviewers. Among 1892 retrieved studies, 203 (17%) met inclusion criteria for initial evaluation.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were reporting guideline was followed. Data were extracted by multiple independent reviewers. Risk of death, cancer-specific mortality, and recurrence were pooled to provide an adjusted hazard ratio (HR) with a 95% CI . A random-effects model was used for the retrospective nature of studies.

Main Outcomes and Measures

The primary outcome of the study was overall survival (OS) in patients with cancer, with and without obesity. Secondary end points were cancer-specific survival (CSS) and progression-free survival (PFS) or disease-free survival (DFS). The risk of events was reported as HRs with 95% CIs, with an HR greater than 1 associated with a worse outcome among patients with obesity vs those without.

Results

A total of 203 studies with 6 320 365 participants evaluated the association of OS, CSS, and/or PFS or DFS with obesity in patients with cancer. Overall, obesity was associated with a reduced OS (HR, 1.14; 95% CI, 1.09-1.19; P < .001) and CSS (HR, 1.17; 95% CI, 1.12-1.23; P < .001). Patients were also at increased risk of recurrence (HR, 1.13; 95% CI, 1.07-1.19; P < .001). Conversely, patients with obesity and lung cancer, renal cell carcinoma, or melanoma had better survival outcomes compared with patients without obesity and the same cancer (lung: HR, 0.86; 95% CI, 0.76-0.98; P = .02; renal cell: HR, 0.74; 95% CI, 0.53-0.89; P = .02; melanoma: HR, 0.74; 95% CI, 0.57-0.96; P < .001).

Conclusions and Relevance

In this study, obesity was associated with greater mortality overall in patients with cancer. However, patients with obesity and lung cancer, renal cell carcinoma, and melanoma had a lower risk of death than patients with the same cancers without obesity. Weight-reducing strategies may represent effective measures for reducing mortality in these patients.

Prognostic value of testosterone for the castration-resistant prostate cancer patients: a systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis aimed to assess the prognostic value of testosterone in patients with castration-resistant prostate cancer (CRPC).

MATERIALS AND METHODS

PubMed, Web of Science, and Scopus databases were systematically searched until December 2019, according to the Preferred Reporting Items for Systemic Review and Meta-analysis statement. The endpoints were progression-free survival (PFS) and overall survival (OS).

RESULTS

We identified 11 articles with 4206 patients for systematic review and nine articles with 4136 patients for meta-analysis. Higher testosterone levels were significantly associated with better OS (pooled HR 0.74, 95% CI 0.58-0.95) and better PFS (pooled HR 0.51, 95% CI 0.30-0.87). Subgroup analyses based on the treatment type revealed that higher testosterone levels were significantly associated with better OS in CRPC patients treated with androgen receptor-targeted agents (ARTAs) (pooled HR 0.64, 95% CI 0.55-0.75), but not in those treated with chemotherapy (pooled HR 0.78, 95% CI 0.53-1.14).

CONCLUSION

This meta-analysis demonstrated that the PFS and OS were significantly greater in patients with CRPC in those with higher testosterone levels than that of those with lower testosterone levels. In the subgroup analyses, lower testosterone levels were a consistently poor prognostic factor for OS in patients treated with ARTAs, but not in those treated with chemotherapy. Therefore, higher testosterone levels could be a useful biomarker to identify patient subgroups in which ARTAs should be preferentially recommended in the CRPC setting.

Assessment of body composition in the advanced stage of castration-resistant prostate cancer: special focus on sarcopenia

PURPOSE

To assess the prevalence of sarcopenia and whether body composition parameters are associated with disease progression and overall survival (OS) in castration-resistant prostate cancer (CRPC) patients.

MATERIALS AND METHODS

This single-centre retrospective study evaluated data of 186 consecutive patients who underwent chemohormonal therapy between 2005 and 2016 as first-line systemic treatment for CRPC. Skeletal muscle and fat indices were determined using computerized tomography data before initiation of chemotherapy. Sarcopenia was defined as SMI of <55 cm²/m². Visceral-to-subcutaneous fat ratio and skeletal muscle volume were calculated with body composition specific areas. Harrell's concordance index was used for predictive accuracy.

RESULTS

A total of 154 (82.8%) patients met the criteria for sarcopenia; 139 (74.7%) individuals completed at least six cycles of docetaxel. Within a median follow-up of 24.1 months, age (HR 1.03, 95% CI 1.01-1.06, p = 0.02), high PSA (1.55, 95% CI 1.07-2.25, p = 0.02) and low skeletal muscle volume (HR 1.61, 95% CI 1.10-2.35, p = 0.02) were the only independent prognostic factor for tumor progression. Overall, 93 (50%) patients died during the follow-up period. The established prognosticator, the prechemotherapy presence of liver metastases (HR 1.32, 95% CI 1.08-1.61, p < 0.01) was associated with shorter OS. Moreover, we noted that patients with an elevated visceral-to-subcutaneous fat ratio tended to have a shorter OS (p = 0.06).

CONCLUSION

The large majority of men with CRPC suffers from sarcopenia. In our cohort, low skeletal muscle volume was an independent adverse prognosticator for progression of disease. We could not detect a statistically significant body composition parameter for OS, although patients with a high proportion of visceral fat had a trend for shorter OS. However, we suggest that body composition parameters determined by CT data can provide useful objective prognostic factors that may support tailored treatment decision-making.

Pre-treatment ratio of periprostatic to subcutaneous fat thickness on MRI is an independent survival predictor in hormone-naïve men with advanced prostate cancer

BACKGROUND

Epidemiological studies have shown an association between obesity and prostate cancer (PCa) aggressiveness. However, little is known about periprostatic fat (PPF) and its relationship with overall fat deposition in PCa. PPF is thought to contribute to PCa growth and migration via secreted factors and induction of chronic inflammation. We investigated if pre-treatment PPF thickness correlates with overall survival (OS).

METHODS

We reviewed 85 hormone-naïve men with advanced PCa who had received androgen deprivation therapy (ADT). PPF thickness was measured by magnetic resonance imaging (MRI) and compared with subcutaneous fat (SCF) thickness as an internal control. Visceral fat (VF) area measured by computed tomography served as an additional control. We evaluated the relationship between laboratory data, pathology results, and obesity parameters and OS.

RESULTS

Median follow-up was 50.6 months. Thirty-six patients died during follow-up. Univariate analysis revealed that nadir PSA titer, Gleason score, N stage, M stage, extent of disease by bone scan grade, hemoglobin, lactate dehydrogenase, alkaline phosphatase, and PPF/SCF ratio were associated with OS. Multivariate analysis revealed that nadir PSA titer, N stage, and PPF/SCF ratio were independent prognostic factors for survival. The 5-year OS in the patients with higher PPF/SCF ratio (≥ 1) and lower PPF/SCF ratio (< 1) was 49.5% and 66.5%, respectively (P = 0.039).

CONCLUSIONS

Pre-treatment ratio of PPF-to-SCF thickness on MRI is an independent predictor of survival in hormone-naïve men with advanced PCa. This could be useful for predicting which patients are more likely to develop castration-resistant PCa.

Obese patients with castration-resistant prostate cancer may be at a lower risk of all-cause mortality: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database

OBJECTIVE

To assess whether obesity is associated with progression to metastasis, prostate cancer-specific mortality (PCSM), and all-cause mortality (ACM), in patients with non-metastatic castration-resistant prostate cancer (non-mCRPC). At the population level, obesity is associated with prostate cancer mortality; however, some studies have found that higher body mass index (BMI) is associated with better long-term prostate cancer outcomes amongst men with mCRPC.

PATIENTS AND METHODS

We identified 1 192 patients with non-mCRPC from the Shared Equal Access Regional Cancer Hospital (SEARCH) database. BMI was calculated from height and weight abstracted from the medical records at the time closest to but prior to CRPC diagnosis and categorised as underweight (<21 kg/m² ), normal weight (21-24.9 kg/m² ), overweight (25-29.9 kg/m² ), and obese (≥30 kg/m² ). Competing risks regression and Cox models were used to test associations between obesity and progression to metastasis, PCSM, and ACM, accounting for confounders.

RESULTS

Overall, 51 (4%) men were underweight, 239 (25%) were normal weight, 464 (39%) were overweight, and 438 (37%) were obese. In adjusted analysis, higher BMI was significantly associated with reduced ACM (hazard ratio [HR] 0.98, P = 0.012) but not PCSM (HR 1.00, P = 0.737) or metastases (HR 0.99, P = 0.225). Likewise, when BMI was treated as a categorical variable in adjusted models, obesity was not associated with PCSM (HR 1.11, P = 0.436) or metastases (HR 1.06, P = 0.647), but was associated with decreased ACM (HR 0.79, P = 0.016) compared to normal weight. No data were available on treatments received after CRPC diagnosis.

CONCLUSIONS

Amongst patients with non-mCRPC obesity was associated with better overall survival. Although this result mirrors evidence from men with mCRPC, obesity was not associated with prostate cancer outcomes. Larger studies are needed to confirm these findings.

Association among metabolic syndrome, inflammation, and survival in prostate cancer

BACKGROUND

Metabolic syndrome (MS) and inflammation (INF) alterations are among the factors involved in cancer progression. The study aimed to assess the relationship between MS and INF and its effect on progression-free/overall survival (PFS/OS) in metastatic castration-resistant prostate cancer (mCRPC) treaed with abiraterone or enzalutamide.

METHODS

We, retrospectively, evaluated patients with mCRPC in 7 Italian Institutes between March 2011 and October 2016. MS was defined by modified adult treatment panel-III criteria. INF was characterized by at least one of these criteria: neutrophil to lymphocyte ratio ≥ 3, elevated erythrocyte sedimentation rate or C-reactive protein.

RESULTS

Eighty-three of 551 (15.1%) patients met MS criteria at baseline and 34 (6.2%) during treatment. MS patients (MS+) presented a greater INF profile compared to MS- (P<0.0001). Median PFS was 3.7 for MS+ vs. 8.7 months for MS- (hazard ratio [HR] = 2.77; 95% CI: 2.12-3.61; P<0.0001). Median OS was 6.9 and 19 months in MS+ and MS-, respectively (HR = 3.43; 95% CI: 2.56-4.58; P<0.0001). We also demonstrated INF led to shorter PFS and OS (4.5 vs. 8.5 months, HR = 1.48, 95% CI: 1.15-1.90, P = 0.002, and 11.2 vs. 18.8 months, HR =1.66, 95% CI: 1.26-2.18, P = 0.0003, respectively). The combination of MS with INF provided the identification of high-risk prognostic group (MS+/INF+ vs. MS-/INF-) with worse PFS (3.7 vs. 9 months, HR = 2.7, 95% CI: 1.88-3.89, P<0.0001) and OS (6.3 vs. 20.4 months, HR = 4.04, 95% CI: 2.75-5.93, P<0.0001). Multivariable analysis confirmed that MS was independently associated with PFS (HR = 2.07; 95% CI: 1.03-4.18; P = 0.041) and OS (HR = 4.87; 95% CI: 2.36-10.03; P<0.0001). The absence of INF as an independent predictor of survival underlined the correlation between MS/INF.

CONCLUSIONS

Pretreatment identification of MS and INF alterations might represent an available and easy tool for better prognostication of patients with mCRPC. A prospective evaluation is warranted.

Subcutaneous Fat Distribution is a Prognostic Biomarker for Men with Castration Resistant Prostate Cancer

PURPOSE

The relationship between body fat distribution and survival remains unclear in patients with castration resistant prostate cancer treated with docetaxel and androgen receptor axis targeted agents. We investigated whether body composition parameters could predict radiographic progression-free and cancer specific survival in patients with castration resistant prostate cancer.

MATERIALS AND METHODS

In this multicenter retrospective study we evaluated data on 282 consecutive patients diagnosed with castration resistant prostate cancer between September 2009 and March 2017. The subcutaneous fat index, the visceral fat index and the skeletal muscle index at the diagnosis of castration resistant prostate cancer were determined by computerized tomography data. Survival analyses were performed using the subcutaneous fat, visceral fat and skeletal muscle indexes dichotomized at 39.9, 58 and 52.4 cm²/m², respectively.

RESULTS

At the diagnosis of castration resistant prostate cancer, cancer specific survival was independently predicted using prostate specific antigen levels, Gleason score 8 or greater, performance status, a shorter interval from androgen deprivation therapy to castration resistant prostate cancer and a subcutaneous fat index of less than 39.9 cm²/m². During the median followup of 16.0 months patients with a subcutaneous fat index of 39.9 cm²/m² or greater received more docetaxel cycles than patients with a subcutaneous fat index of less than 39.9 cm²/m². Compared to patients with a subcutaneous fat index of less than 39.9 cm²/m² those with an index of 39.9 cm²/m² or greater had better 1-year progression-free and 2-year cancer specific survival (p = 0.009 and 0.021, respectively).

CONCLUSIONS

Patients with a subcutaneous fat index of 39.9 cm²/m² or greater at the diagnosis of castration resistant prostate cancer showed higher progression-free and cancer specific survival rates than those with a subcutaneous fat index of less 39.9 cm²/m² at diagnosis. The subcutaneous fat index determined by computerized tomography data could serve as a useful objective prognostic factor to discuss patient therapeutic options. Further studies are needed to define the roles of each body composition parameter in relation to pharmacokinetics and oncologic outcome.

Uncontrolled diabetes predicts poor response to novel antiandrogens

Metabolic abnormalities including hyperglycemia and hyperlipidemia have been associated with worse prognosis of prostate cancer (PCa), but there are limited data regarding their impact on the prognosis of castrate-resistant prostate cancer (CRPC) and the response of novel antiandrogens, namely abiraterone acetate (AA) and enzalutamide. Retrospective analysis of 61 patients with CRPC on AA or enzalutamide, treated at the Boston Medical Center, was performed. We evaluated hemoglobin A1c (HbA1c), HDL, LDL, Triglycerides and BMI within 2months before the initiation of treatment with AA or enzalutamide and progression-free survival (PFS) under this treatment. Regression analysis and analysis of variance were used to evaluate the data. HbA1c levels were found to predict adversely the PFS on the novel agents (df (1, 37), P=0.00, R(2)=0.40, coeff=-3.28). The Kaplan-Meier analysis showed that there is significant difference in survival between the HbA1c 4.7-5.9% compared with patients with HbA1c 7.8-11.6% (6.72±1.3months, log rank test P<0.0001) LDL (P=0.07), HDL (P=0.14), and triglycerides (P=0.33) were not found to predict PFS. BMI predicted PFS positively (df (1.59), P=0.02, R(2)=0.09, coeff=0.03), but not independently of HbA1c (P=0.07). No significant implications of social and family history, previous chemotherapy regimen, and Gleason score with PFS were found. Multiple markers of patients' health state were not associated with HbA1c values. Uncontrolled diabetes can predict for poor response of CRPC patients to AA and enzalutamide determining PFS under this treatment. Elevated BMI can positively affect PFS at this stage of disease.

Obesity and Outcomes in Patients with Metastatic Urothelial Carcinoma

Background: Obesity has been associated with worse outcomes in patients with clinically localized urothelial cancer. However, this impact has not been evaluated in metastatic disease.

Objective: To assess the impact of obesity on outcomes of patients with metastatic urothelial cancer.

Methods: Data from 537 patients were aggregated from eight phase II and phase III clinical trials investigating first-line cisplatin-based combination therapy in metastatic urothelial cancer. Chemotherapy regimen, adverse events, treatment response, and survival outcomes were compared across body mass index (BMI) and body surface area (BSA) categories.

Results: BMI was classified according to WHO criteria (<18.5 underweight, 18.5–24.99 normal weight, 25–29.99 overweight, >30 obese). BSA was classified as either below or greater than or equal to (average for this cohort (1.87 m² for males and 1.66 m² for females). There was no significant difference in number of chemotherapy cycles, adverse events, and response rate or survival outcomes (overall and progression-free) across BMI and BSA categories. There was no significant difference in adverse events across BMI categories, but the incidences of embolic events and renal failure were higher in patients with an average or higher BSA than those with a lower than average BSA (6.6% vs. 3.1% for renal failure p = 0.06; 5.9% vs. 2.7% for renal failure, p = 0.07). There was no significant difference in response rate or survival outcomes (overall and progression-free) amongst BMI and BSA categories.

Conclusions: Obese patients with metastatic urothelial cancer on cisplatin-based therapies have similar response rates, survival outcomes, and tolerability of cisplatin-based therapy to non-obese patients.

Impact of Doxorubicin Treatment on the Physiological Functions of White Adipose Tissue

White adipose tissue (WAT) plays a fundamental role in maintaining energy balance and important endocrine functions. The loss of WAT modifies adipokine secretion and disrupts homeostasis, potentially leading to severe metabolic effects and a reduced quality of life. Doxorubicin is a chemotherapeutic agent used clinically because of its good effectiveness against various types of cancer. However, doxorubicin has deleterious effects in many healthy tissues, including WAT, liver, and skeletal and cardiac muscles. Our objective was to investigate the effects of doxorubicin on white adipocytes through in vivo and in vitro experiments. Doxorubicin reduced the uptake of glucose by retroperitoneal adipocytes and 3T3-L1 cells via the inhibition of AMP-activated protein kinase Thr172 phosphorylation and glucose transporter 4 content. Doxorubicin also reduced the serum level of adiponectin and, to a greater extent, the expression of genes encoding lipogenic (Fas and Acc) and adipogenic factors (Pparg, C/ebpa, and Srebp1c) in retroperitoneal adipose tissue. In addition, doxorubicin inhibited both lipogenesis and lipolysis and reduced the hormone-sensitive lipase and adipose tissue triacylglycerol lipase protein levels. Therefore, our results demonstrate the impact of doxorubicin on WAT. These results are important to understand some side effects observed in patients receiving chemotherapy and should encourage new adjuvant treatments that aim to inhibit these side effects.

Body mass index and mortality in prostate cancer patients: a dose-response meta-analysis

BACKGROUND

Previous studies concerning the association between body mass index (BMI) and mortality in prostate cancer yielded mixed results. We investigated the association by performing a meta-analysis of all available studies.

METHODS

Relevant studies were identified by searching PubMed and EMBASE to August 2015. We calculated the summary hazard ratio (HR) and 95% confidence interval (CI) using random-effects models. We estimated combined HRs associated with defined increments of BMI, using random-effects meta-analysis and dose-response meta-regression models.

RESULTS

Thirty-seven cohort studies and one case-control study involving 27 38 000 patients of prostate cancer were selected for meta-analysis. The summary results indicated higher prediagnosis BMI but not postdiagnosis BMI was associated with increased risk of death from prostate cancer. An increment of every 5 kg/m(2) in prediagnosis BMI was associated with a 15% higher prostate cancer-specific mortality (HR=1.15, 95% CI: 1.07-1.23, P<0.01). Prediagnosis or postdiagnosis BMI showed no effect on all-cause mortality in prostate cancer patients.

CONCLUSIONS

In conclusion, higher prediagnosis BMI is associated with a higher risk of death from prostate cancer. Considering the significant heterogeneity among included studies, these findings require confirmation in future studies.

Impact of body mass index on clinico-pathological parameters and outcome in patients with metastatic prostate cancer

BACKGROUND

This study evaluates the correlation between body mass index (BMI) and clinicopathological parameters of metastatic prostate cancer (MPC) and its impact on survival.

METHOD

During the study period, 71 MPC patients were eligible. Patients with BMI<25.0kg/m(2) were categorized as level I and patients with BMI⩾25.0kg/m(2) were categorized as level II. Demographic features and survival rates were evaluated by the Kaplan-Meier method and Cox proportional models.

RESULTS

31 patients belonged to level I while the rest belonged to level II with insignificant higher median follow-up duration in level II; p=0.5. In terms of age, metastasis, serum level of albumin, prostatic specific antigen, alkaline phosphatase (AKP) and Gleason score, there was no significant difference between the two levels. The cumulative survival probability in the 12th, 24th and 36th month in level I vs; level II was; 86.7%, 68.7%, 64.1% vs; 74.4%, 67.7%, 55.1%, respectively with 7 patients dead in level I compared to 14 patients dead in level II denoting a higher PC-specific death rate in the level II group. In univariate and multivariate analysis, poor prognosis was associated with increasing AKP (HR=1.0005, 95% CI, p=0.03; HR=1.001, 95% CI, p=0.03) respectively, while better prognosis was associated with no visceral metastasis (HR=0.09, 95% CI, p=0.000; HR=0.04, 95% CI, p=0.000) and increasing albumin levels (HR=0.17, 95% CI, p=0.000; HR=0.15, 95% CI, p=0.000) respectively. In multivariate analysis only, patients belonging to level I were associated with better prognosis (HR=0.17, 95% CI, p=0.02).

CONCLUSION

BMI is dependent on prognostic factors in patients with MPC.

Relationship between mortality and BMI after fracture: a population-based study of men and women aged ≥40 years

Fractures in obese older individuals contribute significantly to the overall burden on primary health care, but data on their impact on mortality are lacking. We studied the association between obesity and mortality following hip and nonhip clinical fractures in a retrospective, population-based cohort study. The Sistema d'Informació pel Desenvolupament de la Investigació en Atenció Primària (SIDIAP(Q) ) database contains primary care computerized medical records of a representative sample of >2.1 million people (35% of the population) in Catalonia (Spain), linked to hospital admissions data. We included in this analysis anyone aged 40 years and older suffering a hip or nonhip clinical fracture in 2007 to 2009 in the SIDIAP(Q) database. The main exposure was the most recent body mass index (BMI) measured before fracture, categorized as underweight (<18.5 kg/m2), normal (18.5 to <25 kg/m2 ), overweight (25 to <30 kg/m2), and obese (≥30 kg/m2). Furthermore, the study outcome was all-cause mortality in 2007 to 2009 as provided to SIDIAP(Q) by the National Office of Statistics. Time to death after fracture was modeled using Cox regression. Multivariate models were adjusted for age, gender, smoking, alcohol intake, oral glucocorticoid use, and Charlson comorbidity index. Within the study period, 6988 and 29,372 subjects with a hip or nonhip clinical fracture were identified and followed for a median (interquartile range) of 1.17 (0.53-2.02) and 1.36 (0.65-2.15) years, respectively. Compared to subjects of normal weight, adjusted hazard ratios (HRs) for mortality in overweight and obese subjects were 0.74 (95% CI, 0.62-0.88; p = 0.001) and 0.74 (95% CI, 0.60-0.91; p = 0.004) after hip and 0.50 (95% CI, 0.32-0.77; p = 0.002), 0.56 (95% CI, 0.36-0.87; p = 0.010) after nonhip fracture. In conclusion, the highest mortality was observed in individuals with low BMI, but compared to subjects of normal weight, obese and overweight individuals survived longer following fracture. The latter observation is consistent with data reported in other chronic conditions, but the reasons for reduced mortality in obese and overweight subjects when compared to those of normal weight require further research.

The emerging relevance of heterogeneity of treatment effect in clinical care: a study using stage IV prostate cancer as a model

AIM

Heterogeneity of treatment effect (HTE) occurs when patient factors modify a treatment's effect on health outcomes due to interactions between these factors and the treatment. This article reviews evidence regarding HTE in stage IV prostate cancer (S4PC).

METHOD

A systematic literature review was conducted in the MEDLINE and PubMed databases. Inclusion criteria required that articles examine the treatment-related impact of HTE factors on survival, adverse events or health-related quality of life in S4PC patients. The quality of evidence was graded good, fair or poor based on Agency for Healthcare Research and Quality guidelines.

RESULTS

The search identified 2659 articles, of which 92 met the inclusion/exclusion criteria. HTE in S4PC was studied for biologic factors including age, race, clinical signs/symptoms, measures of S4PC disease severity, genetic factors, laboratory data, prior treatment, concurrent medications and comorbidities. Nonbiologic factors that were studied included social, geographic and dietary factors. Age and race seldom showed any correlation with S4PC outcomes.

CONCLUSION

Diverse biologic and nonbiologic factors contribute to HTE in S4PC. This review in S4PC also provides an approach for examining HTE for other medical conditions. Ultimately, such knowledge can help oncologists prescribe more personalized medicine, help patients make more informed treatment choices, and inform policy-making and treatment coverage decisions.

Body mass index and its association with clinical outcomes for advanced non-small-cell lung cancer patients enrolled on Eastern Cooperative Oncology Group clinical trials

INTRODUCTION

Obesity increases the risk of death from many adverse health outcomes and has also been linked with cancer outcomes. The impact of obesity on outcomes of advanced non-small-cell lung cancer patients is unclear.

METHODS

The authors evaluated the association of body mass index (BMI) and outcomes in 2585 eligible patients enrolled in three consecutive first-line trials conducted by the Eastern Cooperative Oncology Group. BMI was categorized as underweight (BMI < 18.5 kg/m), normal weight (BMI: 18.5 to < 25 kg/m), overweight (BMI: 25 to < 30 kg/m), and obese (BMI ≥ 30 kg/m). In addition to analyzing overall and progression-free survival, reasons for treatment discontinuation were also assessed by BMI group.

RESULTS

Of the patients enrolled, 4.6% were underweight, 44.1% were normal weight, 34.3% of patients were classified as overweight, and 16.9% were obese. Nonproportional hazards existed for obese patients relative to the other three groups of patients, with a change in overall survival hazard occurring at approximately 16 months. In multivariable Cox models, obese patients had superior outcomes earlier on study compared with normal/overweight patients 0.86 (HR=0.86, p=0.04; 95% CI: 0.75-0.99), but later experienced increased hazard (HR=1.54, p< 0.001; 95% CI: 1.22-1.94), indicating a time effect while undergoing treatment.

CONCLUSION

Data from these three trials suggest differential outcomes associated with BMI, and additional studies of the mechanisms underlying this observation, as well as dietary and lifestyle interventions, are warranted to help optimize therapy.

Metabolic syndrome as a peculiar target for management of prostate cancer patients

An interesting and reciprocal association between the metabolic syndrome and prostate cancer has been identified. Metabolic alterations, such as hyperinsulinemia, increased levels of insulin growth factor-1, and insulin resistance could be on the basis of development and progression of many tumors, including prostate cancer, and changes in body composition, in turn, can represent some side effects of androgen deprivation therapy and novel drugs, such as mammalian target of rapamycin inhibitors. This review evaluates this interrelation between metabolic syndrome and prostate tumor scanning in many clinical and preclinical epidemiological studies and describes possible pathogenetic biological mechanisms. Finally, this article discusses feasible clinical implications for the management, prevention, diagnosis, prognosis, and treatment of patients affected by metabolic syndrome and prostate cancer, with particular attention to the metformin action.

Predictive factors for premature discontinuation of docetaxel-based systemic chemotherapy in men with castration-resistant prostate cancer

Purpose

The objective was to determine predictive factors for premature discontinuation of docetaxel-based systemic chemotherapy in men with castration-resistant prostate cancer (CRPC).

Materials and Methods

We retrospectively reviewed the medical records of men who were treated with docetaxel-based systemic chemotherapy for CRPC in a single institution between May 2005 and April 2010. After being screened, 30 patients fit the eligibility criteria for inclusion in this study. Group 1 included 12 patients who were treated with five or fewer cycles of docetaxel chemotherapy for CRPC, and group 2 included 18 patients who were treated with six or more cycles of docetaxel chemotherapy for CRPC. The treatment consisted of 5 mg prednisolone twice daily and 75 mg/m² docetaxel once every 3 weeks.

Results

The median age was 72 years, and the median Eastern Cooperative Oncology Group (ECOG) performance status was 0. The median baseline prostate-specific antigen (PSA) level was 33.8 ng/mL. The median cycle of docetaxel-based chemotherapy was 5.8. Of 30 patients, 13 patients (48.2%) had a decline in PSA of >50% from baseline; 3 of 22 patients (13.6%) with measurable disease had achieved partial response on imaging. No differences in age, ECOG performance status, hemoglobin, serum creatinine, or PSA response were observed between the two groups. Body mass index was significantly lower (p=0.034) in group 1 (21.8 kg/m²) than in group 2 (23.6 kg/m²). Group 1 included more patients with prior systemic chemotherapy (p=0.039), and group 1 had a shorter overall survival rate (p=0.039).

Conclusions

Premature discontinuation of docetaxel-based systemic chemotherapy is associated with lower body mass index and prior systemic chemotherapy. Premature discontinuation of docetaxel-based chemotherapy is associated with a shorter overall survival rate.

Prognostic value of body mass index in korean patients with castration-resistant prostate cancer

Purpose

We investigated the correlation between body mass index (BMI) and the prognosis of castration-resistant prostate cancer (CRPC) in patients who received docetaxel treatment.

Materials and Methods

A retrospective study was conducted of 55 patients who were diagnosed with CRPC and received docetaxel treatment between 2003 and 2009 at our institution. Patients with a normal or lower BMI (<23.0 kg/m²) were categorized as group I and patients with an overweight or greater BMI (≥23.0 kg/m²) were categorized as group II. Clinicopathological features and survival rates were evaluated by using the Kaplan-Meier method and Cox proportional hazards models.

Results

On the basis of BMI, 27 patients (49.1%) belonged to group I and 28 (50.9%) patients belonged to group II. Mean follow-up periods were 30 months and 34.2 months, respectively (p=0.381). There were no significant differences between the two groups in terms of age, prostate-specific antigen (PSA), Gleason score, Eastern Cooperative Oncology Group Performance Status, hemoglobin level, alkaline phosphatase level, distant metastasis, radiation treatments, or performance of radical prostatectomy (p>0.05). In the univariate analysis for predicting survival rates, BMI (p=0.005; hazard ratio [HR], 0.121), logPSA (p=0.044; HR, 2.878), and alkaline phosphatase level (p=0.039; HR, 8.582) were significant factors for prediction. In the multivariate analysis, BMI (p=0.005; HR, 0.55), logPSA (p=0.008; HR, 7.836), Gleason score (p=0.018; HR, 6.434), hemoglobin (p=0.006; HR, 0.096), alkaline phosphatase level (p=0.005; HR, 114.1), and metastasis to the internal organs (p=0.028; HR, 5.195) were significant factors for prediction.

Conclusions

Better effects on the cancer-specific survival rate were observed in cases with higher BMI.

Insulin-like growth factor pathway: a link between androgen deprivation therapy (ADT), insulin resistance, and disease progression in patients with prostate cancer?

Androgen deprivation therapy (ADT) is standard of care for patients with metastatic hormone-sensitive prostate cancer (HSPC), yet through its induction of a hypogonadal state leads to metabolic perturbations, including insulin resistance (IR) and obesity. IR and obesity have been associated with an increased risk of progression to castrate-resistant prostate cancer (CRPC) and ultimately increased prostate cancer-specific mortality. On a molecular level, this association between obesity/IR and prostate cancer progression may be mediated by alterations in the insulin-like growth factor (IGF) axis, which has been shown to be up-regulated upon disease progression to CRPC. Targeting the IGF axis, either by anti-IGF therapy or via enhancement of peripheral insulin sensitivity, represents a viable therapeutic target in patients with prostate cancer. Using the development of IR and/or obesity may represent a clinically available biomarker that may predict those patients most likely to respond to such therapy, and warrants testing in future prospective clinical trials.

Body mass index, prostate cancer-specific mortality, and biochemical recurrence: a systematic review and meta-analysis

Increasing evidence suggested obesity, measured by body mass index (BMI), was associated with prostate cancer-specific mortality, and its impact on biochemical recurrence was also inconclusive. We systematically searched MEDLINE, EMBASE, and bibliographies of retrieved studies up to January 5, 2010. We used random-effects meta-analysis to assess the relative risks (RR) of prostate cancer-specific mortality and biochemical recurrence associated with a 5 kg/m(2) increase in BMI. Among the six population-based cohort studies in 1,263,483 initially cancer-free men, 6,817 prostate cancer deaths occurred; a 5 kg/m(2) increase in BMI was associated with 15% (RR: 1.15, 95% confidence interval (CI): 1.06-1.25, P < 0.01) higher risk of dying of prostate cancer. In the six postdiagnosis survival studies on 18,203 patients with 932 prostate cancer deaths, a 5 kg/m(2) increase in BMI was associated with 20% higher prostate cancer-specific mortality (RR: 1.20, 95% CI: 0.99-1.46, P = 0.06). In the sixteen studies which followed 26,479 prostate cancer patients after primary treatment, a 5 kg/m(2) increase in BMI was significantly associated with 21% increased risk of biochemical recurrence (RR: 1.21, 95% CI: 1.11-1.31 P < 0.01). Elevated BMI is associated with risk of prostate cancer-specific mortality in prospective cohort studies and biochemical recurrence in prostate cancer patients. Its association with prostate cancer-specific mortality in diagnosed patients needs to be further evaluated.

Impact of body mass index on outcomes after conformal radiotherapy in patients with prostate cancer

PURPOSE

Several retrospective analyses have suggested that obese men with prostate cancer treated with external beam radiotherapy (EBRT) have outcomes inferior to those of normal-weight men. However, a recently presented analysis for the first time challenged this association between body mass index (BMI) and treatment failure. It is therefore important to provide further data on this issue.

METHODS AND MATERIALS

This was a retrospective analysis of 564 men treated with risk-adapted conformal EBRT at a single institution. Low-risk patients received EBRT alone, and the other patients received EBRT plus endocrine treatment. In addition, high-risk patients were treated to higher EBRT doses (74 Gy). A rectal balloon catheter for internal immobilization, which can be identified on portal images, was used in 261 patients (46%). Thus, localization did not rely on bony landmarks alone in these cases.

RESULTS

The median BMI was 26, and 15% of patients had BMI≥30. Neither univariate nor multivariate analyses detected any significant impact of BMI on biochemical relapse, prostate cancer-specific survival, or overall survival. The 5-year biochemical relapse rate was 21% and prostate cancer-specific survival 96%.

CONCLUSIONS

The present analysis of a large cohort of consecutively treated patients suggests that efforts to reduce prostate movement and geographic miss might result in comparable outcomes in obese and normal-weight patients.

Association between body mass index and mortality in patients with glioblastoma mutliforme

PURPOSE

To examine the association between obesity and survival in patients with glioblastoma mutliforme (GBM) METHODS: Using a prospective design, 1,259 patients with previously untreated GBM were recruited between 1991 and 2008. Height and weight were self-reported or abstracted from medical records at study entry and used to calculate body mass index (BMI) [weight (kg)/[height (m)](2). Cox proportional models were used to estimate the risk of death associated with BMI as a continuous variable or categorized using established criteria (normal weight, 18.5-24.9 kg/m(2); overweight, 25.0-29.9 kg/m(2); obese, ≥ 30.0 kg/m(2)).

RESULTS

Median follow-up was 40 months, and 1,069 (85%) deaths were observed during this period. For all patients, minimal adjusted analyses indicated no significant association between BMI treated as a continuous variable and survival. Compared with patients with a BMI 18.5-24.9 kg/m(2), the minimally adjusted HR for overall survival was 1.08 (95% CI, 0.94-1.24) for a BMI 25-29.9 kg/m(2) and 1.08 (95% CI, 0.91-28) for a BMI ≥ 30.0 kg/m(2). After additional adjustment for adjuvant therapy, the HR for those with a BMI of 25.0-29.9 kg/m(2) was 1.14 (95% CI, 0.99-1.32) and 1.09 (95% CI, 0.91-1.30) for those with a BMI ≥ 30.0 kg/m(2). No significant interactions were revealed for BMI and any demographic variables.

CONCLUSION

BMI was not associated with survival in newly diagnosed and previously untreated patients with GBM. Further research investigating the prognostic significance of alternative, quantitative measures of body habitus, and functional performance are required.

Evidence for a novel serum factor distinct from zinc alpha-2 glycoprotein that promotes body fat loss early in the development of cachexia

We provide evidence that a factor other than the previously identified lipid mobilizing factor, zinc alpha-2 glycoprotein, promotes lipolysis in the MCA-induced sarcoma-bearing cachexia model. Cachexia is characterized by progressive loss of adipose tissue and skeletal muscle without a concurrent increase in food intake to restore lost tissue stores. We compared tumor-bearing ad lib fed (TB) animals to nontumor bearing ad lib fed (NTB) animals or nontumor-bearing pair-fed (PF) animals at various time points throughout development of tumor derived cachexia. Prior to cachexia, the TB animals lost more than 10 +/- 0.7% of their body fat before losing protein mass and decreasing their food intake. Fat loss occurred because adipocyte size, not number, was reduced. Increased turnover of palmitate and significantly higher serum triglyceride levels prior to cachexia were further indicators of an early loss of lipid from the adipocytes. Yet, circulating levels of norepinephrine, epinephrine, TNF-alpha, and zinc alpha-2 glycoprotein were not increased prior to the loss of fat mass. We provide evidence for a serum factor(s), other than zinc alpha-2 glycoprotein, that stimulates release of glycerol from 3T3-L1 adipocytes and promotes the loss of stored adipose lipid prior to the loss of lean body mass in this model.

Obesity and cancer

The article examines the importance of managing weight to reduce risk for developing cancer and for survival among cancer patients and presents a set of strategies that can be useful to guide clinical advice to patients for whom weight control is an important adjunct to risk management or to improve quality of life and disease-free survival after diagnosis.

Weight, weight gain, and obesity account for approximately 20% of all cancer cases. Evidence on the relation of each to cancer is summarized, including esophageal, thyroid, colon, renal, liver, melanoma, multiple myeloma, rectum, gallbladder, leukemia, lymphoma, and prostate in men; and postmenopausal breast and endometrium in women. Different mechanisms drive etiologic pathways for these cancers. Weight loss, particularly among postmenopausal women, reduces risk for breast cancer. Among cancer patients, data are less robust, but we note a long history of poor outcomes after breast cancer among obese women. While evidence on obesity and outcomes for other cancers is mixed, growing evidence points to benefits of physical activity for breast and colon cancers. Dosing of chemotherapy and radiation therapy among obese patients is discussed and the impact on therapy-related toxicity is noted. Guidelines for counseling patients for weight loss and increased physical activity are presented and supported by strong evidence that increased physical activity leads to improved quality of life among cancer survivors. The “Five A's” model guides clinicians through a counseling session: assess, advise, agree, assist, arrange. The burden of obesity on society continues to increase and warrants closer attention by clinicians for both cancer prevention and improved outcomes after diagnosis.

Factors involved in the paradox of reverse epidemiology

BACKGROUND & AIMS

The hypothesis of reverse epidemiology holds that some cardiovascular risk factors, such as obesity, hypercholesterolemia and hypertension, in the elderly or in some chronic diseases are not harmful but permit better survival. However, this phenomenon is controversial and the underlying reasons are poorly understood.

OBJECTIVE

To search for factors simultaneously linked to reverse epidemiology and to short or long term survival.

METHODS

We included 400 patients, older than 60 years, hospitalized in a general internal medicine unit; 61 died in hospital and 338 were followed up by telephone.

RESULTS

Obesity, higher blood pressure and serum cholesterol, besides being related to lower mortality both in hospital and after discharge, were associated with better nutrition and functional capacity, less intense acute phase reaction and organ dysfunction, and lower incidence of high-mortality diseases such as dementia, pneumonia, sepsis or cancer. These associations may explain why obesity and other reverse epidemiology data are inversely related to mortality. Weight loss was related to mortality independently of BMI. Patients with BMI under 30 kg/m(2) who died in hospital showed more weight loss than those who survived; the lower the BMI, the greater the weight loss. In contrast, patients with BMI over 30 kg/m(2) who died in hospital gained more weight than those who survived; the higher the BMI, the greater the weight gain.

CONCLUSION

In patients over 60 years of age admitted to an internal medicine ward, obesity did not show independent survival value, being displaced by other nutritional parameters, functional capacity, acute phase reaction, organ dysfunction and diseases with poor prognosis.

New insights into adipose tissue atrophy in cancer cachexia

Profound loss of adipose and other tissues is a hallmark of cancer cachexia, a debilitating condition associated with increased morbidity and mortality. Fat loss cannot be attributable to reduced appetite alone as it precedes the onset of anorexia and is much more severe in experimental models of cachexia than in food restriction. Morphological examination has shown marked remodelling of adipose tissue in cancer cachexia. It is characterised by the tissue containing shrunken adipocytes with a major reduction in cell size and increased fibrosis in the tissue matrix. The ultrastructure of 'slimmed' adipocytes has revealed severe delipidation and modifications in cell membrane conformation. Although the molecular mechanisms remain to be established, evidence suggests that altered adipocyte metabolism may lead to adipose atrophy in cancer cachexia. Increased lipolysis appears to be a key factor underlying fat loss, while inhibition of adipocyte development and lipid deposition may also contribute. Both tumour and host-derived factors are implicated in adipose atrophy. Zinc-alpha2-glycoprotein (ZAG), which is overexpressed by certain malignant tumours, has been identified as a novel adipokine. ZAG transcripts and protein expression in adipose tissue are up regulated in cancer cachexia but reduced with adipose tissue expansion in obesity. Studies in vitro demonstrate that recombinant ZAG stimulates lipolysis. ZAG may therefore act locally, as well as systemically, to promote lipid mobilisation in cancer cachexia. Further elucidation of ZAG function in adipose tissue may lead to novel targets for preventing adipose atrophy in malignancy.

Body mass index and risk of all-cause and cardiovascular mortality in hospitalized elderly patients with diabetes mellitus

AIMS

Obesity is linked to increased morbidity and mortality risk in both the general population and in patients with diabetes mellitus; however, recent reports suggest that, in hospitalized elderly individuals, the association between body mass index (BMI) and mortality may be inverse. The present study sought to investigate the association between BMI and survival in hospitalized elderly individuals with diabetes mellitus.

METHODS

The medical records of 470 patients (226 males, mean age of 81.5 +/- 7.0 years) admitted to an acute geriatric ward between 1999 and 2000 were reviewed. Of the 140 patients with diabetes mellitus, 122 had more than 6 months of follow-up and were included in this analysis. Patients were followed up until 31 August 2004. Mortality data were extracted from death certificates.

RESULTS

During a mean follow-up of 3.7 +/- 1.6 years, 69 (56.6%) subjects died, 31 (25.4%) from cardiovascular causes. Those who died from any cause had lower baseline BMI than those who survived (24.0 +/- 4.0 vs. 27.1 +/- 4.3 kg/m(2); P < 0.0001). Similarly, those who died of cardiovascular causes had lower baseline BMI than those who did not (23.7 +/- 3.6 vs. 25.9 +/- 4.5, P = 0.01). BMI was inversely associated with all-cause [relative risk (RR) 0.89, 95% confidence interval (CI) 0.83-0.96, P = 0.002] and cardiovascular death (RR 0.83, 95% CI 0.74-0.93, P = 0.002) even after controlling for age, sex, smoking, dyslipidaemia and reason for hospital admission.

CONCLUSIONS

In very elderly subjects with diabetes mellitus, increased BMI was associated with reduced mortality risk.

The relationship of body mass index and serum testosterone with disease outcomes in men with castration-resistant metastatic prostate cancer

The purpose of this study was to evaluate the relationship of baseline body mass index (BMI) and serum testosterone level with prostate cancer outcomes in men with castration-resistant metastatic prostate cancer (CRPC). BMI and testosterone levels were evaluated for their ability to predict overall survival (OS) and prostate-specific antigen (PSA) declines in the TAX327 clinical trial, an international phase III randomized trial of one of the two schedules of docetaxel and prednisone compared with mitoxantrone and prednisone. In this study of 1006 men with CRPC, the median serum testosterone level was 14.5 ng per 100 ml (range 0-270), the median BMI was 27 kg m(-2) (range 15.7-46.5), and 26% of men were obese or morbidly obese (BMI>or=30). Obesity was associated with younger age, lower PSA and alkaline phosphatase levels, and higher performance status, primary Gleason sum, testosterone and hemoglobin compared to absence of obesity. In multivariate analysis, neither BMI, presence of obesity, nor baseline testosterone was significantly associated with OS or PSA declines. Higher testosterone levels among obese men suggest incomplete gonadal suppression with current therapies, but these differences may not be clinically relevant in men with CRPC. There was evidence of potential hemodilution of PSA and alkaline phosphatase levels in obese men.