Prostate cancer-specific survival in men treated with hormonal therapy after failure of radical prostatectomy

Prognostic Value of Biochemical Recurrence Following Treatment with Curative Intent for Prostate Cancer: A Systematic Review

CONTEXT

In men with prostate cancer (PCa) treated with curative intent, controversy exists regarding the impact of biochemical recurrence (BCR) on oncological outcomes.

OBJECTIVE

To perform a systematic review of the existing literature on BCR after treatment with curative intent for nonmetastatic PCa. Objective 1 is to investigate whether oncological outcomes differ between patients with or without BCR. Objective 2 is to study which clinical factors and tumor features in patients with BCR have an independent prognostic impact on oncological outcomes.

EVIDENCE ACQUISITION

Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. For objective 1, prospective and retrospective studies comparing survival outcomes of patients with or without BCR following radical prostatectomy (RP) or radical radiotherapy (RT) were included. For objective 2, all studies with at least 100 participants and reporting on prognostic patient and tumor characteristics in patients with BCR were included. Risk-of-bias and confounding assessments were performed according to the Quality in Prognosis Studies tool. Both a narrative synthesis and a meta-analysis were undertaken.

EVIDENCE SYNTHESIS

Overall, 77 studies were included for analysis, of which 14 addressed objective 1, recruiting 20 406 patients. Objective 2 was addressed by 71 studies with 29 057, 11 301, and 4272 patients undergoing RP, RT, and a mixed population (mix of patients undergoing RP or RT as primary treatment), respectively. There was a low risk of bias for study participation, confounders, and statistical analysis. For most studies, attrition bias, and prognostic and outcome measurements were not clearly reported. BCR was associated with worse survival rates, mainly in patients with short prostate-specific antigen doubling time (PSA-DT) and a high final Gleason score after RP, or a short interval to biochemical failure (IBF) after RT and a high biopsy Gleason score.

CONCLUSIONS

BCR has an impact on survival, but this effect appears to be limited to a subgroup of patients with specific clinical risk factors. Short PSA-DT and a high final Gleason score after RP, and a short IBF after RT and a high biopsy Gleason score are the main factors that have a negative impact on survival. These factors may form the basis of new BCR risk stratification (European Association of Urology BCR Risk Groups), which needs to be validated formally.

PATIENT SUMMARY

This review looks at the risk of death in men who shows rising prostate-specific antigen (PSA) in the blood test performed after curative surgery or radiotherapy. For many men, rising PSA does not mean that they are at a high risk of death from prostate cancer in the longer term. Men with PSA that rises shortly after they were treated with radiotherapy or rapidly rising PSA after surgery and a high tumor grade for both treatment modalities are at the highest risk of death. These factors may form the basis of new risk stratification (European Association of Urology biochemical recurrence Risk Groups), which needs to be validated formally.

Tools for Predicting Clinical and Patient-reported Outcomes in Prostate Cancer Patients Undergoing Androgen Deprivation Therapy: A Systematic Review of Prognostic Accuracy and Validity

Androgen deprivation therapy (ADT) can result in a range of adverse symptoms that reduce patients' quality of life. Careful patient counseling on the likely clinical outcomes and adverse effects is therefore vital. The present systematic review was undertaken to identify and characterize all the tools used for the prediction of clinical and patient-reported outcome measures (PROMs) in patients with prostate cancer undergoing ADT. PubMed and EMBASE were systematically searched from 2007 to 2016. Search terms related to the inclusion criteria were: prostate cancer, clinical outcomes, PROMs, ADT, and prognosis. Titles and abstracts were reviewed to find relevant studies, which were advanced to full-text review. The reference lists were screened for additional studies. The Centre for Evidence Based Medicine critical appraisal of prognostic studies tool was applied. The search strategy identified 8755 studies. Of the 8755 studies, 22 on clinical outcomes were identified. However, no studies of PROMs were found. Nine tools could be used to predict clinical outcomes in treatment-naive patients and 10 in patients with recurrence. The Japan Cancer of the Prostate Risk Assessment (J-CAPRA) nomogram was the best performing and validated tool for the prediction of clinical outcomes in treatment-naive patients, and the Chi and Shamash prognostic indexes have been validated for use in patients with castration-resistant disease in different clinical contexts. Using the J-CAPRA nomogram should help clinicians deliver accurate, evidence-based counseling to patients undergoing primary ADT. A strong need exists for primary studies that derive and validate tools for the prediction of PROMs in patients undergoing ADT under any circumstance because these are currently absent from the literature.

Role of Hormonal Treatment in Prostate Cancer Patients with Nonmetastatic Disease Recurrence After Local Curative Treatment: A Systematic Review

CONTEXT

The relative benefits and harms of hormonal treatment (HT) versus no or deferred HT in patients with nonmetastatic prostate cancer (PCa) relapse after primary curative therapy are controversial.

OBJECTIVE

To assess the effectiveness of HT for nonmetastatic PCa relapse, prognostic factors for treatment outcome, timing of treatment, and the most effective treatment strategy to provide guidance for clinical practice.

EVIDENCE ACQUISITION

A systematic literature search was undertaken incorporating Medline, Embase, and the Cochrane Library (search ended March 2015). Studies were critically appraised for risk of bias. The outcomes included overall and cancer-specific survival, metastasis-free survival, symptom-free survival, progression to castrate resistance, adverse events, and quality of life.

EVIDENCE SYNTHESIS

Of 9687 articles identified, 27 studies were eligible for inclusion (2 RCTs, 8 nonrandomised comparative studies, and 17 case series). The results suggest that only a subgroup of patients, especially those with high-risk disease, may benefit from early HT. The main predictors for unfavourable outcomes were shorter PSA doubling time (<6-12 mo) and higher Gleason score (>7). Early HT may be warranted for patients with high-risk disease. An intermittent HT strategy appears feasible. Most studies had a moderate to high risks of bias.

CONCLUSIONS

HT for PCa relapse after primary therapy with curative intent should be reserved for patients at highest risk of progression and with a long life expectancy. The potential benefits of starting HT should be judiciously balanced against the associated harms.

PATIENT SUMMARY

This article summarises the evidence on the benefits and harms of hormonal treatment in prostate cancer (PCa) patients in whom the disease has recurred following earlier curative treatment. We found that only a select group of patients with aggressive PCa and a fast rising prostate-specific antigen may benefit from early hormonal treatment (HT), whereas in others HT may be more harmful than beneficial.

Very-high-risk localized prostate cancer: definition and outcomes

BACKGROUND

Outcomes in men with National Comprehensive Cancer Network (NCCN) high-risk prostate cancer (PCa) can vary substantially-some will have excellent cancer-specific survival, whereas others will experience early metastasis even after aggressive local treatments. Current nomograms, which yield continuous risk probabilities, do not separate high-risk PCa into distinct sub-strata. Here, we derive a binary definition of very-high-risk (VHR) localized PCa to aid in risk stratification at diagnosis and selection of therapy.

METHODS

We queried the Johns Hopkins radical prostatectomy database to identify 753 men with NCCN high-risk localized PCa (Gleason sum 8-10, PSA >20 ng ml(-1), or clinical stage ≥T3). Twenty-eight alternate permutations of adverse grade, stage and cancer volume were compared by their hazard ratios for metastasis and cancer-specific mortality. VHR criteria with top-ranking hazard ratios were further evaluated by multivariable analyses and inclusion of a clinically meaningful proportion of the high-risk cohort.

RESULTS

The VHR cohort was best defined by primary pattern 5 present on biopsy, or ≥5 cores with Gleason sum 8-10, or multiple NCCN high-risk features. These criteria encompassed 15.1% of the NCCN high-risk cohort. Compared with other high-risk men, VHR men were at significantly higher risk for metastasis (hazard ratio 2.75) and cancer-specific mortality (hazard ratio 3.44) (P<0.001 for both). Among high-risk men, VHR men also had significantly worse 10-year metastasis-free survival (37% vs 78%) and cancer-specific survival (62% vs 90%).

CONCLUSIONS

Men who meet VHR criteria form a subgroup within the current NCCN high-risk classification who have particularly poor oncological outcomes. Use of these characteristics to distinguish VHR localized PCa may help in counseling and selection optimal candidates for multimodal treatments or clinical trials.

Risk stratification in the hormonal treatment of patients with prostate cancer

Prostate cancer (PCa) is the most common type of cancer found in American men, other than skin cancer. The American Cancer Society estimates that there will be 186,320 new cases of prostate cancer in the United States in 2008. About 28,660 men will die of this disease this year and PCa remains the second-leading cause of cancer death in men. One in six men will get PCa during his lifetime and one in 35 will die of the disease. Today, more than 2 million men in the United States who have had PCa are still alive. The death rate for PCa continues to decline, chiefly due to early detection and treatment, and improved salvage therapy such as hormone therapy (HT). HT continues to be a mainstay for primary-recurrent PCa and locally-advanced PCa. However, HT is associated with many undesirable side effects including sexual dysfunction, osteoporosis and hot flashes, all of which can lead to decreased quality of life (QOL). These risks are seen in both long- and short-term HT regimens. Additionally, research in recent years has revealed trends related to clinico pathological variables and their predictive ability in HT outcomes. Awareness of the potential adverse effects, the risks associated with HT and the prognostic ability of clinical and pathological variables is important in determining optimal therapy for individual patients. A rigorous evaluation of the current scientific literature associated with HT was conducted with the goal of identifying the most favorable balance of benefits and risks associated with HT.

Stromal cell-derived factor-1 and vascular endothelial growth factor as biomarkers for lymph node metastasis and poor cancer-specific survival in prostate cancer patients after radical prostatectomy

OBJECTIVES

This study aims to analyze the clinicopathologic significance of stromal cell-derived factor-1 (SDF-1), vascular endothelial growth factor (VEGF), and matrix metalloproteinase-9 (MMP-9) expression in human prostate cancer (CaP), and their involvement in the prognosis of CaP.

MATERIALS AND METHODS

The expression of SDF-1, VEGF, and MMP-9 were measured using immunohistochemistry in 148 CaP patients who underwent radical prostatectomy for clinically localized disease and in 10 samples of benign prostatic hyperplasia (BPH).

RESULTS

In the CaP group, VEGF and MMP-9 were more strongly expressed in the tumor cells compared with the BPH group. High intensity SDF-1, VEGF, and MMP-9 stains in tumor areas strongly correlated with lymph node metastasis, pathologic stage, and differentiation. Univariate and multivariate analysis showed that SDF-1, VEGF, and lymph node metastasis were independent prognostic factors for prostate cancer-specific survival. High levels of MMP-9, pathologic stage, and differentiation were associated with prostate cancer-specific survival in univariate analysis but the risk estimate was not significant in multivariate analysis.

CONCLUSIONS

High expression levels of SDF-1, VEGF, and MMP-9 are more correlated with lymph node metastatic prostate carcinoma compared with non-lymph-node metastatic cancer. High expression levels of SDF-1 and VEGF strongly predict the biochemical progression in CaP patients after radical prostatectomy.

Critical review of prostate cancer predictive tools

Prostate cancer is a very complex disease, and the decision-making process requires the clinician to balance clinical benefits, life expectancy, comorbidities and potential treatment-related side effects. Accurate prediction of clinical outcomes may help in the difficult process of making decisions related to prostate cancer. In this review, we discuss attributes of predictive tools and systematically review those available for prostate cancer. Types of tools include probability formulas, look-up and propensity scoring tables, risk-class stratification prediction tools, classification and regression tree analysis, nomograms and artificial neural networks. Criteria to evaluate tools include discrimination, calibration, generalizability, level of complexity, decision analysis and ability to account for competing risks and conditional probabilities. The available predictive tools and their features, with a focus on nomograms, are described. While some tools are well-calibrated, few have been externally validated or directly compared with other tools. In addition, the clinical consequences of applying predictive tools need thorough assessment. Nevertheless, predictive tools can facilitate medical decision-making by showing patients tailored predictions of their outcomes with various alternatives. Additionally, accurate tools may improve clinical trial design.

Development of a prostate cancer metagram: a solution to the dilemma of which prediction tool to use in patient counseling

Many treatment options are available to the human with clinically localized prostate cancer, including surgery, radiation, and even active surveillance. To the authors' knowledge, there is no consensus on the optimal management of this patient population, with most clinicians tending to recommend the treatment with which they are most familiar. Effective patient counseling allowing informed decision making can be best achieved with a formalized system that offers accurate predictions of outcomes for all available treatment approaches. The authors organized the currently available prostate cancer prediction tools toward the formation of a metagram that can be used to tailor management to the individual patient. A comprehensive review of the literature was performed to identify published prediction tools intended for use in prostate cancer. Tools were categorized by a combination of treatment modality and the outcome being predicted, and incorporated into a metagram constructed of 16 different treatment options and 10 outcomes related to cancer control, survival, and morbidity. A search of the literature revealed 44 prostate cancer prediction tools that assessed at least 1 of the 160 treatment/outcome combinations that comprise the metagram. Only 31 cells of the metagram were populated with currently available tools. Prediction tools offer the most accurate estimates of outcomes in prostate cancer, but their current role in patient counseling is complicated by the large number of existing tools, as well as a lack of comparative data. To address this, the authors incorporated the most relevant prediction tools currently available into a prostate cancer metagram that may offer evidence-based and individualized predictions for multiple endpoints after all available treatment options in clinically localized prostate cancer. The metagram also reveals areas of deficiency in the current catalog of prediction tools. Many more prediction tools are needed. Cancer 2009;115(13 suppl):3039-45. (c) 2009 American Cancer Society.

Persistence of expression of the TMPRSS2:ERG fusion gene after pre-surgery androgen ablation may be associated with early prostate specific antigen relapse of prostate cancer: preliminary results

BACKGROUND

The recently identified TMPRSS2: ERG fusion gene is a candidate oncogene for prostate cancer (PCa).

SUBJECTS AND METHODS

We have tested for the presence of this gene in tumor samples from 84 patients who had radical prostatectomy in 1998-2000. Sixty patients (group A) had surgery only; 24 patients (group B) received androgen ablation therapy for 3 months before surgery. The occurrence of the rearrangement was evaluated by RT-PCR and by fluorescent in situ hybridization analysis.

RESULTS

A TMPRSS2:ERG fusion gene was present and expressed, as demonstrated by RT-PCR, in 84% of patients in group A and in 54% of patients in group B (p=0.01). The presence of TMPRSS2:ERG transcripts and the levels of ERG RNA, measured by quantitative Real Time-PCR, did not correlate significantly with clinical and pathologic characteristics of the tumors. In patients of group A, but not in those of group B, ERG expression showed a negative correlation with the Gleason score (p=0.0001). Histochemical analysis showed that ERG expression is limited to tumor cells, and in group A patients (but not in group B patients) it is limited to those glands that express TMPRSS2:ERG.

CONCLUSION

The lower proportion of patients expressing TMPRSS2: ERG in group B suggests that androgen ablation inhibits the expression of TMPRSS2:ERG. Moreover, in group B, but not in group A, patients with expression of the fusion gene had earlier prostate specific antigen recurrence (p=0.007). Although preliminary, the data indicate that tumors in which pre-surgery androgen ablation fails to suppress expression of the fusion gene have a higher risk of recurrence.

Inventory of prostate cancer predictive tools

PURPOSE OF REVIEW

We created an inventory of current predictive tools available for prostate cancer. This review may serve as an initial step toward a comprehensive reference guide for physicians to locate published nomograms that apply to the clinical decision in question. Using MEDLINE a literature search was performed on prostate cancer predictive tools from January 1966 to November 2007. We describe the patient populations to which they apply and the outcomes predicted, and record their individual characteristics.

RECENT FINDINGS

The literature search generated 111 published prediction tools that may be applied to patients in various clinical stages of disease. Of the 111 prediction tools, only 69 had undergone validation. We present an inventory of models with input variables, prediction form, number of patients used to develop the prediction tools, the outcome being predicted, prediction tool-specific features, predictive accuracy, and whether validation was performed.

SUMMARY

Decision rules, such as nomograms, provide evidence-based and at the same time individualized predictions of the outcome of interest. Such predictions have been repeatedly shown to be more accurate than those of clinicians, regardless of their level of expertise. Accurate risk estimates are also required for clinical trial design, to ensure homogeneous high-risk patient groups for whom new cancer therapeutics will be investigated.

Targeted therapy of cancer: new roles for pathologists--prostate cancer

The clinical dilemma today in the management of prostate cancer (PCA) is to distinguish men who need definitive treatment from men who have indolent disease. As demonstrated most recently by the randomized Scandinavian trial evaluating the benefit of prostatectomy over Watchful Waiting, surgery significantly decreased the risk of death from PCA. However, this same study also suggests that 19 men need to be treated to benefit one man. Given the high prevalence of the disease, the aging of the population, and the potential morbidity of treatment, the ability to distinguish aggressive from indolent forms of PCA is critical. Treatment for advanced PCA begins with androgen ablation, but eventually hormone-refractory (HR) PCA emerges. Novel therapies are in various stages of clinical trials, including kinase inhibitors, antisense oligonucleotides, and inhibitors of heat-shock proteins. The discovery of novel therapeutic approaches is an active area of clinical research. Eliminating HR PCA before it advances is a high priority in the biomarker field. Therefore, the development of molecular signatures of lethal PCA are critical. In addition, the recent discovery that a significant percentage of PCAs harbor a TMPRSS2-ETS gene fusion suggests that targeting either the ETS transcription factors or the fusion product may offer a novel approach to therapy. However, in 2007, the mainstay of treatment for advanced PCA remains androgen ablation therapy as originally introduced in the early 1940s.

Role of nomograms for prostate cancer in 2007

Nomograms have been developed to predict prostate cancer (PCa) related outcomes. We report what has been achieved and what can be expected in 2007 and in the future. We reviewed the literature to provide guidelines in terms of criteria, limitations and clinical value of nomograms in 2007. Further, we report a set of recent PCa nomograms, where certain criteria are listed which were used to develop each nomogram. Our findings suggest a demand for an update of nomograms as well as head-to-head comparisons to determine the best-suited model in select fields of PCa outcomes. In 2007 and the future, an increasing number of nomograms will address important endpoints such as PSA recurrence, local and distant metastases, or androgen-independent PCa-specific survival. Our results suggest that nomograms represent valid risk stratification models to achieve most accurate predictions. In 2007 and the future, more specific and refined nomograms will be available which address relevant clinical end points. Moreover, novel markers in PCa outcomes will be quantified using the nomogram approach.