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El-Taji O, Taktak S, Jones C, Brown M, Clarke N, Sachdeva A. Cardiovascular Events and Androgen Receptor Signaling Inhibitors in Advanced Prostate Cancer: A Systematic Review and Meta-Analysis. JAMA Oncol 2024; 10:874-884. [PMID: 38842801 PMCID: PMC11157448 DOI: 10.1001/jamaoncol.2024.1549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/29/2023] [Indexed: 06/07/2024]
Abstract
Importance Cardiovascular (CV) events remain a substantial cause of mortality among men with advanced and metastatic prostate cancer (PCa). The introduction of novel androgen receptor signaling inhibitors (ARSI) has transformed the treatment landscape of PCa in recent years; however, their associated CV toxic effects remains unclear. Objective To assess the incidence of CV events with addition of ARSI to standard of care (SOC) in locally advanced (M0) and metastatic (M1) PCa. Data Sources Systematic searches of PubMed, Scopus, Web of Science, EMBASE, and ClinicalTrials.gov were performed from inception up to May 2023. Study Selection Randomized clinical trials of ARSI agents (abiraterone, apalutamide, darolutamide, enzalutamide) that reported CV events among individuals with M0 and M1, hormone-sensitive prostate cancer (HSPC) and castration-resistant prostate cancer (CRPC). Data Extraction and Synthesis A systematic review was performed in accordance with PRISMA guidance. Two authors screened and independently evaluated studies eligible for inclusion. Data extraction and bias assessment was subsequently performed. Main Outcomes and Measures A random-effects meta-analysis was performed to estimate risk ratios for the incidence of all grade and grade 3 or higher CV events (primary outcomes), in addition to hypertension, acute coronary syndrome (ACS), cardiac dysrhythmia, CV death, cerebrovascular event, and venous thromboembolism (secondary outcomes). Sources of heterogeneity were explored using meta-regression. Results There were 24 studies (n = 22 166 patients; median age range, 63-77 years; median follow-up time range, 3.9-96 months) eligible for inclusion. ARSI therapy was associated with increased risk of all grade CV event (risk ratio [RR], 1.75; 95% CI, 1.50-2.04; P < .001) and grade 3 or higher CV events (RR, 2.10; 95%, 1.72-2.55; P < .001). ARSI therapy also was associated with increased risk for grade 3 or higher events for hypertension (RR, 2.25; 95% CI, 1.74-2.90; P < .001), ACS (RR, 1.93; 95% CI, 1.43-1.60; P < .01), cardiac dysrhythmia (RR, 1.64; 95% CI, 1.23-2.17; P < .001), cerebrovascular events (RR, 1.86; 95% CI, 1.34-2.59; P < .001) and for CV-related death (RR, 2.02; 95% CI, 1.32-3.10; P = .001). Subgroup analysis demonstrated increased risk of all CV events across the disease spectrum (M0 HSPC: RR, 2.26; 95% CI, 1.36-3.75; P = .002; M1 HSPC: RR, 1.85; 95% CI, 1.47-2.31; P < .001; M0 CRPC: RR, 1.79; 95% CI, 1.13-2.81; P = .01; M1 CRPC: RR, 1.46; 95% CI, 1.16-1.83; P = .001). Conclusions and Relevance This systematic review and meta-analysis found that the addition of ARSIs to traditional ADT was associated with increased risk of CV events across the prostate cancer disease spectrum. These results suggest that patients with prostate cancer should be advised about and monitored for the potential of increased risk of CV events with initiation of ARSI therapy alongside conventional hormonal therapy.
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Affiliation(s)
- Omar El-Taji
- Genito Urinary Cancer Research Group, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Department of Urology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, United Kingdom
| | - Samih Taktak
- Wirral University Teaching Hospitals NHS Foundation Trust, Wirral, United Kingdom
| | - Craig Jones
- Genito Urinary Cancer Research Group, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Department of Urology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, United Kingdom
| | - Mick Brown
- Genito Urinary Cancer Research Group, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Noel Clarke
- Genito Urinary Cancer Research Group, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Department of Urology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, United Kingdom
| | - Ashwin Sachdeva
- Genito Urinary Cancer Research Group, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, United Kingdom
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Zhang W, Liu H, Liu M, Ying S, Yuan R, Zeng H, Zhang Z, Han S, Si Z, Hu B, Wen S, Xu P, Yu W, Chen H, Wang L, Lin Z, Dai T, Lin Y, Xu T. Prevalence and risk evaluation of cardiovascular disease in the newly diagnosed prostate cancer population in China: A nationwide, multi-center, population-based cross-sectional study. Chin Med J (Engl) 2024; 137:1324-1331. [PMID: 38613214 PMCID: PMC11191028 DOI: 10.1097/cm9.0000000000003087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) has emerged as the leading cause of death from prostate cancer (PCa) in recent decades, bringing a great disease burden worldwide. Men with preexisting CVD have an increased risk for major adverse cardiovascular events when treated with androgen deprivation therapy (ADT). The present study aimed to explore the prevalence and risk evaluation of CVD among people with newly diagnosed PCa in China. METHODS Clinical data of newly diagnosed PCa patients were retrospectively collected from 34 centers in China from 2010 to 2022 through convenience sampling. CVD was defined as myocardial infarction, arrhythmia, heart failure, stroke, ischemic heart disease, and others. CVD risk was estimated by calculating Framingham risk scores (FRS). Patients were accordingly divided into low-, medium-, and high-risk groups. χ2 or Fisher's exact test was used for comparison of categorical variables. RESULTS A total of 4253 patients were enrolled in the present study. A total of 27.0% (1147/4253) of patients had comorbid PCa and CVD, and 7.2% (307/4253) had two or more CVDs. The enrolled population was distributed in six regions of China, and approximately 71.0% (3019/4253) of patients lived in urban areas. With imaging and pathological evaluation, most PCa patients were diagnosed at an advanced stage, with 20.5% (871/4253) locally progressing and 20.5% (871/4253) showing metastasis. Most of them initiated prostatectomy (46.6%, 1983/4253) or regimens involving ADT therapy (45.7%, 1944/4253) for prostate cancer. In the present PCa cohort, 43.1% (1832/4253) of patients had hypertension, and half of them had poorly controlled blood pressure. With FRS stratification, as expected, a higher risk of CVD was related to aging and metabolic disturbance. However, we also found that patients with treatment involving ADT presented an originally higher risk of CVD than those without ADT. This was in accordance with clinical practice, i.e., aged patients or patients at advanced oncological stages were inclined to accept systematic integrative therapy instead of surgery. Among patients who underwent medical castration, only 4.0% (45/1118) received gonadotropin releasing hormone antagonists, in stark contrast to the grim situation of CVD prevalence and risk. CONCLUSIONS PCa patients in China are diagnosed at an advanced stage. A heavy CVD burden was present at the initiation of treatment. Patients who accepted ADT-related therapy showed an original higher risk of CVD, but the awareness of cardiovascular protection was far from sufficient.
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Affiliation(s)
- Weiyu Zhang
- Department of Urology, Peking University People’s Hospital, Beijing 100044, China
| | - Huixin Liu
- Department of Clinical Epidemiology and Biostatistics, Peking University People’s Hospital, Beijing 100044, China
| | - Ming Liu
- Department of Urology, Beijing Hospital, National Center of Gerontology, Beijing 100005, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100005, China
| | - Shi Ying
- Department of Urology, Wuhan Union Hospital, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China
| | - Renbin Yuan
- Department of Urology, The Third People’s Hospital of Chengdu, Chengdu, Sichuan 610014, China
| | - Hao Zeng
- Department of Urology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Zhenting Zhang
- Department of Urologic Oncology, Tianjin Medical University Cancer Institute & Hospital, Tianjin 300060, China
| | - Sujun Han
- Department of Urology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- National Cancer Center, Beijing 100021, China
- National Clinical Research Center for Cancer, Beijing 100021, China
| | - Zhannan Si
- Department of Urology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- National Cancer Center, Beijing 100021, China
- National Clinical Research Center for Cancer, Beijing 100021, China
| | - Bin Hu
- Department of Urology, Liaoning Cancer Hospital, Shenyang, Liaoning 110801, China
| | - Simeng Wen
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin 300141, China
- Tianjin Institute of Urology, Tianjin Medical University, Tianjin 300141, China
| | - Pengcheng Xu
- Department of Urology, Lu’an Affiliated Hospital of Anhui Medical University, Lu’an, Anhui 237322, China
| | - Weimin Yu
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
| | - Hui Chen
- Department of Urology, Harbin Medical University Affiliated Cancer Hospital, Harbin, Heilongjiang 150081, China
| | - Liang Wang
- Department of Urology, The Second Hospital of Dalian Medical University, Dalian, Liaoning 116023, China
| | - Zhitao Lin
- Department of Urology Surgery, Fujian Cancer Hospital, Fuzhou, Fujian 350014, China
| | - Tao Dai
- Department of Urology Surgery, Hunan Cancer Hospital, Changsha, Hunan 410031, China
| | - Yunzhi Lin
- Department of Urology Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350004, China
| | - Tao Xu
- Department of Urology, Peking University People’s Hospital, Beijing 100044, China
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Li X, Wang M, Kalina JO, Preckel B, Hollmann MW, Albrecht M, Zuurbier CJ, Weber NC. Empagliflozin prevents oxidative stress in human coronary artery endothelial cells via the NHE/PKC/NOX axis. Redox Biol 2024; 69:102979. [PMID: 38061206 PMCID: PMC10749278 DOI: 10.1016/j.redox.2023.102979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/27/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Empagliflozin (EMPA) ameliorates reactive oxygen species (ROS) generation in human endothelial cells (ECs) exposed to 10 % stretch, but the underlying mechanisms are still unclear. Pathological stretch is supposed to stimulate protein kinase C (PKC) by increasing intracellular calcium (Ca2+), therefore activating nicotinamide adenine dinucleotide phosphate oxidase (NOX) and promoting ROS production in human ECs. We hypothesized that EMPA inhibits stretch-induced NOX activation and ROS generation through preventing PKC activation. METHODS Human coronary artery endothelial cells (HCAECs) were pre-incubated for 2 h before exposure to cyclic stretch (5 % or 10 %) with either vehicle, EMPA or the PKC inhibitor LY-333531 or PKC siRNA. PKC activity, NOX activity and ROS production were detected after 24 h. Furthermore, the Ca2+ chelator BAPTA-AM, NCX inhibitor ORM-10962 or NCX siRNA, sodium/potassium pump inhibitor ouabain and sodium hydrogen exchanger (NHE) inhibitor cariporide were applied to explore the involvement of the NHE/Na+/NCX/Ca2+ in the ROS inhibitory capacity of EMPA. RESULTS Compared to 5 % stretch, 10 % significantly increased PKC activity, which was reduced by EMPA and PKC inhibitor LY-333531. EMPA and LY-333531 showed a similar inhibitory capacity on NOX activity and ROS generation induced by 10 % stretch, which was not augmented by combined treatment with both drugs. PKC-β knockdown inhibits the NOX activation induced by Ca2+ and 10 % stretch. BAPTA, pharmacologic or genetic NCX inhibition and cariporide reduced Ca2+ in static HCAECs and prevented the activation of PKC and NOX in 10%-stretched cells. Ouabain increased ROS generation in cells exposed to 5 % stretch. CONCLUSION EMPA reduced NOX activity via attenuation of the NHE/Na+/NCX/Ca2+/PKC axis, leading to less ROS generation in HCAECs exposed to 10 % stretch.
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Affiliation(s)
- Xiaoling Li
- Amsterdam, University Medical Centers, Location AMC, Department of Anesthesiology, Laboratory of Experimental Intensive Care and Anesthesiology-L.E.I.C.A, Amsterdam Cardiovascular Science (ACS), Meibergdreef 11, 1105 AZ, Amsterdam, the Netherlands
| | - Mengnan Wang
- Amsterdam, University Medical Centers, Location AMC, Department of Anesthesiology, Laboratory of Experimental Intensive Care and Anesthesiology-L.E.I.C.A, Amsterdam Cardiovascular Science (ACS), Meibergdreef 11, 1105 AZ, Amsterdam, the Netherlands
| | - Jan-Ole Kalina
- Amsterdam, University Medical Centers, Location AMC, Department of Anesthesiology, Laboratory of Experimental Intensive Care and Anesthesiology-L.E.I.C.A, Amsterdam Cardiovascular Science (ACS), Meibergdreef 11, 1105 AZ, Amsterdam, the Netherlands; Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Schleswig-Holstein, Campus Kiel, 24105, Kiel, Germany
| | - Benedikt Preckel
- Amsterdam, University Medical Centers, Location AMC, Department of Anesthesiology, Laboratory of Experimental Intensive Care and Anesthesiology-L.E.I.C.A, Amsterdam Cardiovascular Science (ACS), Meibergdreef 11, 1105 AZ, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Amsterdam, University Medical Centers, Location AMC, Department of Anesthesiology, Laboratory of Experimental Intensive Care and Anesthesiology-L.E.I.C.A, Amsterdam Cardiovascular Science (ACS), Meibergdreef 11, 1105 AZ, Amsterdam, the Netherlands
| | - Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Schleswig-Holstein, Campus Kiel, 24105, Kiel, Germany
| | - Coert J Zuurbier
- Amsterdam, University Medical Centers, Location AMC, Department of Anesthesiology, Laboratory of Experimental Intensive Care and Anesthesiology-L.E.I.C.A, Amsterdam Cardiovascular Science (ACS), Meibergdreef 11, 1105 AZ, Amsterdam, the Netherlands
| | - Nina C Weber
- Amsterdam, University Medical Centers, Location AMC, Department of Anesthesiology, Laboratory of Experimental Intensive Care and Anesthesiology-L.E.I.C.A, Amsterdam Cardiovascular Science (ACS), Meibergdreef 11, 1105 AZ, Amsterdam, the Netherlands.
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Yu A, Thaliffdeen R, Park SK, Park C. Hospital outcomes and costs for prostate cancer patients with comorbid heart failure by age group: An analysis of the US Nationwide Inpatient Sample. J Eval Clin Pract 2023; 29:1016-1024. [PMID: 37256549 DOI: 10.1111/jep.13869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/28/2023] [Accepted: 04/30/2023] [Indexed: 06/01/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The prevalence of patients hospitalized with comorbid prostate cancer (PC) and heart failure (HF) has been steadily increasing. Both diseases share a set of common risk factors, with the most prominent being age. This study aimed to examine the outcomes and costs for patients with comorbid PC and HF, stratified by age. METHODS We analyzed 41,340 hospitalization events of patients with PC using the US National Inpatient Sample from 2015 to 2018. Associations of HF with in-hospital mortality, length of stay (LOS), and hospital costs per hospitalization were measured using multivariable logistic regression, negative binomial regression, and generalized linear regression with log-link and gamma distribution, respectively, controlling for covariates. Subgroup analyses were performed for age groups <65 and ≥65. RESULTS Visits of comorbid HF patients made up 2.3% (n = 952) of the PC study sample. Compared with PC patients without HF, those with HF had higher in-hospital mortality rates (odds ratio = 1.33, 95% confidence interval [CI] = 0.96-1.84, p = 0.085), longer hospital stays (incidence rate ratio = 1.32, 95% CI = 1.21-1.44, p < 0.001), and higher hospital costs (cost ratio = 1.17, 95% CI = 1.07-1.27, p = 0.001), controlling for covariates. On average, this amounted to a higher in-hospital mortality rate of 2.10%, an increased LOS of 1.73 days, and higher hospital costs of $2110 per patient. While in-hospital mortality did not differ significantly in patients aged <65 (p = 0.900), patients aged ≥65 had a 41% increased risk of in-hospital mortality compared with those without HF (p = 0.047). CONCLUSIONS In comparison to those without HF, PC patients with comorbid HF showed higher rates of in-hospital mortality, LOS, and hospital costs, with mortality showing a significant difference exclusively in the ≥65 population. Effective management of older patients with PC is needed to improve outcomes and decrease costs.
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Affiliation(s)
- Anthony Yu
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Ryan Thaliffdeen
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Sun-Kyeong Park
- School of Pharmacy, The Catholic University of Korea, Bucheon, South Korea
| | - Chanhyun Park
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
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Oderda M, Bertetto O, Barbera G, Calleris G, Falcone M, Filippini C, Marquis A, Marra G, Montefusco G, Peretti F, Gontero P. Appropriateness and complications of androgen deprivation therapy for prostate cancer: Can we do better? A retrospective observational analysis from a referral center. Urologia 2023; 90:100-108. [PMID: 36703243 DOI: 10.1177/03915603221149502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Androgen deprivation therapy (ADT) is the key of medical treatment for advanced prostate cancer (PCa), especially in elderly patients. However, the adherence of ADT prescription to current guidelines is not optimal and must be balanced against possible side effects. Aim of this study was to evaluate the prescriptive appropriateness of ADT and ADT-related adverse events in a referral center for PCa. METHODS Five hundred fifty six patients who received an outpatient prescription for ADT from 2014 to 2018 were retrospectively identified from an administrative database. Only standard ADT was considered, including GnRH agonists, GnRH antagonists, and antiandrogens. Prescriptive appropriateness was defined according to the last European Association of Urology (EAU) guidelines. Our cohort was stratified according to age categories and patient follow-up was updated. RESULTS Four hundred twenty five patients were available for analysis. Mean age was 80 years; 96.3% of our patients fell in the "elderly" category. There was a predominance of GnRH agonists over the antagonists (84.9% vs 13%). 15.5% of ADTs did not have an appropriate indication according to guidelines. Patient compliance to ADT was evaluated as good in 372 (87.5%) cases. ADT-related complications were detected in 166 (39%) patients: bone, cardiovascular, and other complications were reported in 7.3%, 8.9%, and 19% of patients. Progression of disease was noted in 165 (38.8%) cases during ADT. At last follow-up, 124 (30.1%) patients were deceased. CONCLUSIONS In a referral center, most ADT prescriptions followed EAU guidelines, but a non-negligible proportion still did not fall within these indications, exposing patients to unnecessary side effects. Compliance to ADT was generally good with a predominant use of GnRH agonists. Tolerance to ADT was fair, even if standardized reports were lacking.
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Affiliation(s)
- Marco Oderda
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Oscar Bertetto
- Rete Oncologica del Piemonte e della Valle d'Aosta, Torino, Italy
| | - Giulia Barbera
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Giorgio Calleris
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Marco Falcone
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | | | - Alessandro Marquis
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Giancarlo Marra
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Gabriele Montefusco
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Federica Peretti
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Paolo Gontero
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
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Martinez-Recio S, Perez-Wert JP, Martinez-Fdez S, Jimenez-Bou D, Ruiz-Gutierrez I, Peña J, Pertejo A, Espinosa E, Pinto A. COMPARISON OF 2-WEEKLY AND 3-WEEKLY DOSING OF DOCETAXEL IN METASTATIC PROSTATE CANCER. Clin Genitourin Cancer 2022; 20:363-370. [DOI: 10.1016/j.clgc.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 12/20/2022]
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Salvage Radical Prostatectomy for Radio-Recurrent Prostate Cancer: An Updated Systematic Review of Oncologic, Histopathologic and Functional Outcomes and Predictors of Good Response. ACTA ACUST UNITED AC 2021; 28:2881-2892. [PMID: 34436018 PMCID: PMC8395524 DOI: 10.3390/curroncol28040252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 11/23/2022]
Abstract
A valid treatment option for recurrence after definite radiotherapy (RT) for localized prostate cancer (PC) is salvage radical prostatectomy (SRP). However, data on SRP are scarce, possibly resulting in an underutilization. A systematic review was performed using MEDLINE (Pubmed), Embase, and Web of Science databases including studies published between January 1980 and April 2020. Overall, 23 English language articles including a total number of 2323 patients were selected according to PRISMA criteria. The overall median follow-up was 37.5 months (IQR 35.5–52.5). Biochemical-recurrence (BCR)-free probability ranged from 34% to 83% at five years, respectively, and from 31% to 37% at 10 years. Cancer specific survival (CSS) and overall survival (OS) ranged from 88.7% to 98% and 64% to 95% at five years and from 72% to 83% and 65% to 72% at 10 years, respectively. Positive surgical margins ranged from 14% to 45.8% and pathologic organ-confined disease was reported from 20% to 57%. The rate of pathologic > T2-disease ranged from 37% to 80% and pN1 disease differed between 0% to 78.4%. Pre-SRP PSA, pre-SRP Gleason Score (GS), pathologic stage after SRP, and pathologic lymph node involvement seemed to be the strongest prognostic factors for good outcomes. SRP provides accurate histopathological and functional outcomes, as well as durable cancer control. Careful patient counseling in a shared decision-making process is recommended.
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Okwuosa TM, Morgans A, Rhee JW, Reding KW, Maliski S, Plana JC, Volgman AS, Moseley KF, Porter CB, Ismail-Khan R. Impact of Hormonal Therapies for Treatment of Hormone-Dependent Cancers (Breast and Prostate) on the Cardiovascular System: Effects and Modifications: A Scientific Statement From the American Heart Association. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2021; 14:e000082. [PMID: 33896190 DOI: 10.1161/hcg.0000000000000082] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cardiovascular disease and cancer are the leading causes of death in the United States, and hormone-dependent cancers (breast and prostate cancer) are the most common noncutaneous malignancies in women and men, respectively. The hormonal (endocrine-related) therapies that serve as a backbone for treatment of both cancers improve survival but also increase cardiovascular morbidity and mortality among survivors. This consensus statement describes the risks associated with specific hormonal therapies used to treat breast and prostate cancer and provides an evidence-based approach to prevent and detect adverse cardiovascular outcomes. Areas of uncertainty are highlighted, including the cardiovascular effects of different durations of hormonal therapy, the cardiovascular risks associated with combinations of newer generations of more intensive hormonal treatments, and the specific cardiovascular risks that affect individuals of various races/ethnicities. Finally, there is an emphasis on the use of a multidisciplinary approach to the implementation of lifestyle and pharmacological strategies for management and risk reduction both during and after active treatment.
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Van Poppel H, Abrahamsson PA. Considerations for the use of gonadotropin-releasing hormone agonists and antagonists in patients with prostate cancer. Int J Urol 2020; 27:830-837. [PMID: 32662187 DOI: 10.1111/iju.14303] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/01/2020] [Indexed: 12/20/2022]
Abstract
Prostate cancer is the second most common cause of cancer-related deaths in men, representing a major source of morbidity and mortality. Androgen deprivation therapy is the primary treatment for patients with advanced prostate cancer at disease presentation, which can be achieved either with surgical or chemical castration. The development of gonadotropin-releasing hormone agonists revolutionized the treatment of advanced prostate cancer, replacing the need for surgical castration. Agonists downregulate gonadotropin-releasing hormone agonist receptors in the pituitary gland, and thus decrease the release of luteinizing hormone and testosterone. Although agonists are a common therapeutic option to date, their use is associated with testosterone surges, metabolic dysfunction and an increase in the risk of cardiovascular disease; they might contribute to tumor flares and potentially an increase in non-cancer mortality. More recently, gonadotropin-releasing hormone antagonists have entered the prostate cancer treatment landscape. Unlike agonists, antagonists directly inhibit the androgen receptor in the pituitary gland, and thus do not cause initial testosterone surges. In this article, we provide a concise review of the mechanism of actions, safety and efficacy of the approved agonists and antagonists for prostate cancer treatment.
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Cardiovascular risk profiles of GnRH agonists and antagonists: real-world analysis from UK general practice. World J Urol 2020; 39:307-315. [PMID: 32979057 PMCID: PMC7910366 DOI: 10.1007/s00345-020-03433-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/30/2020] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Androgen deprivation therapy (ADT) is the mainstay for the management of metastatic prostate cancer. Available pharmaceutical ADTs include gonadotropin-releasing hormone (GnRH) agonists and antagonists. Here, real-world data are presented from the UK general practitioner Optimum Patient Care Research Database. The study investigated the hypothesis that GnRH antagonists have lower cardiac event rates than GnRH agonists. METHODS The incidence of cardiac events following initiation of GnRH antagonist or agonist therapy was investigated in a population-based cohort study conducted in UK primary care between 2010 and 2017. RESULTS Analysis of real-world data from the UK primary care setting showed that relative risk of experiencing cardiac events was significantly lower with degarelix, a GnRH antagonist, compared with GnRH agonists (risk ratio: 0.39 [95% confidence interval 0.191, 0.799]; p = 0.01). Patients that received degarelix as first-line treatment switched treatment more frequently (33.7%), often to a GnRH agonist, than those who initiated treatment with a GnRH agonist (6.7-18.6%). CONCLUSION Screening for known or underlying vascular disease and identifying those at high risk of a cardiac event is important for risk mitigation in patients with prostate cancer receiving hormone therapy. The GnRH antagonist degarelix conferred a significantly lower risk of cardiac events than GnRH agonists. Prior to treatment, patients should be stratified based on level of cardiovascular (CV) risk, and appropriate lifestyle, and pharmacological interventions to mitigate CV risk should be recommended. CV risk factors and patient response to the intervention should be monitored at regular intervals.
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Margel D, Ber Y, Peer A, Shavit-Grievink L, Pinthus JH, Witberg G, Baniel J, Kedar D, Rosenbaum E. Cardiac biomarkers in patients with prostate cancer and cardiovascular disease receiving gonadotrophin releasing hormone agonist vs antagonist. Prostate Cancer Prostatic Dis 2020; 24:177-185. [PMID: 32737420 DOI: 10.1038/s41391-020-0264-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/12/2020] [Accepted: 07/24/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Gonadotrophin releasing hormone (GnRH) agonists and antagonists reduce testosterone levels for the treatment of advanced and metastatic prostate cancer. Androgen deprivation therapy (ADT) is associated with increased risk of cardiovascular (CV) events and CV disease (CVD), especially in patients with preexisting CVD treated with GnRH agonists. Here, we investigated the potential relationship between serum levels of the cardiac biomarkers N-terminal pro-B-type natriuretic peptide (NTproBNP), D-dimer, C-reactive protein (CRP), and high-sensitivity troponin (hsTn) and the risk of new CV events in prostate cancer patients with a history of CVD receiving a GnRH agonist or antagonist. METHODS Post-hoc analyses were performed of a phase II randomized study that prospectively assessed CV events in patients with prostate cancer and preexisting CVD, receiving GnRH agonist or antagonist. Cox proportional hazards models were used to determine whether the selected biomarkers had any predictive effect on CV events at baseline and across a 12-month treatment period. RESULTS Baseline and disease characteristics of the 80 patients who took part in the study were well balanced between treatment arms. Ischemic heart disease (66%) and myocardial infarction (37%) were the most common prior CVD and the majority (92%) of patients received CV medication. We found that high levels of NTproBNP (p = 0.008), and hsTn (p = 0.004) at baseline were associated with the development of new CV events in the GnRH agonist group but not in the antagonist. In addition, a nonsignificant trend was observed between higher levels of NTproBNP over time and the development of new CV events in the GnRH agonist group. CONCLUSIONS The use of cardiac biomarkers may be worthy of further study as tools in the prediction of CV risk in prostate cancer patients receiving ADT. Analysis was limited by the small sample size; larger studies are required to validate biomarker use to predict CV events among patients receiving ADT.
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Affiliation(s)
- David Margel
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yaara Ber
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel
| | - Avivit Peer
- Department of Oncology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Liat Shavit-Grievink
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel.,Davidoff Cancer Centre, Rabin Medical Center, Petach Tikva, Israel
| | - Jehonathan H Pinthus
- Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Guy Witberg
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Jack Baniel
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Kedar
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel
| | - Eli Rosenbaum
- Davidoff Cancer Centre, Rabin Medical Center, Petach Tikva, Israel
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12
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Kenk M, Grégoire JC, Coté MA, Connelly KA, Davis MK, Dresser G, Ghosh N, Goodman S, Johnson C, Fleshner N. Optimizing screening and management of cardiovascular health in prostate cancer: A review. Can Urol Assoc J 2020; 14:E458-E464. [PMID: 32569573 DOI: 10.5489/cuaj.6685] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In clinical practice, cancer management does not consistently encompass screening and identification of cardiovascular (CV) risk. The use of androgen deprivation therapy (ADT) in prostate cancer has been associated with increased CV risk and development of metabolic syndrome, necessitating identification of patients at risk in this population (e.g., those with pre-existing CV disease). A multidisciplinary team of Canadian physicians was assembled to develop a series of recommendations intended to identify patients who may benefit from optimal management of their CV disease and/or modification of cardiac risk factors. A key goal was the development of a simple screening tool for identification of patients with pre-existing CV disease. This simple and inclusive set of recommendations are intended for use within urology clinics to facilitate holistic approaches and simplify the management of patients.
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Affiliation(s)
- Miran Kenk
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Marc-Andre Coté
- Centre hospitalier universitaire de Quebec, Québec City, QC, Canada
| | - Kim A Connelly
- St. Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Margot K Davis
- University of British Columbia Diamond Health Care Center, Vancouver, BC, Canada
| | - George Dresser
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, ON, Canada
| | - Nina Ghosh
- Queensway Carleton Hospital, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Shaun Goodman
- Division of Cardiology, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Neil Fleshner
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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13
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Cereda V, Falbo PT, Manna G, Iannace A, Menghi A, Corona M, Semenova D, Calò L, Carnevale R, Frati G, Lanzetta G. Hormonal prostate cancer therapies and cardiovascular disease: a systematic review. Heart Fail Rev 2020; 27:119-134. [PMID: 32500365 DOI: 10.1007/s10741-020-09984-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Therapeutic intervention for prostate cancer mostly relies on eliminating circulating androgen or antagonizing its effect at the cellular level. As the use of endocrine therapies grows, an under-reported incidence of cardiovascular toxicities occurs in prostate cancer patients. In this review, we summarize data of clinical studies, investigating the cardiovascular and metabolic alterations associated with the use of old and new endocrine drugs (gonadotropin-releasing hormone [GnRH] agonists and antagonists, androgen receptor inhibitors, 17α-hydroxylase/c-17,20-lyase [CYP17] inhibitor) in prostate cancer. To date, studies looking for links between cardiovascular complications and hormone-mediated therapies in prostate cancer have reached conflicting results. Several confounding factors, such as age of patients and related cardiovascular liability, other comorbidities, and use of concomitant drugs, have to be carefully evaluated in future clinical trials. Further research is needed given the continuous advancements being made in prostate cancer treatment.
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Affiliation(s)
- Vittore Cereda
- Clinical Oncology Unit, Istituto Neurotraumatologico Italiano (I.N.I.) Grottaferrata, via di S.Anna snc, Grottaferrata, 00046, Rome, Italy.
| | - Pina T Falbo
- Clinical Oncology Unit, Istituto Neurotraumatologico Italiano (I.N.I.) Grottaferrata, via di S.Anna snc, Grottaferrata, 00046, Rome, Italy
| | - Gaia Manna
- Clinical Oncology Unit, Istituto Neurotraumatologico Italiano (I.N.I.) Grottaferrata, via di S.Anna snc, Grottaferrata, 00046, Rome, Italy
| | - Alessandro Iannace
- Clinical Oncology Unit, Istituto Neurotraumatologico Italiano (I.N.I.) Grottaferrata, via di S.Anna snc, Grottaferrata, 00046, Rome, Italy
| | - Antonello Menghi
- Clinical Oncology Unit, Istituto Neurotraumatologico Italiano (I.N.I.) Grottaferrata, via di S.Anna snc, Grottaferrata, 00046, Rome, Italy
| | - Michela Corona
- Clinical Oncology Unit, Istituto Neurotraumatologico Italiano (I.N.I.) Grottaferrata, via di S.Anna snc, Grottaferrata, 00046, Rome, Italy
| | - Diana Semenova
- Clinical Oncology Unit, Istituto Neurotraumatologico Italiano (I.N.I.) Grottaferrata, via di S.Anna snc, Grottaferrata, 00046, Rome, Italy
| | - Leonardo Calò
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169, Rome, Italy
| | - Roberto Carnevale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100, Latina, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100, Latina, Italy
| | - Gaetano Lanzetta
- Clinical Oncology Unit, Istituto Neurotraumatologico Italiano (I.N.I.) Grottaferrata, via di S.Anna snc, Grottaferrata, 00046, Rome, Italy
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14
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Perrone V, Degli Esposti L, Giacomini E, Veronesi C, Blini V, Oderda M. Cardiovascular Risk Profile in Prostate Cancer Patients Treated with GnRH Agonists versus Antagonists: An Italian Real-World Analysis. Ther Clin Risk Manag 2020; 16:393-401. [PMID: 32440137 PMCID: PMC7216299 DOI: 10.2147/tcrm.s249208] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/30/2020] [Indexed: 01/22/2023] Open
Abstract
Purpose To evaluate and compare the incidence of cardiovascular (CV) events in a large contemporary cohort of patients diagnosed with prostate cancer (PCa) and in treatment with GnRH agonists or GnRH antagonists. Patients and Methods An Italian observational retrospective cohort study based on administrative databases of three local health units and two Regions was performed. PCa patients treated with GnRH agonists or antagonist were included between January 01, 2013 and December 31, 2016. Index date (ID) was the date of first GnRH agonist/antagonist prescription during inclusion period. Follow-up was from ID to December 31, 2017. Patients were excluded if they were under abiraterone treatment or combination therapy with antiandrogens during follow-up. The incidence rate of CV events (acute myocardial infarction, ischemic heart diseases, cerebrovascular diseases, cardiac dysrhythmias, heart failure, atherosclerosis, aneurism, other CV-related conditions) was calculated among patients not switching to androgen deprivation therapy (ADT) in the overall cohort and in a sub-cohort of patients without previous CV events. Results In total, 9785 (mean age 76.8 ± 8.5) patients were included: 9158 (93.6%) were treated with a GnRH agonist and 627 (6.4%) with a GnRH antagonist. Of them, 9627 did not switch to ADT and were considered in the analyses. The incidence of CV events was significantly higher in patients treated with GnRH agonists rather than antagonists (8.8 vs 6.2, p=0.002). Mean time to CV event was beyond 1 year of treatment in both groups. In the multivariable regression analysis, the risk of experiencing CV events was significantly lower in patients treated with GnRH antagonist rather than those treated with GnRH agonists [HR (95% CI): 0.76 (0.60-0.95), p=0.018]. These findings were confirmed in the sub-cohort of patients without previous CV events. Conclusion This Italian observational study shows that most patients received a GnRH agonist rather than a GnRH antagonist prescription. GnRH antagonist seems to have a better CV risk profile than GnRH agonist, both in patients with and without a history of CV events.
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Affiliation(s)
| | | | - Elisa Giacomini
- CliCon S.r.l. Health, Economics & Outcomes Research, Ravenna, Italy
| | - Chiara Veronesi
- CliCon S.r.l. Health, Economics & Outcomes Research, Ravenna, Italy
| | - Valerio Blini
- CliCon S.r.l. Health, Economics & Outcomes Research, Ravenna, Italy
| | - Marco Oderda
- Department of Surgical Sciences - Urology, Città Della Salute e Della Scienza Di Torino, Molinette Hospital, University of Turin, Turin, Italy
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15
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Pongkan W, Banjongkankul W, Ketyungyuenwong P, Kongtueng P, Buddhachat K, Nganvongpanit K. New findings of branching variations in subclavian arteries and supra-aortic arteries in Felis catus. Anat Sci Int 2020; 95:440-454. [PMID: 32207054 DOI: 10.1007/s12565-020-00539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/11/2020] [Indexed: 11/29/2022]
Abstract
The branching of blood vessels around the heart is varied in each animal. Three branching patterns of the brachiocephalic trunk in cats have been reported. However, supra-aortic arteries in the hearts of cats have never been investigated. In this study, we hypothesized that the variations of the aortic arch, supra-aortic arteries, and vena cava were observed in domestic cats. Sixty-one hearts obtained from the cadavers of domestic cats (Felis catus) were analyzed in terms of anatomical characteristics, size, and the length of these supra-aortic vessels by using a 3D scanner. New variations of the left and right subclavian arteries were observed using the location of the internal thoracic (ITA) and vertebral artery (VA) as the criterion to group the varying patterns. We found four patterns of the left subclavian artery, which included ITA budding contralateral before VA (5%), VA budding opposite to ITA (75%), VA budding contralateral before ITA (13%) and ITA budding ipsilateral before VA (7%). In contrast, only three patterns were found in the right subclavian artery, which included VA budding opposite to ITA (20%), VA budding contralateral before ITA (19%), and ITA budding contralateral before VA (61%). Moreover, although an average vascular diameter in male cats was higher than in female subjects, the supra-aortic blood volume in both sexes was not different. The findings of this study could help fill the existing gap of knowledge on the anatomical variations of supra-aortic arteries in cats and could be used in clinical applications based on relevant anatomical data.
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Affiliation(s)
- Wanpitak Pongkan
- Department of Veterinary Biosciences and Public Health, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand.,Center of Excellence in Veterinary Biosciences, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand
| | - Wiravarn Banjongkankul
- Department of Veterinary Biosciences and Public Health, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand
| | - Piyawan Ketyungyuenwong
- Department of Veterinary Biosciences and Public Health, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand
| | - Piyamat Kongtueng
- Central Laboratory, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand
| | - Kittisak Buddhachat
- Department of Biology, Faculty of Science, Naresuan University, Phitsanulok, 65000, Thailand
| | - Korakot Nganvongpanit
- Department of Veterinary Biosciences and Public Health, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand. .,Center of Excellence in Veterinary Biosciences, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand.
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16
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Kirby MG, Allchorne P, Appanna T, Davey P, Gledhill R, Green JSA, Greene D, Rosario DJ. Prescription switching: Rationales and risks. Int J Clin Pract 2020; 74:e13429. [PMID: 31573733 DOI: 10.1111/ijcp.13429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 09/21/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Therapeutic drug switching is commonplace across a broad range of indications and, within a drug class, is often facilitated by the availability of multiple drugs considered equivalent. Such treatment changes are often considered to improve outcomes via better efficacy or fewer side effects, or to be more cost-effective. Drug switching can be both appropriate and beneficial for several reasons; however, switching can also be associated with negative consequences. AIM To consider the impact of switching in two situations: the use of statins as a well-studied example of within-class drug switching, and gonadotropin-releasing hormone (GnRH)-targeting drug switching as an example of cross-class switching. RESULTS With the example of statins, within-class switching may be justified to reduce side effects, although the decision to switch is often also driven by the lower cost of generic formulations. With the example of GnRH agonists/antagonists, switching often occurs without the realisation that these drugs belong to different classes, with potential clinical implications. CONCLUSION Lessons emerging from these examples will help inform healthcare practitioners who may be considering switching drug prescriptions.
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Affiliation(s)
| | - Paula Allchorne
- Barts Health NHS Trust, The Royal London Hospital, London, UK
| | | | | | | | - James S A Green
- Barts Health NHS Trust, The Royal London Hospital, London, UK
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17
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Plummer C, Steingart RM, Jurczak W, Iakobishvili Z, Lyon AR, Plastaras JP, Minotti G. Treatment specific toxicities: Hormones, antihormones, radiation therapy. Semin Oncol 2019; 46:414-420. [PMID: 31784040 DOI: 10.1053/j.seminoncol.2019.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/23/2019] [Indexed: 11/11/2022]
Abstract
Session IV of the Second International Colloquium on Cardio-Oncology held in Kraków, focused on the cardiovascular risks of using hormone replacement therapy in breast cancer and androgen deprivation therapy in prostate cancer and continued the theme from Session 3 with a discussion of risk reduction strategies. The discussion then moved to an overview of modern radiation therapy and evolving mechanisms of cardioprotection. The risks and late cardiotoxic effects that must be considered in patients treated prior to the "modern era" were enumerated stressing the importance of long term follow-up of this population.
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Affiliation(s)
| | - Richard M Steingart
- Memorial Sloan Kettering Cancer Center and Weill Medical College of Cornell University, New York, NY
| | - Wojcech Jurczak
- Department of Haematology, Jagiellonian University, Krakow, Poland
| | | | - Alex R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital, and National Heart and Lung Institute, Imperial College London, London, UK
| | - John P Plastaras
- Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Giorgio Minotti
- University Campus Bio-Medico, Via Alvaro del Portillo 21,00128 Rome, Italy.
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18
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Tully KH, Nguyen DD, Herzog P, Jin G, Noldus J, Nguyen PL, Kibel AS, Sun M, McGregor B, Basaria S, Trinh QD. Risk of Dementia and Depression in Young and Middle-aged Men Presenting with Nonmetastatic Prostate Cancer Treated with Androgen Deprivation Therapy. Eur Urol Oncol 2019; 4:66-72. [PMID: 31624049 DOI: 10.1016/j.euo.2019.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/17/2019] [Accepted: 08/13/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Previous studies have found an association between androgen deprivation therapy (ADT) and an increased risk of dementia and depression in elderly men. This association remains controversial, and little is known about the effects of ADT in younger men. OBJECTIVE To examine the association between the receipt of ADT and these outcomes in young men aged 40-64 yr presenting with nonmetastatic prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS For this observational study, we identified 9117 men aged 40-64 yr diagnosed with localized PCa between 2007 and 2014, without a pre-existing neurocognitive diagnosis, using the TRICARE military database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Kaplan-Meier curves were fitted to compare ADT versus no ADT. We also performed a subgroup analysis in patients undergoing ADT for ≥12 mo. The association between ADT and new-onset dementia or depression was evaluated using inverse-probability-of treatment-weight-adjusted Cox proportional hazards regression analysis. RESULTS AND LIMITATIONS Patients receiving ADT had a significantly higher incidence of depression (30.2 vs 15.8 per 1000 person years) and dementia (17.9 vs 7.5 per 1000 person years). The risk of developing either outcome was higher in the ADT cohort (depression: hazard ratio [HR] 2.07, p < 0.001; dementia: HR 1.70, p = 0.052). Additionally, there was a dose-response relationship between the duration of ADT and either outcome. CONCLUSIONS In our cohort of young men with PCa, the receipt of ADT was associated with an increased risk of developing dementia and depression. Long-term use of ADT was associated with the highest risk of neurocognitive outcomes. PATIENT SUMMARY In this study, we looked at the risk of dementia and depression in patients <65 yr of age undergoing androgen deprivation therapy (ADT) for prostate cancer. We found that these patients had a higher risk of dementia and depression than those who did not undergo ADT.
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Affiliation(s)
- Karl H Tully
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - David-Dan Nguyen
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Peter Herzog
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joachim Noldus
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Adam S Kibel
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maxine Sun
- Lank Center for Genitourinary Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Bradley McGregor
- Lank Center for Genitourinary Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Shehzad Basaria
- Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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19
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Assaly R, Giuliano F, Clement P, Laurin M, Favier M, Teo P, Bernabe J, Alexandre L, Behr-Roussel D. Extracorporeal Shock Waves Therapy Delivered by Aries Improves Erectile Dysfunction in Spontaneously Hypertensive Rats Through Penile Tissue Remodeling and Neovascularization. Sex Med 2019; 7:441-450. [PMID: 31551177 PMCID: PMC6963128 DOI: 10.1016/j.esxm.2019.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/06/2019] [Accepted: 08/06/2019] [Indexed: 11/24/2022] Open
Abstract
Background Low-intensity extracorporeal shock wave therapy (Li-ESWT) has been reported to improve erectile function in patients with moderate-to-severe erectile dysfunction (ED) or even convert phosphodiesterase type 5 inhibitors nonresponders to responders. ED is highly prevalent in hypertensive patients. The effect of Li-ESWT on an animal model of hypertension-associated ED has not been reported. Aim To investigate the effect of Li-ESWT on hypertension-associated ED and provide plausible mechanisms of action of Li-ESWT on local mechanisms of penile erection. Methods Spontaneously hypertensive rats (SHRs) in the active group (n = 13) received Li-ESWT at energy flux density 0.06 mJ/mm2 (Aries; Dornier MedTech, Wessling, Germany) twice weekly for 6 weeks. The emitter was set to zero for SHRs in the sham group (n = 12). Erectile function was assessed 4 weeks post-treatment by monitoring intracavernosal pressure (ICP) in response to electrical stimulation of cavernous nerve before and after single dose of 0.3 mg/kg intravenous sildenafil. Cavernosal tissue was then evaluated for collagen/smooth muscle content, neuronal nitric oxide synthase (nNOS), and vascular endothelial factor (CD31) expression. Outcomes Erectile function was assessed with ICP, erectile tissue remodeling was studied by smooth muscle/collagen ratio, nNOS and CD31 were semiquantitatively evaluated on cavernosal sections. Results The improvement of ICP parameters was greater in Li-ESWT–treated rats compared with controls with and without sildenafil. Sildenafil led to 20% increase in area under the intracavernosal pressure curve measured during the entire response/mean arterial pressure at 10 Hz in ESWT_SHR + sildenafil compared with ESWT_SHR. The smooth muscle/collagen ratio increased 2.5-fold in Li-ESWT compared with sham. Expression of CD31 tended to be increased whereas nNOS was unchanged. Conclusions Li-ESWT by Aries may represent an effective noninvasive therapeutic alternative and a relevant add-on therapy to phosphodiesterase type 5 inhibitors for ED in hypertensive patients, and it is suggested that it acts via remodeling of the penile tissue and promoting cavernosal vascularization. Assaly R, Giuliano F, Clement P, et al. Extracorporeal Shock Waves Therapy Delivered by Aries Improves Erectile Dysfunction in Spontaneously Hypertensive Rats Through Penile Tissue Remodeling and Neovascularization. Sex Med 2019;7:441–450
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Affiliation(s)
- Rana Assaly
- Pelvipharm, Montigny-le-Bretonneux, France; UMR1179, Université Versailles Saint Quentin en Yvelines, Montigny-le-Bretonneux, France
| | - François Giuliano
- Pelvipharm, Montigny-le-Bretonneux, France; UMR1179, Université Versailles Saint Quentin en Yvelines, Montigny-le-Bretonneux, France; AP-HP, Neuro-Uro-Andrology, Department of Physical Medicine and Rehabilitation, Raymond Poincaré Hospital, Garches, France
| | - Pierre Clement
- Pelvipharm, Montigny-le-Bretonneux, France; UMR1179, Université Versailles Saint Quentin en Yvelines, Montigny-le-Bretonneux, France
| | - Miguel Laurin
- Pelvipharm, Montigny-le-Bretonneux, France; UMR1179, Université Versailles Saint Quentin en Yvelines, Montigny-le-Bretonneux, France
| | | | | | - Jacques Bernabe
- Pelvipharm, Montigny-le-Bretonneux, France; UMR1179, Université Versailles Saint Quentin en Yvelines, Montigny-le-Bretonneux, France
| | | | - Delphine Behr-Roussel
- Pelvipharm, Montigny-le-Bretonneux, France; UMR1179, Université Versailles Saint Quentin en Yvelines, Montigny-le-Bretonneux, France.
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20
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A lifestyle intervention of weight loss via a low-carbohydrate diet plus walking to reduce metabolic disturbances caused by androgen deprivation therapy among prostate cancer patients: carbohydrate and prostate study 1 (CAPS1) randomized controlled trial. Prostate Cancer Prostatic Dis 2019; 22:428-437. [PMID: 30664736 DOI: 10.1038/s41391-019-0126-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/23/2018] [Accepted: 01/06/2019] [Indexed: 01/26/2023]
Abstract
PURPOSE The objective of this study was to test a low-carbohydrate diet (LCD) plus walking to reduce androgen deprivation therapy (ADT)-induced metabolic disturbances. MATERIALS AND METHODS This randomized multi-center trial of prostate cancer (PCa) patients initiating ADT was designed to compare an LCD (≤20g carbohydrate/day) plus walking (≥30 min for ≥5 days/week) intervention vs. control advised to maintain usual diet and exercise patterns. Primary outcome was change in insulin resistance by homeostatic model assessment at 6 months. To detect 20% reduction in insulin resistance, 100 men were required. The study was stopped early after randomizing 42 men due to slow accrual. Secondary outcomes included weight, body composition, lipids, and prostate-specific antigen (PSA). Changes from baseline were compared between arms using rank-sum tests. RESULTS At 6 months, LCD/walking reduced insulin resistance by 4% vs. 36% increase in control (p = 0.13). At 3 months, vs. control, LCD/walking arm significantly lost weight (7.8kg; p<0.001), improved insulin resistance (↑36%; p = 0.015), hemoglobin A1c (↓3.3%; p = 0.01), high-density lipoprotein (HDL) (↑13%; p = 0.004), and triglyceride (↓37%; p = 0.036). At 6 months, weight loss (10.6kg; p<0.001) and HDL (↑27%; p = 0.003) remained significant. LCD/walking preserved total body bone mineral count (p = 0.025), reduced fat mass (p = 0.002), lean mass (p = 0.036), and percent body fat (p = 0.004). There were no differences in PSA. Limitations include the effect of LCD, weight loss vs. walking instruction are indistinguishable, and small sample size. CONCLUSIONS In an underpowered study, LCD/walking did not improve insulin sensitivity at 6 months. Given most secondary outcomes were improved at 3 months with some remaining improved at 6 months and a secondary analysis showed that LCD/walking reduced insulin resistance over the study, supporting future larger studies of LCD/walking intervention to reduce ADT-induced disturbances.
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Mazzone E, Preisser F, Nazzani S, Tian Z, Bandini M, Gandaglia G, Fossati N, Soulières D, Graefen M, Montorsi F, Shariat SF, Saad F, Briganti A, Karakiewicz PI. Location of Metastases in Contemporary Prostate Cancer Patients Affects Cancer-Specific Mortality. Clin Genitourin Cancer 2018; 16:376-384.e1. [DOI: 10.1016/j.clgc.2018.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 11/30/2022]
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Merseburger A, Bro Falkenberg A, Kornilova OJ. New study suggests patients with advanced prostate cancer on androgen deprivation therapy need more dialogue with health care provider, especially around cardiovascular risk. World J Urol 2018; 37:1085-1093. [PMID: 30244335 DOI: 10.1007/s00345-018-2495-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 09/14/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To study the current level of patients' awareness, and patient-health care provider (HCP) dialogue with respect to treatment-related risks, especially cardiovascular risk (CVR) associated with advanced prostate cancer (PCa) treatment. METHODS This 10-min online survey summarised data by treatment, region, and CVR (high or low). RESULTS Of the 411 patients, 83% were at high CVR while only 8% patients were aware of CVR associated with PCa treatment, majority of which (80%) were informed about this risk by HCPs. No significant difference in treatment approach was reported, regardless of patient's CVR status. Compared to other potential risks, patients were more likely to initiate discussion about heart problems with HCPs (38% patients). When prompted, 26% patients rated heart problems as the most concerning risk factor, and this concern was twice in patients with high CVR (28%) versus low CVR (14%). Lifestyle modifications were made by 64% patients, of which 45% patients reported an improvement in overall well-being. Improved diet was the most adopted lifestyle modification. CONCLUSION There is a need to enhance a constant patient-HCP dialogue, and both groups need to make a conscious effort in that direction. This would help in increasing patients' awareness of risks, having better treatment choice and acceptance, and reducing side-effects.
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Affiliation(s)
- Axel Merseburger
- University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | | | - Olga J Kornilova
- Ferring International Center, Chemin de la Vergognausaz 50, Saint-Prex, Switzerland
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Bandini M, Fossati N, Gandaglia G, Preisser F, Dell'Oglio P, Zaffuto E, Stabile A, Gallina A, Suardi N, Shariat SF, Montorsi F, Karakiewicz PI, Briganti A. Neoadjuvant and adjuvant treatment in high-risk prostate cancer. Expert Rev Clin Pharmacol 2018; 11:425-438. [PMID: 29355037 DOI: 10.1080/17512433.2018.1429265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION High-risk prostate cancer (HRPCa) represents a heterogeneous disease with potential risk for local and distant progression. In these patients, a multi-modal approach consisting of neoadjuvant and/or adjuvant systemic therapies has been proposed. The aim of this review is to summarize the emerging roles of neoadjuvant and adjuvant therapies in HRPCa patients. Areas covered: This review collects the most relevant phase III randomized controlled trials (RCTs) testing the effect of neoadjuvant and adjuvant systemic therapies in combination with radical prostatectomy (RP) or radiotherapy (RT) for HRPCa patients. Specifically, the review examines the benefit provided by androgen deprivation therapy (ADT), chemotherapy (CHT), and novel antiandrogen agents in this setting. A search of bibliographic databases for peer-reviewed literature was conducted. Expert commentary: Three decades of RCTs demonstrated that adjuvant ADT is fundamental in HRPCa treated with RT. Conversely, ADT and CHT did not improve the survival of HRPCa patients managed with RP. The recent introduction of novel antiandrogen agents combined with an appropriated selection of patients at risk of cancer progression, may ultimately extend the indication of neoadjuvant and adjuvant therapy in surgical- and radio-treated patients.
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Affiliation(s)
- Marco Bandini
- a Division of Oncology/Unit of Urology , URI, IRCCS Hospital San Raffaele , Milan , Italy.,b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy.,c Cancer Prognostics and Health Outcomes Unit , University of Montreal Health Center , Montreal , Quebec , Canada
| | - Nicola Fossati
- a Division of Oncology/Unit of Urology , URI, IRCCS Hospital San Raffaele , Milan , Italy.,b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy
| | - Giorgio Gandaglia
- a Division of Oncology/Unit of Urology , URI, IRCCS Hospital San Raffaele , Milan , Italy.,b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy
| | - Felix Preisser
- c Cancer Prognostics and Health Outcomes Unit , University of Montreal Health Center , Montreal , Quebec , Canada.,d Department of Urology , Martini Klinik, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Paolo Dell'Oglio
- a Division of Oncology/Unit of Urology , URI, IRCCS Hospital San Raffaele , Milan , Italy.,b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy
| | - Emanuele Zaffuto
- a Division of Oncology/Unit of Urology , URI, IRCCS Hospital San Raffaele , Milan , Italy.,b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy
| | - Armando Stabile
- a Division of Oncology/Unit of Urology , URI, IRCCS Hospital San Raffaele , Milan , Italy.,b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy
| | - Andrea Gallina
- a Division of Oncology/Unit of Urology , URI, IRCCS Hospital San Raffaele , Milan , Italy.,b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy
| | - Nazareno Suardi
- b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy.,e Urology Department, IRCCS San Raffaele Scientific Institute , Ville Turro Division , Milan , Italy
| | - Shahrokh F Shariat
- f Department of Urology , Medical University of Vienna , Vienna , Austria
| | - Francesco Montorsi
- a Division of Oncology/Unit of Urology , URI, IRCCS Hospital San Raffaele , Milan , Italy.,b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy
| | - Pierre I Karakiewicz
- c Cancer Prognostics and Health Outcomes Unit , University of Montreal Health Center , Montreal , Quebec , Canada
| | - Alberto Briganti
- a Division of Oncology/Unit of Urology , URI, IRCCS Hospital San Raffaele , Milan , Italy.,b Division of Oncology/Unit of Urology , Vita-Salute San Raffaele University , Milan , Italy
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Prati V, Ruatta F, Aversa C, Gernone A, Galizia D, Bonzano A, Torino S, Nuzzolese I, Marandino L, Aglietta M, Ortega C. Cardiovascular safety of abiraterone acetate in metastatic castration-resistant prostate cancer patients: a prospective evaluation. Future Oncol 2018; 14:443-448. [PMID: 29318908 DOI: 10.2217/fon-2017-0385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
AIM The aim of this study is to evaluate cardiotoxicity of abiraterone acetate (AA) in metastatic castration-resistant prostate cancer patients (pts) with cardiovascular comorbidities or coronary artery disease (CAD) risk factors. PATIENTS & METHODS We prospectively analyzed pts receiving AA in order to evaluate correlations between cardiotoxicity onset and CAD risk factors or cardiovascular comorbidities. RESULTS Eighty-seven pts were enrolled, with median treatment duration of 9 months (1-44). At baseline, 84 pts (96%) had CAD risk factors. During treatment four pts (4; 6%) developed hypertension and 26 pts (30%) worsened the preexisting hypertension. Median left ventricular ejection fraction were 64 and 63% at baseline and after treatment, respectively. CONCLUSION AA appears to be safe in pts with cardiovascular comorbidities or CAD risk factors.
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Affiliation(s)
- Veronica Prati
- Medical Oncology I, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy.,Medical Oncology, ASL CN 2, Alba e Bra, Cuneo, Italy
| | - Fiorella Ruatta
- Medical Oncology I, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy
| | - Caterina Aversa
- Medical Oncology I, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy
| | | | - Danilo Galizia
- Medical Oncology II, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy
| | - Alessandro Bonzano
- Cardiology Unit, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy
| | - Sofia Torino
- Medical Oncology I, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy
| | - Imperia Nuzzolese
- Medical Oncology I, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy
| | - Laura Marandino
- Medical Oncology I, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy
| | - Massimo Aglietta
- Medical Oncology I, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy
| | - Cinzia Ortega
- Medical Oncology I, Fondazione Del Piemonte Per l'Oncologia, IRCCS Candiolo, Turin, Italy.,Medical Oncology, ASL CN 2, Alba e Bra, Cuneo, Italy
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25
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Current and future strategies for the nutritional management of cardiometabolic complications of androgen deprivation therapy for prostate cancer. Nutr Res Rev 2017; 30:220-232. [DOI: 10.1017/s0954422417000087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractAndrogen deprivation therapy (ADT) is used widely as part of a combined modality for the treatment of prostate cancer. However, ADT has also been associated with the development of cardiometabolic complications that can increase mortality from cardiovascular events. There is emerging evidence to suggest that ADT-related cardiometabolic risk can be mitigated by diet and lifestyle modification. While the clinical focus for a nutritional approach for achieving this effect is unclear, it may depend upon the timely assessment and targeting of dietary changes to the specific risk phenotype of the patient. The present review aims to address the metabolic origins of ADT-related cardiometabolic risk, existing evidence for the effects of dietary intervention in modifying this risk, and the priorities for future dietary strategies.
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26
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Mamas MA, Sperrin M, Watson MC, Coutts A, Wilde K, Burton C, Kadam UT, Kwok CS, Clark AB, Murchie P, Buchan I, Hannaford PC, Myint PK. Do patients have worse outcomes in heart failure than in cancer? A primary care-based cohort study with 10-year follow-up in Scotland. Eur J Heart Fail 2017; 19:1095-1104. [PMID: 28470962 DOI: 10.1002/ejhf.822] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/05/2017] [Accepted: 02/26/2017] [Indexed: 12/16/2022] Open
Abstract
AIMS This study was designed to evaluate whether survival rates in patients with heart failure (HF) are better than those in patients with diagnoses of the four most common cancers in men and women, respectively, in a contemporary primary care cohort in the community in Scotland. METHODS AND RESULTS Data were obtained from the Primary Care Clinical Informatics Unit from a database of 1.75 million people registered with 393 general practices in Scotland. Sex-specific survival modelling was undertaken using Cox proportional hazards models, adjusted for potential confounders. A total of 56 658 subjects were eligible for inclusion in the study. These represented a total of 147 938 person-years of follow-up (median follow-up: 2.04 years). In men, HF (reference group; 5-year survival: 55.8%) had worse mortality outcomes than prostate cancer [hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.57-0.65; 5-year survival: 68.3%], and bladder cancer (HR 0.88, 95% CI 0.81-0.96; 5-year survival: 57.3%), but better outcomes than lung cancer (HR 3.86, 95% CI 3.65-4.07; 5-year survival: 8.4%) and colorectal cancer (HR 1.23, 95% CI 1.16-1.31; 5-year survival: 48.9%). In women, HF (reference group; 5-year survival: 49.5%) had worse mortality outcomes than breast cancer (HR 0.55, 95% CI 0.51-0.59; 5-year survival 77.7%), but better outcomes than colorectal cancer (HR 1.21, 95% CI 1.13-1.29; 5-year survival 51.5%), lung cancer (HR 3.82, 95% CI 3.60-4.05; 5-year survival 10.4%), and ovarian cancer (HR 1.98, 95% CI 1.80-2.17; 5-year survival 38.2%). CONCLUSIONS Despite advances in management, HF remains as 'malignant' as some of the common cancers in both men and women.
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Affiliation(s)
- Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, UK.,Academic Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, UK.,Farr Institute, University of Manchester, Manchester, UK
| | | | - Margaret C Watson
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Alasdair Coutts
- Research Applications and Data Management Team, IT Services, University of Aberdeen, Aberdeen, UK
| | - Katie Wilde
- Research Applications and Data Management Team, IT Services, University of Aberdeen, Aberdeen, UK
| | - Christopher Burton
- Academic Unit of Primary Medical Care, Northern General Hospital, Sheffield, UK
| | - Umesh T Kadam
- Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, UK
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, UK.,Academic Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, UK.,Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Allan B Clark
- Norwich Research Park Cardiovascular Research Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Peter Murchie
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Iain Buchan
- Farr Institute, University of Manchester, Manchester, UK
| | - Philip C Hannaford
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Phyo K Myint
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Veccia A, Maines F, Kinspergher S, Galligioni E, Caffo O. Cardiovascular toxicities of systemic treatments of prostate cancer. Nat Rev Urol 2017; 14:230-243. [PMID: 28117849 DOI: 10.1038/nrurol.2016.273] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prostate cancer is the most common cancer in men, with an incidence that is expected to increase in the coming years. Prostate cancer is usually diagnosed in men >65 years of age, thus the concurrent presence of cardiovascular diseases might influence the treatment, owing to the increased risk of cardiovascular mortality. The introduction of new drugs, such as abiraterone and enzalutamide for the management of metastatic disease has created further interest in treatment-related cardiovascular toxicities, although limited data from trials specifically designed to identify cardiovascular toxicities of these agents are currently available. The only available data are derived from published phase II-III study reports, expanded access or compassionate use programmes and meta-analyses of the effects of systemic therapies that are already approved for use in clinical practice or are in the early phases of development. These data are conflicting, although they seem to suggest that certain drugs are associated with an increased risk of cardiovascular adverse events. Clinical trial methodology could be improved by the enrolment of greater numbers of patients >65 years of age, and the use of comprehensive cardiological evaluations. Moreover, closer collaboration between oncologists and cardiologists is essential for the identification and/or management of cardiovascular adverse events in patients with prostate cancer.
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Affiliation(s)
- Antonello Veccia
- Medical Oncology Department, Santa Chiara Hospital, Largo Medaglie d'Oro 38100 Trento, Italy
| | - Francesca Maines
- Medical Oncology Department, Santa Chiara Hospital, Largo Medaglie d'Oro 38100 Trento, Italy
| | - Stefania Kinspergher
- Medical Oncology Department, Santa Chiara Hospital, Largo Medaglie d'Oro 38100 Trento, Italy
- Medical Oncology, Azienda Ospedaliera Universitaria Integrata, University of Verona, Piazzale L.A. Scuro 10, 37124 Verona, Italy
| | - Enzo Galligioni
- Medical Oncology Department, Santa Chiara Hospital, Largo Medaglie d'Oro 38100 Trento, Italy
| | - Orazio Caffo
- Medical Oncology Department, Santa Chiara Hospital, Largo Medaglie d'Oro 38100 Trento, Italy
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Son YJ, Jang M, Jun EY. Prevalence of Erectile Dysfunction and Associated Factors in Korean Older Adults With Coronary Artery Disease. J Gerontol Nurs 2016; 42:32-41. [PMID: 27379456 DOI: 10.3928/00989134-20160701-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 06/10/2016] [Indexed: 12/21/2022]
Abstract
The current study aimed to identify the prevalence and associated factors of erectile dysfunction (ED) among 161 Korean adults 60 and older with coronary artery disease (CAD). ED was diagnosed in 72.2% of patients-the prevalence of which was significantly associated with age, education, employment, monthly income, frequency of sexual intercourse, body mass index, and low-density lipoprotein. Health-related quality of life (HRQoL) was lower in patients with ED than in those without ED (p < 0.001). Hierarchical multiple regression analysis revealed that ED significantly influenced HRQoL in patients with CAD after adjusting for sociodemographic and disease-related characteristic variables (p < 0.001). Interventions and training courses for health care providers should focus on improving caregivers' knowledge and communication skills with patients and spouses regarding sexual health. Furthermore, guidelines to improve HRQoL in patients with CAD should consider incorporating sexual counseling. [Journal of Gerontological Nursing, 42(10), 32-41.].
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Verzoni E, Grassi P, Ratta R, Niger M, De Braud F, Valdagni R, Procopio G. Safety of long-term exposure to abiraterone acetate in patients with castration-resistant prostate cancer and concomitant cardiovascular risk factors. Ther Adv Med Oncol 2016; 8:323-30. [PMID: 27583024 DOI: 10.1177/1758834016656493] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We aimed to evaluate the long-term safety profile of abiraterone in patients with metastatic castration-resistant prostate cancer (mCRPC) with controlled cardiovascular comorbidities or risk factors. METHODS We retrospectively analysed the clinical charts of consecutive mCRPC patients with cardiac disorders/risk factors who had been treated with abiraterone 1000 mg once daily plus prednisone 5 mg twice daily for a median duration of 16 months at an oncology referral centre between April 2011 and July 2015. Patients underwent an electrocardiogram (ECG) and echocardiographic assessments, including measurement of left ventricular ejection fraction (LVEF) at baseline and at the end of treatment. Blood pressure (BP) was measured daily at home. During follow up (median 24 months), all adverse events were recorded. Cardiac events (CEs) were defined, according to Common Terminology Criteria for Adverse Events version 4.0, as the appearance of a symptomatic CE that required medical intervention. RESULTS A total of 51 patients (median age 71 years) were evaluated. Pre-existing cardiovascular conditions included hypertension (41%), cardiac ischaemia (12%), stroke (9%), dyslipidaemia (18%) and type 2 diabetes mellitus (12%). No CEs were recorded and no changes in LVEF were observed. The most frequently reported adverse events were Grade 1-2 fluid retention (18%), hypertension (16%) and asthenia (16%). No patients permanently discontinued abiraterone due to cardiac events. CONCLUSIONS Long-term abiraterone treatment was well tolerated in mCRPC patients with controlled cardiovascular comorbidities/risk factors, with no apparent worsening of cardiovascular conditions from baseline over an extended observation period.
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Affiliation(s)
- Elena Verzoni
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Paolo Grassi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Raffaele Ratta
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Monica Niger
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo De Braud
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Riccardo Valdagni
- Prostate Cancer Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giuseppe Procopio
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, via G. Venezian 1, 20133 Milano, Italy
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Pongkan W, Pintana H, Sivasinprasasn S, Jaiwongkam T, Chattipakorn SC, Chattipakorn N. Testosterone deprivation accelerates cardiac dysfunction in obese male rats. J Endocrinol 2016; 229:209-20. [PMID: 27000685 DOI: 10.1530/joe-16-0002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 03/17/2016] [Indexed: 12/20/2022]
Abstract
Low testosterone level is associated with increased risks of cardiovascular diseases. As obese-insulin-resistant condition could impair cardiac function and that the incidence of obesity is increased in aging men, a condition of testosterone deprivation could aggravate the cardiac dysfunction in obese-insulin-resistant subjects. However, the mechanism underlying this adverse effect is unclear. This study investigated the effects of obesity on metabolic parameters, heart rate variability (HRV), left ventricular (LV) function, and cardiac mitochondrial function in testosterone-deprived rats. Orchiectomized or sham-operated male Wistar rats (n=36per group) were randomly divided into groups and were given either a normal diet (ND, 19.77% of energy fat) or a high-fat diet (HFD, 57.60% of energy fat) for 12weeks. Metabolic parameters, HRV, LV function, and cardiac mitochondrial function were determined at 4, 8, and 12weeks after starting each feeding program. We found that insulin resistance was observed after 8weeks of the consumption of a HFD in both sham (HFS) and orchiectomized (HFO) rats. Neither the ND sham (NDS) group nor ND orchiectomized (NDO) rats developed insulin resistance. The development of depressed HRV, LV contractile dysfunction, and increased cardiac mitochondrial reactive oxygen species production was observed earlier in orchiectomized (NDO and HFO) rats at week 4, whereas HFS rats exhibited these impairments later at week 8. These findings suggest that testosterone deprivation accelerates the impairment of cardiac autonomic regulation and LV function via increased oxidative stress and impaired cardiac mitochondrial function in obese-orchiectomized male rats.
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Affiliation(s)
- Wanpitak Pongkan
- Cardiac Electrophysiology Research and Training CenterFaculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Cardiac Electrophysiology UnitDepartment of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai University, Chiang Mai, Thailand
| | - Hiranya Pintana
- Cardiac Electrophysiology Research and Training CenterFaculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Cardiac Electrophysiology UnitDepartment of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai University, Chiang Mai, Thailand
| | - Sivaporn Sivasinprasasn
- Cardiac Electrophysiology Research and Training CenterFaculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Cardiac Electrophysiology UnitDepartment of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai University, Chiang Mai, Thailand
| | - Thidarat Jaiwongkam
- Cardiac Electrophysiology Research and Training CenterFaculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Cardiac Electrophysiology UnitDepartment of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training CenterFaculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Cardiac Electrophysiology UnitDepartment of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Department of Oral Biology and Diagnostic ScienceFaculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training CenterFaculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Cardiac Electrophysiology UnitDepartment of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai University, Chiang Mai, Thailand
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Abstract
In patients diagnosed with prostate cancer, the selection of treatment, including the type of therapy and its aggressiveness, is often based on a patient's age and life expectancy. Life expectancy estimates are too often calculated solely on the patient's chronological age, overlooking comorbid conditions and their severity, which can greatly affect life expectancy. If, in addition to chronological age, comorbid conditions are used to assess a patient's life expectancy, the most appropriate treatment options are more likely to be selected. Older, healthy patients might be able to tolerate more aggressive treatment than would be administered on the basis of their age alone, and younger patients with numerous comorbid conditions could avoid harsh therapy that might not be appropriate given their current state of health. The key idea to consider in treatment selection is what a patient's quality of life would be like with or without a particular treatment option. In an era of precision medicine, decisions regarding the provision of health care should be made rationally and on the basis of objective estimates of the threat of disease and the benefits and costs of intervention and within the context of the patient's characteristics and desires.
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Dell'Oglio P, Abou-Haidar H, Leyh-Bannurah SR, Tian Z, Larcher A, Gandaglia G, Fossati N, Shariat SF, Capitanio U, Briganti A, Montorsi F, Graefen M, Saad F, Karakiewicz PI. Assessment of the Rate of Adherence to International Guidelines for Androgen Deprivation Therapy with External-beam Radiation Therapy: A Population-based Study. Eur Urol 2016; 70:429-35. [PMID: 26951945 DOI: 10.1016/j.eururo.2016.02.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/19/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The National Comprehensive Cancer Network and the European Association of Urology guidelines recommend using radiation therapy (RT) with androgen deprivation therapy (ADT) to treat high-risk and locally advanced prostate cancer patients. OBJECTIVE To evaluate the degree of adherence to these guidelines. DESIGN, SETTING, AND PARTICIPANTS Between 2003 and 2009, in the Surveillance Epidemiology and End Results (SEER)-Medicare database, 14 180 patients were diagnosed with high-risk (T1-T2 with World Health Organization histologic grade 3) or locally advanced (T3-T4 with any histologic grade) prostatic adenocarcinoma. INTERVENTION Administration of RT-ADT versus RT alone. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We assessed the rate of adherence to guidelines with respect to use of RT-ADT in the overall population and after stratification according to stage-grade groupings (T1-T2 G3 vs T3-T4 any grade), age (66-69, 70-74, 75-79, ≥80 yr), Charlson Comorbidity Index (CCI) (0, 1, ≥2), and preexisting baseline cardiovascular (CV) disease. We depicted the rate of RT-ADT administration graphically over the study period. Multivariable logistic regression analyses were performed to assess the predictors of RT-ADT use. RESULTS AND LIMITATIONS RT-ADT rates and guideline adherence were 58-75%, with the highest rate (75%) in 2003 and the lowest (58%) in 2009. When stratified according to stage-grade groupings, age, CCI, and preexisting baseline CV disease, similar results were obtained. In multivariable analyses, year of diagnosis (p<0.001), patient age (p<0.001), stage-grade groupings (p<0.001), CCI (p=0.036), race (p<0.001), marital status (p<0.001), population density (p<0.001), and US regions (p<0.001) were independent predictors of RT-ADT use. The limitations of our study include age >65 yr and exclusive Medicare coverage. CONCLUSIONS The rate of guideline adherence regarding the use of RT-ADT is suboptimal and decreases with time instead of increasing. PATIENT SUMMARY This population-based study provides evidence of low adherence to international urologic guidelines regarding the combination of radiation therapy (RT) with androgen deprivation therapy (ADT) for high-risk and locally advanced prostate cancer (PCa) patients. Despite the increasing number of randomized controlled trials over time that showed a survival benefit for patients with high-risk and locally advanced PCa treated with RT-ADT compared with RT alone, the rate of adherence to guidelines decreased with time.
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Affiliation(s)
- Paolo Dell'Oglio
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Hiba Abou-Haidar
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Department of Urology, University of Montreal Health Center, Montreal, Canada
| | - Sami-Ramzi Leyh-Bannurah
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Martini-Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Alessandro Larcher
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giorgio Gandaglia
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Fossati
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna and General Hospital, Vienna, Austria
| | - Umberto Capitanio
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Briganti
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Montorsi
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Markus Graefen
- Martini-Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fred Saad
- Department of Urology, University of Montreal Health Center, Montreal, Canada
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Department of Urology, University of Montreal Health Center, Montreal, Canada
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Zareba P, Duivenvoorden W, Leong DP, Pinthus JH. Androgen deprivation therapy and cardiovascular disease: what is the linking mechanism? Ther Adv Urol 2015; 8:118-29. [PMID: 27034724 DOI: 10.1177/1756287215617872] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The past decade has brought increased awareness of the potential adverse effects of androgen deprivation therapy (ADT) in men with prostate cancer. Arguably the most important and controversial of these is the increased risk of cardiovascular morbidity and mortality. Although multiple observational studies have shown that men treated with ADT are at increased risk of developing atherosclerotic cardiovascular disease, our understanding of the biological mechanisms that might underlie this phenomenon is still evolving. In this review, we discuss some of the mechanisms that have been proposed to date, including ADT-induced metabolic changes that promote the development and progression of atherosclerotic plaques as well as direct local effects of hormonal factors on plaque growth, rupture and thrombosis.
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Affiliation(s)
- Piotr Zareba
- Division of Urology, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Wilhelmina Duivenvoorden
- Division of Urology, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Darryl P Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jehonathan H Pinthus
- Department of Surgery, Juravinski Hospital and Cancer Centre, 711 Concession St, Hamilton, Ontario L8V 1C3, Canada
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