Androgen-deprivation therapy in treatment of prostate cancer and risk of myocardial infarction and stroke: a nationwide Danish population-based cohort study. Eur Urol. 2014;65:704-709. [PMID: 23433805 DOI: 10.1016/j.eururo.2013.02.002]

Perspectives on the Cardiovascular and Metabolic Effects of Androgen Deprivation Therapy in Prostate Cancer

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of non-cancer mortality in men with prostate cancer. This review summarizes the existing and emerging literature examining the cardiometabolic effects of androgen deprivation therapy (ADT) in prostate cancer.

RECENT FINDINGS

The evidence behind the metabolic effects of ADT is derived from older studies and has not been validated in modern cohorts. Most of the newer studies focus on the risk of cardiovascular disease (CVD) with ADT. Recently published studies like the HERO and PRONOUNCE trials have once again sparked debate about the effects of different types and durations of ADT on cardiovascular outcomes. The link between ADT and CVD is inherently complex with a majority of the evidence collected from population-based or non-randomized trials without enriching for high-risk populations. Ongoing clinical trials may provide more informative data to guide the cardiovascular care of prostate cancer survivors.

A Repurposing Programme Evaluating Transdermal Oestradiol Patches for the Treatment of Prostate Cancer Within the PATCH and STAMPEDE Trials: Current Results and Adapting Trial Design

AIMS

Androgen deprivation therapy (ADT), usually achieved with luteinising hormone releasing hormone analogues (LHRHa), is central to prostate cancer management. LHRHa reduce both testosterone and oestrogen and are associated with significant long-term toxicity. Previous use of oral oestrogens as ADT was curtailed because of cardiovascular toxicity. Transdermal oestrogen (tE2) patches are a potential alternative ADT, supressing testosterone without the associated oestrogen-depletion toxicities (osteoporosis, hot flushes, metabolic abnormalities) and avoiding cardiovascular toxicity, and we here describe their evaluation in men with prostate cancer.

MATERIALS AND METHODS

The PATCH (NCT00303784) adaptive trials programme (incorporating recruitment through the STAMPEDE [NCT00268476] platform) is evaluating the safety and efficacy of tE2 patches as ADT for men with prostate cancer. An initial randomised (LHRHa versus tE2) phase II study (n = 251) with cardiovascular toxicity as the primary outcome measure has expanded into a phase III evaluation. Those with locally advanced (M0) or metastatic (M1) prostate cancer are eligible. To reflect changes in both management and prognosis, the PATCH programme is now evaluating these cohorts separately.

RESULTS

Recruitment is complete, with 1362 and 1128 in the M0 and M1 cohorts, respectively. Rates of androgen suppression with tE2 were equivalent to LHRHa, with improved metabolic parameters, quality of life and bone health indices (mean absolute change in lumbar spine bone mineral density of -3.0% for LHRHa and +7.9% for tE2 with an estimated difference between arms of 9.3% (95% confidence interval 5.3-13.4). Importantly, rates of cardiovascular events were not significantly different between the two arms and the time to first cardiovascular event did not differ between treatment groups (hazard ratio 1.11, 95% confidence interval 0.80-1.53; P = 0.54). Oncological outcomes are awaited.

FUTURE

Efficacy results for the M0 cohort (primary outcome measure metastases-free survival) are expected in the final quarter of 2023. For M1 patients (primary outcome measure - overall survival), analysis using restricted mean survival time is being explored. Allied translational work on longitudinal samples is underway.

The Cardiovascular Safety of Five-Alpha-Reductase Inhibitors Among Men with Benign Prostatic Hyperplasia: A Population-Based Cohort Study

BACKGROUND

Five-alpha reductase inhibitors (5αRIs) are used to treat benign prostatic hyperplasia (BPH). However, the cardiovascular effects of 5αRIs remain poorly understood. The study objective was to compare the rate of hospitalization for heart failure among men with BPH prescribed 5αRIs to that of men with BPH not prescribed BPH medications.

METHODS

Using the Clinical Practice Research Datalink linked with hospitalization and vital statistics data, we conducted a population-based cohort study among patients newly diagnosed with BPH. We defined exposure as the current use of 5αRIs, current use of alpha-blockers, and no current use of BPH medications in a time-varying approach. The primary endpoint was hospitalization for heart failure, and secondary endpoints were myocardial infarction, stroke, and cardiovascular death. We used time-dependent Cox-proportional hazards models to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Our cohort included 94,440 men with incident BPH. A total of 3893 hospitalizations for heart failure occurred over 527,660 person-years of follow-up (incidence rate 7.38; 95% CI, 7.15-7.61, per 1000 person-years). Compared with no current use of BPH medications, current use of 5αRIs was not associated with an increased risk of hospitalization for heart failure (HR 0.94; 95% CI, 0.86-1.03), myocardial infarction (HR 0.92; 95% CI, 0.81-1.05), stroke (HR 0.94; 95% CI, 0.85-1.05), or cardiovascular death (HR 0.89; 95% CI, 0.80-0.99).

CONCLUSIONS

The use of 5αRIs was not associated with an increased risk of hospitalization for heart failure, myocardial infarction, stroke, or cardiovascular death compared with non-use.

Review of Cardiovascular Risk of Androgen Deprivation Therapy and the Influence of Race in Men with Prostate Cancer

Androgen deprivation therapy is the cornerstone of prostate cancer therapy. Recent studies have revealed an association between androgen deprivation therapy and cardiovascular adverse effects such as myocardial infarction and stroke. This review summarizes the available research on the cardiovascular risk of men using androgen deprivation therapy. We also discuss racial disparities surrounding both prostate cancer and cardiovascular disease, emphasizing the importance of biological/molecular and socioeconomic factors in assessing baseline risk in patients beginning androgen ablation. Based on the literature, we provide recommendations for monitoring patients who are at high risk for a cardiovascular adverse event while being treated on androgen deprivation therapy. This review aims to present the current research on androgen deprivation therapy and cardiovascular toxicity with an emphasis on racial disparities and provides a framework for clinicians to decrease the cardiovascular morbidity in men that are being treated with hormone therapy.

Androgen-deprivation therapy with leuprolide increases abdominal adiposity without causing cardiac dysfunction in middle-aged male mice: effect of sildenafil

Androgen-deprivation therapy (ADT) is the primary systemic therapy for treating advanced or metastatic prostate cancer (PCa), which has improved survival outcomes in patients with PCa. However, ADT may develop metabolic and cardiovascular adverse events that impact the quality of life and lifespan in PCa survivors. The present study was designed to establish a murine model of ADT with a gonadotropin-releasing hormone (GnRH) agonist leuprolide and to investigate its effects on metabolism and cardiac function. We also examined the potential cardioprotective role of sildenafil (inhibitor of phosphodiesterase 5) under chronic ADT. Middle-aged male C57BL/6J mice received a 12-wk subcutaneous infusion via osmotic minipumps containing either saline or 18 mg/4 wk leuprolide with or without 1.3 mg/4 wk sildenafil cotreatment. Compared with saline controls, leuprolide treatment significantly reduced prostate weight and serum testosterone levels, confirming chemical castration in these mice. The ADT-induced chemical castration was not affected by sildenafil. Leuprolide significantly increased the weight of abdominal fat after 12-wk treatment without a change in total body weight, and sildenafil did not block the proadipogenic effect of leuprolide. No signs of left ventricular systolic and diastolic dysfunction were observed throughout the leuprolide treatment period. Interestingly, leuprolide treatment significantly elevated serum levels of cardiac troponin I (cTn-I), a biomarker of cardiac injury, and sildenafil did not abolish this effect. We conclude that long-term ADT with leuprolide increases abdominal adiposity and cardiac injury biomarker without cardiac contractile dysfunction. Sildenafil did not prevent ADT-associated adverse changes.

Androgen-deprivation therapy and risk of death from cardio-vascular disease in prostate cancer patients: a nationwide lithuanian population-based cohort study

Purpose: The main purpose of this study was to evaluate the risk of CVD mortality in the national cohort of patients diagnosed with prostate cancer and treated with ADT compared with the ADT non-users.Materials and methods: We performed a retrospective cohort study of patients aged 40-79 years and diagnosed with prostate cancer between 1 January 2012 and 31 December 2016 using the Lithuanian Cancer registry data. In total, 13 343 prostate cancer patients were included in the final study cohort who exclusively used gonadotropin-releasing hormone agonists. The primary outcomes that were registered during the follow-up of this study were overall CVD death.Results: There was a higher risk of CVD death in the cohort of patients treated with ADT than in ADT non-users (HR 2.14, 95% CI [1.86-2.45], p < 0.001). Moreover, there was an increased risk of death from ischemic heart disease and stroke (HR 1.42, 95% CI [1.16-1.73] and 1.70, 95% CI [1.18-2.45], respectively) among ADT users. Finally, the risk of CVD-related mortality was highest in the 70-79 age group of ADT users (HR 4.78, 95% CI [3.79-6.04]).Conclusions: This study shows that ADT usage is associated with increased CVD-related mortality risk for patients diagnosed with prostate cancer compared with ADT non-users. The highest mortality risk was found for ischemic heart disease and stroke. CVD-related mortality was increased in the elder group of patients also.

Association between medical androgen deprivation therapy and long-term cardiovascular disease and all-cause mortality in non-metastatic prostate cancer

Studies have suggested that prostate cancer (PCa) patients receiving androgen deprivation therapy (ADT) are at increased risk of developing or exacerbating cardiovascular disease (CVD). We aimed to explore the association between ADT for PCa and subsequent CVD and all‐cause mortality in this nationwide, longitudinal study. We also evaluated the role of cardiovascular risk and ADT duration to determine effect modification. Norwegian registry data were used to identify patients with PCa from 2008‐18 and who received primary ADT in the first year after diagnosis. The associations between ADT and composite cardiovascular events, and the individual components of myocardial infarction, stroke and heart failure, in addition to atrial fibrillation and all‐cause mortality, were explored using time‐varying Cox regression models. We included 30 923 PCa patients, of whom 8449 (27%) received primary ADT. Mean follow‐up was 2.9 and 3.8 years for CVD events and mortality, respectively. We found an association between ADT and composite CVD (adjusted HR 1.13: 95% CI 1.05‐1.21), myocardial infarction (1.18: 1.05‐1.32), stroke (1.21: 1.06‐1.38), heart failure (1.23: 1.13‐1.35) and all‐cause mortality (1.49: 1.39‐1.61). These associations persisted in those with low and moderate CVD risk and ADT longer than 7 months. A relationship between ADT and composite CVD and all‐cause mortality was observed, especially in those with moderate CVD risk and longer treatment duration. Future studies with more detailed cancer data are needed to verify the clinical relevance of these results, especially when considering all‐cause mortality within the context of treatment guidelines and benefits of ADT.

Androgen deprivation therapy and cardiovascular risk in prostate cancer

INTRODUCTION

Androgen-deprivation therapy (ADT), with or without palliative local treatments, is the standard of care for many patients with locally-advanced and/or metastatic prostate cancer. However, the possible cardiovascular (CV) risks associated with gonadotropin-releasing hormone (GnRH) antagonists and agonists continue to be the subject of concern, especially in a patient population that may already be at increased CV risk.

EVIDENCE ACQUISITION

The present review provides a narrative summary of the evidence regarding the CV risks associated with GnRH antagonists and agonists from randomized clinical trials (RCTs), real-world evidence, and meta-analyses.

EVIDENCE SYNTHESIS

From RCTs, it appears clear that there is a direct class effect for CV risk in patients with prostate cancer being administered GnRH agonists and antagonists, with the latter being associated with reduced CV risk. Real-world data and the available meta-analyses largely indicate that CV risk is lower with GnRH antagonists than with GnRH agonists.

CONCLUSIONS

A review of the pathophysiological mechanisms of gives further support to the possibility that GnRH antagonists are associated with lower CV risk than agonists. It can be highlighted that when treating patients with advanced or metastatic prostate cancer it is important to screen for underlying comorbidities prior to choosing the most appropriate therapy; moreover, patients should be closely monitored for factors associated with CV risk in order to optimize outcomes. Further studies are needed to define the most appropriate treatment according to the individual patient characteristics.

Association of Gonadotropin-Releasing Hormone Therapies With Venous Thromboembolic Events in Patients With Prostate Cancer: A National Cohort Study

Although androgen deprivation therapy (ADT) has been proposed to be associated with a higher risk of venous thromboembolisms (VTEs), whether gonadotropin-releasing hormones (GnRHs), such as both agonists and antagonists, are also associated with VTEs remain unclear. Using the Taiwan Cancer Registry (TCR) linked with the National Health Insurance Research Database, we identified patients diagnosed with prostate cancer from 2008 to 2015. Patients who received GnRH were 1:1 propensity score matched with non-GnRH users by age and cancer stage at diagnosis and clinical stage. Cox regression analysis was applied to estimate the incidences of VTEs with death as a competing event at the 5-year follow-up. The VTE incidence among GnRH users was 1.13% compared with 0.98% among non-users. After adjusting with potential confounding factors, the risk of VTEs showed borderline statistical significance among GnRH users and non-users. Notably, in the subgroup analysis among patients receiving GnRH therapy, those younger than 70 years old or at an earlier stage (stage I/II) were at a higher risk of VTEs. Different from previous studies, our findings highlighted critical concerns regarding the cardiac safety of GnRH therapies in prostate cancer patients at a relatively younger age or at an earlier stage.

The Risk of Venous Thromboembolism (VTE) in Men with Benign Prostatic Hyperplasia Treated with 5-Alpha Reductase Inhibitors (5ARIs)

Background

Many men receive 5-alpha reductase inhibitors (5ARIs) for ongoing treatment of benign prostatic hyperplasia (BPH). The increased risk of cardiovascular complications with 5ARIs has been documented in BPH studies and the occurrence of cerebral venous thrombosis, presumably due to increased estrogen level following 5ARI use, was described in multiple case reports. The objective of this study was to determine if 5ARIs with or without alpha blockers (AB) were associated with an increased risk of venous thromboembolism (VTE) in males with BPH.

Methods

We conducted a nested case–control study among a population of men ages 40–79 who received at least one 5ARI or AB prescription for treatment of BPH between 1995 and 2015 in the UK-based Clinical Practice Research Datalink GOLD. Cases of incident VTE (pulmonary embolism [PE] or deep venous thrombosis [DVT]) and matched controls were identified from this population. We used descriptive analyses and conditional logistic regression to evaluate the risk of VTE in users of 5ARIs compared to users of ABs.

Results

For 5ARI only users, the adjusted odds ratios (aORs), (95% CI) for VTE were 1.51 (0.98–2.32) in current 5ARI users and 1.23 (0.70–2.17) in recent/distant past, compared to AB only users. However, the aOR (95% CI) in men who had 50 or more current 5ARI prescriptions compared to users of ABs only was higher: 2.29 (1.14–4.63). For 5ARI with AB use, the aORs, (95% CI) for VTE were 1.16 (0.64–2.10) in current 5ARI+AB users and 1.93 (0.71–5.25) in recent/distant past, compared to AB only users. The aOR (95% CI) in men who had 50 or more current 5ARI+AB prescriptions compared to users of ABs only was 1.65 (0.64–4.26).

Conclusion

Current use of 5ARI, particularly long-term use, is associated with an increased risk of incident idiopathic VTE compared to patients treated with AB use only.

Risk of cardiovascular intervention after androgen deprivation therapy in prostate cancer patients with a prior history of ischemic cardiovascular and cerebrovascular disease: A nationwide population-based cohort study

BACKGROUND

Androgen deprivation therapy for prostate cancer is known to increase the risk of cardiovascular disease, but there is controversy regarding the cardiovascular risk in patients with preexisting cardiovascular disease. This study assessed the risk of cardiovascular intervention after androgen deprivation therapy in patients with a history of cardiovascular disease, cerebrovascular disease, and cardiovascular intervention.

MATERIALS AND METHODS

Between 2008 and 2017, 195,308 men with newly diagnosed prostate cancer were identified from the nationwide claims database in South Korea. Among them, 49,090 men with a history of ischemic cardiovascular and cerebrovascular diseases were analyzed. The patients were divided into the androgen deprivation therapy (n = 14,092) and non-androgen deprivation therapy (n = 34,988) groups. The primary outcome was cardiovascular interventions (percutaneous transluminal angioplasty and coronary bypass surgery). Cox proportional hazard regression models were used to estimate the adjusted hazard ratios and 95% confidence intervals of the events.

RESULTS

After balancing the covariates with 1:1 exact matching, the two groups had 10,514 subjects each. Multivariable analysis demonstrated that androgen deprivation therapy was not significantly associated with an increased risk of cardiovascular interventions (hazard ratio, 1.060; 95% confidence interval, 0.923-1.217; P = 0.4104), regardless of the duration of therapy. A history of cardiovascular intervention, diabetes mellitus, antithrombotic medication use, and cardiovascular events significantly increased the risk of cardiovascular intervention.

CONCLUSIONS

Androgen deprivation therapy was not associated with cardiovascular intervention in patients with a previous history of cardiovascular disease, regardless of the duration of therapy. Therefore, the cardiovascular risk of androgen deprivation therapy should be reassessed in this population.

Metastatic Prostate Cancer Synchronous with Male Breast Papillary Ductal Carcinoma in situ: Management Dilemma and Literature Review

Prostate cancer is common in men, but tumour of the male breast is rare. For these two tumours to be presented synchronously in a male patient is even rarer. The focus of this paper is the case of a 72-year-old man diagnosed with papillary ductal carcinoma in situ after he presented with a unilateral breast mass associated with nipple discharge. Imaging staging for his breast tumour and subsequent prostate biopsy found an incidental synchronous asymptomatic prostate adenocarcinoma as well as bone metastases. He denies risk factors for malignancies and refuses genetic testing. The first part of our discussion will highlight the uncommon occurrence of male breast ductal carcinoma in situ and its management controversies. The subsequent part of our discussion will focus on the association between male breast cancer and prostate cancer, and implication of this on the future treatment of these patients. More importantly, our case will illustrate the challenges in managing dual primaries that present concurrently.

Canadian Urological Association guideline on androgen deprivation therapy: Adverse events and management strategies

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Reliability of graded cycling test with talk test and 30-s chair-stand test in men with prostate cancer on androgen deprivation therapy

PURPOSE

To investigate the absolute and relative reliability of the "graded cycling test with talk test" (GCT-TT) and the "30-second chair-stand test" (30s-CST) in men with prostate cancer receiving androgen deprivation therapy (ADT).

METHODS

Men with prostate cancer on ADT were included in this test-retest study. GCT-TT and 30s-CST were performed twice with 1 hour between test sessions. All tests were conducted by two experienced physiotherapists and all patients were familiar with the tests. Only intra-tester reliability was investigated as the test and retest of each participant were performed by the same physiotherapist. Intraclass correlation coefficient (ICC_2.1), standard error of measurement (SEM and SEM₉₅), and smallest real difference (SRD) were calculated.

RESULTS

Sixty men were included with a mean age of 70.8 ± 6.6 (mean ± SD) years. All performed 30s-CST twice without any problems. Two participants were excluded from the analysis of the GCT-TT results. Relative reliability for 30s-CST (ICC_2.1) was 0.97 [95% CI: 0.94-0.98] with low measurement error: SEM₉₅, 1.9 repetitions, and SRD, 2.6 repetitions. The corresponding results for GCT-TT were ICC_2.1, 0.90 [95% CI: 0.84-0.94]; SEM₉₅, 19.9 W; and SRD, 28.2 W.

CONCLUSIONS

The reliability of 30s-CST and GCT-TT is substantial for men with prostate cancer receiving ADT. Overall, an average 30s-CST improvement of 1.9 repetitions on a group level and three repetitions for individual patients are considered real improvements. A GCT-TT improvement exceeding 19.9 W represents a real improvement for a group of patients. Individual patients need to improve two steps (30 W).

[Antihormonal therapy of prostate cancer - treatment indication and cardiovascular risk profile - advantage for GnRH antagonists?]

INTRODUCTION

 Prostate cancer is the most common urological tumour disease in men. In the localized tumour stage in combination with radiotherapy and especially in advanced metastastic disease, classical androgen deprivation remains an essential therapy. During the last 10 years, our knowledge of the cardiovascular risk of this therapy has rapidly increased.

MATERIAL AND METHODS

 This non-systematic review highlights the current data on cardiovascular risk in the use of androgen deprivation therapy in prostate cancer.

RESULTS

 Essential publications about the cardiovascular risk of antihormonal therapy are summarised in detail. In particular, the current data on the potential cardiovascular benefit when using GnRH antagonists in androgen deprivation are discussed. The article further highlights the problem of today's antihormonal overtreatment, despite the lack of scientific evidence and points out that patient selection should be improved in the future.

CONCLUSION

 The multicentre prospective PRONOUNCE study has been designed to answer the question in more detail, as to whether GnRH antagonist therapy provides benefit with respect to the cardiovascular risk as compared to classical LHRH analogue androgen deprivation therapy.

Surgical versus Medical Castration for Metastatic Prostate Cancer: Use and Overall Survival in a National Cohort

PURPOSE

Surgical castration for metastatic prostate cancer is used less frequently than medical castration yet costs less, requires less followup and may be associated with fewer adverse effects. We evaluated temporal trends and factors associated with the use of surgical castration.

MATERIALS AND METHODS

This retrospective cohort study sampled 24,805 men with newly diagnosed (de novo) metastatic prostate cancer from a national cancer registry in the United States (2004 to 2016). Multivariable logistic regression assessed the association between sociodemographic factors and surgery. Multivariable Cox regression evaluated the association between castration type and overall survival.

RESULTS

Overall 5.4% of men underwent surgical castration. This figure decreased from 8.5% in 2004 to 3.5% in 2016 (per year later OR 0.89, 95% CI 0.87-0.91, p <0.001). Compared to Medicare, private insurance was associated with less surgery (OR 0.73, 95% CI 0.61-0.87, p <0.001) while Medicaid or no insurance was associated with more surgery (OR 1.68, 95% CI 1.34-2.11, p <0.001 and OR 2.12, 95% CI 1.58-2.85, p <0.001, respectively). Regional median income greater than $63,000 was associated with less surgery (vs income less than $38,000 OR 0.61, 95% CI 0.43-0.85, p=0.004). After a median followup of 30 months castration type was not associated with differences in survival (surgical vs medical HR 1.02, 95% CI 0.95-1.09, p=0.6).

CONCLUSIONS

In a contemporary, real-world cohort surgical castration use is low and decreasing despite its potential advantages and similar survival rate compared to medical castration. Men with potentially limited health care access undergo more surgery, perhaps reflecting a provider bias toward the perceived benefit of permanent castration.

Patterns of practice of androgen deprivation therapy combined to radiotherapy in favorable and unfavorable intermediate risk prostate cancer. Results of The PROACT Survey from the French GETUG Radiation Oncology group

PURPOSE

The intermediate-risk (IR) prostate cancer (PCa) group is heterogeneous in terms of prognosis. For unfavorable or favorable IR PCa treated by radiotherapy, the optimal strategy remains to be defined. In routine practice, the physician's decision to propose hormonal therapy (HT) is controversial. The PROACT survey aimed to evaluate pattern and preferences of daily practice in France in this IR population.

MATERIALS AND METHODS

A web questionnaire was distributed to French radiotherapy members of 91 centers of the Groupe d'Etude des Tumeurs Uro-Genitales (GETUG). The questionnaire included four sections concerning: (i) the specialists who prescribe treatments and multidisciplinary decisions (MTD) validation; (ii) the definition of IR subsets of patients; (iii) radiotherapy parameters; (iv) the pattern of practice regarding cardiovascular (CV) and (iv) metabolic evaluation. A descriptive presentation of the results was used.

RESULTS

Among the 82 responses (90% of the centers), HT schedules and irradiation techniques were validated by specific board meetings in 54% and 45% of the centers, respectively. Three-fourths (76%) of the centers identified a subset of IR patients for a dedicated strategy. The majority of centers consider PSA>15 (77%) and/or Gleason 7 (4+3) (87%) for an unfavorable IR definition. Overall, 41% of the centers performed systematically a CV evaluation before HT prescription while 61% consider only CV history/status in defining the type of HT. LHRH agonists are more frequently prescribed in both favorable (70%) and unfavorable (98%) IR patients. Finally, weight (80%), metabolic profile (70%) and CV status (77%) of patients are considered for follow-up under HT.

CONCLUSION

To the best of our knowledge, this is the first survey on HT practice in IR PCa. The PROACT survey indicates that three-quarters of the respondents identify subsets of IR-patients in tailoring therapy. The CV status of the patient is considered in guiding the HT decision, its duration and type of drug.

Does androgen-deprivation therapy increase the risk of ischemic cardiovascular and cerebrovascular diseases in patients with prostate cancer? A nationwide population-based cohort study

PURPOSE

We investigated whether ADT use was associated with the risk of ischemic cardiovascular diseases (CVD) and cerebrovascular diseases (CrVD) in a nationwide population-based cohort.

METHODS

Claims data of the Health Insurance and Review Assessment system in South Korea were used. In total, 195,308 men with newly diagnosed prostate cancer between January 1, 2008 and December 31, 2017 were identified. After applying the exclusion criteria, 131,189 men were enrolled. The study cohort was divided into ADT and non-ADT groups. Study outcomes were newly developed CVD, cardiovascular intervention (CVI), and CrVD. To control for potential confounders, various cardiovascular risk factors were balanced between groups. Cox proportional hazard regression models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of events.

RESULTS

Univariable analysis revealed that ADT was significantly associated with an increased risk of CVD and CrVD. Multivariable analysis did not reveal this association. In the propensity score matched cohort (n = 61,722), multivariable analysis demonstrated that ADT independently reduced the risk of CVD (HR 0.890; 95% CI 0.846-0.936; p < 0.0001), CVI (HR 0.873; 95% CI 0.770-0.991; p = 0.0352), and CrVD (HR 0.869; 95% CI 0.824-0.917; p < 0.0001). CVD risk was significantly decreased in patients using ADT for over 2 years. CVI and CrVD risks were significantly lower in men using ADT for over 3 years.

CONCLUSION

This study demonstrated that ADT may reduce the risk of CVD, CVI, and CrVD, and ADT duration is associated with this risk reduction.

Cardiovascular risks and toxicity - The Achilles heel of androgen deprivation therapy in prostate cancer patients

Androgen deprivation therapy (ADT) is the primary systemic therapy for treating locally advanced or metastatic prostate cancer (PCa). Despite its positive effect on PCa patient survival, ADT causes various adverse effects, including increased cardiovascular risk factors and cardiotoxicity. Lifespans extension, early use of ADT, and second-line treatment with next-generation androgen receptor pathway inhibitors would further extend the duration of ADT and possibly increase the risk of ADT-induced cardiotoxicity. Meanwhile, information on the molecular mechanisms underlying ADT-induced cardiotoxicity and measures to prevent it is limited, mainly due to the lack of specifically designed preclinical studies and clinical trials. This review article compiles up-to-date evidence obtained from observational studies and clinical trials, in order to gain new insights for deciphering the association between ADT use and cardiotoxicity. In addition, potential cardioprotective strategies involving GnRH receptors and second messenger cGMP are discussed.

Potential Risk of Other-Cause Mortality Due to Long-Term Androgen Deprivation Therapy in Elderly Patients with Clinically Localized Prostate Cancer Treated with Radiotherapy-A Confirmation Study

Androgen deprivation therapy (ADT) is used to improve overall survival (OS) in prostate cancer treatment; however, we encountered that long-term ADT in elderly patients may be related to high other-cause mortality (OCM). This study aimed to confirm the potential risk associated with long-term ADT in elderly patients using a different large cohort. A comparison analysis was conducted between the ≥2- and <2-year ADT groups using open, large data from 1840 patients with clinically localized prostate cancer treated with radiotherapy (1172 treated with high-dose-rate brachytherapy (HDR) + external beam radiotherapy (EBRT) and 668 treated with external beam radiotherapy). The OCM-free survival (OCMFS), overall survival, and prostate cancer-specific survival rates were measured. The 10-year OCMFS rates in patients aged ≥75 years were 94.6% and 86% in the <2- and ≥2-year ADT groups, respectively, but were 96.3% and 93.5% (p = 0.0006) in their younger counterparts. If dividing into HDR and EBRT groups. This inclination was found in brachytherapy group but not in EBRT group. The overall survival rate was also lower in the elderly patients in the ≥2-year ADT group than in the <2-year ADT group; however, the 10-year prostate cancer-specific survival rate was the same in both groups. Long-term ADT in elderly patients resulted in not only higher OCM rates but also poorer OS rates; therefore, longer-term ADT in elderly patients should be performed with meticulous care.

Comparative study of surgical orchidectomy and medical castration in treatment efficacy, adverse effects and cost based on a large prospective metastatic prostate cancer registry

INTRODUCTION

Androgen deprivation therapy (ADT) remains the mainstay of treatment for metastatic prostate cancer (mPCa) but is associated with significant morbidities. Comparisons of medical castration (MC) and surgical orchidectomy (SO) have yielded varied results. We aimed to evaluate the oncological outcomes, adverse effect (AE) profiles and costs of MC and SO in patients with mPCa.

METHODS AND MATERIALS

We reviewed 523 patients who presented with de novo mPCa from a prospectively maintained prostate cancer database over 15 years (2001-2015). All patients received ADT (either MC or SO) within 3 months of diagnosis. The data were analyzed with chi-square, binary and logistics regression models.

RESULTS

One hundred and fifty one (28.9%) patients received SO while 372 (71.1%) patients had MC. The median age of presentation was 73 [67 -79] years old. The median prostate-specific antigen (PSA) was 280ng/ml [82.4-958]. Three hundred and thirty one patients (66.3%) had high volume bone metastasis and 57 patients (10.9%) had visceral metastasis. Clinical demographics and clinicopathological were similar across both groups. Similar oncological outcomes were observed in both groups. The proportion of PSA response (PSA <1ng/ml) was 65.6% for SO and 67.2% for MC (P = 0.212). Both therapies achieve >95% of effective androgen suppression (testosterone <50ng/dL). Time to castrate-resistance was similar (18 vs 16 months, P = 0.097), with comparative overall survival (42 vs. 38.5 months, P = 0.058) and prostate cancer mortality (80.1 vs. 75.9%, P = 0.328). Similarly, no difference was observed for the 4 AE profiles between SO and MC respectively; change in Haemoglobin (-0.75 vs. -1.0g/dL, P = 0.302), newly diagnosed Diabetes mellitus (4.6 vs. 2.9%, P = 0.281), control measured by HbA1c (0.2 vs. 0.25%, P = 0.769), coronary artery disease events (9.9 vs. 12.9%, P = 0.376) and skeletal-related fractures (9.3 vs. 7.3%, P = 0.476). After adjusting for varying governmental subsidies and inflation rates, the median cost of SO was $5275, compared to MC of $9185.80.

CONCLUSION

Both SO and MC have similar oncological outcomes and AE profiles. However, SO remains a much more cost-effective form of ADT for the long-term treatment of mPCa patients.

Risk of dementia in prostate cancer survivors: A nationwide cohort study in Korea

OBJECTIVES

To investigate the effects of prostate cancer (PC) and various treatment modalities for PC, specifically androgen deprivation therapy (ADT), on the risk of dementia and dementia subtypes in PC survivors.

MATERIAL AND METHODS

A total of 51,252 patients newly diagnosed with PC from 2007 to 2013, who had no prior diagnosis of cancer or dementia, were included and matched with 209,659 non-cancer control. The screening subset was comprised of subjects who participated in a health screening program. We used Cox proportional hazards model to estimate the relative risk of dementia and dementia subtypes according to the primary treatment for the PC.

RESULTS

Compared to non-PC matched controls, PC survivors showed slightly higher risk for dementia and Alzheimer disease (AD) only in the screening cohort. While PC survivors who underwent ADT were higher risk for dementia and AD, patients who underwent surgery were lower risk for dementia and AD, compared to the non-cancer population. Compared to surgery, ADT, surgery + ADT, and active surveillance/watchful waiting showed a significantly elevated risk for dementia.

CONCLUSION

PC survivors had slightly higher risk for dementia compared to non-PC controls, which might be related to the screening effects of PC. The risk for dementia was most prominent among PC patients who underwent ADT, followed by patients who underwent AS/WW, and those who underwent surgery + ADT. This finding suggests that individualized ADT strategies that consider the survival benefit and underlying dementia risk in PC survivors are necessary.

Temporal Trends in the Prevalence of Cancer and Its Impact on Outcome in Patients With First Myocardial Infarction: A Nationwide Study

Background Coexistence of cancer and cardiovascular disease is increasingly frequent, but nationwide data covering cancer patients with myocardial infarction (MI) are scarce. We sought to investigate the prevalence of cancer in patients with first MI, and its impact on cardiovascular and bleeding outcome. Methods and Results Using nationwide Swedish quality registries, all patients admitted for first MI between 2001 and 2014 were identified. Data on comorbidity, cancer, and outcome were obtained from the national cancer and patient registries. Stratification was performed according to cancer during the 5 years before MI. Multivariable Cox proportional hazards analyses adjusting for cardiovascular risk factors and invasive treatment assessed the association of cancer with outcome. In total, 175 146 patients with first MI were registered, of whom 9.3% (16 237) had received care for cancer in the 5 years before admission. The cancer rate increased from 6.7% in the years 2001-2002 to 10.7% in 2013-2014, independent of sex and cancer type. The presence of a new cancer diagnosis within 5 years increased from 4.9% to 6.2%. During a median follow-up of 4.3 years, cancer was associated with all-cause mortality (hazard ratio, 1.44; 95% CI, 1.40-1.47), recurrent MI (hazard ratio, 1.08; 95% CI, 1.04-1.12), heart failure (hazard ratio, 1.10; 95% CI, 1.06-1.13), and major bleeding (hazard ratio, 1.45; 95% CI, 1.34-1.57). Risk for adverse events varied strongly according to cancer extent, timing, and type. Conclusions Cancer as a comorbid disorder is increasing and is strongly associated with mortality, severe bleeding, and adverse cardiovascular outcome after first MI.

The Use of Gonadotropin-Releasing Hormone Agonist Does Not Affect the Development of Cardiovascular Disease in Prostate Cancer Patients: a Nationwide Population-Based Cohort Study

BACKGROUND

The objective of this study was to investigate whether androgen deprivation therapy (ADT) with gonadotropin-releasing hormone agonist (GnRHa) in prostate cancer (Pca) patients is associated with cardiovascular disease in the cohort based from the entire Korean population.

METHODS

Using the Korean National Health Insurance database, we conducted an observational study of 579,377 men who sought treatment for Pca between January 1, 2012 and December 31, 2016. After excluding patients with previously diagnosed cardiovascular disease or who had undergone chemotherapy, we extracted the data from 2,053 patients who started GnRHa (GnRHa users) and 2,654 men who were newly diagnosed with Pca (GnRHa nonusers) between July 1, 2012, and December 31, 2012, with follow-up through December 31, 2016. The primary outcomes were cerebrovascular attack (CVA) and ischemic heart disease (IHD).

RESULTS

GnRHa users were older, were more likely to reside in rural areas, had lower socioeconomic status, and had more comorbidities than nonusers (all P < 0.050). Although GnRHa users had an increased incidence of CVA and IHD (P = 0.013 and 0.048, respectively) in univariate analysis, GnRHa use was not associated with the outcomes in multivariate analysis. Furthermore, the cumulative duration of ADT was not associated with the outcomes whereas the associations between age at diagnosis with all diseases were significant.

CONCLUSION

Our complete enumeration of the Korean Pca population shows that ADT is not associated with increased risks of cardiovascular disease.

Prescription switching: Rationales and risks

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.

Effect of Androgen Deprivation Therapy on Metabolic Complications and Cardiovascular Risk

Androgen deprivation therapy (ADT) has been the cornerstone of prostate cancer treatment. ADT delays cancer progression, alleviates cancer-related symptoms, and is associated with survival gains. Despite these established benefits, the extended duration of therapy comes with known side effects. Furthermore, research from the past decade has generated increased awareness for more potentially lethal cardiometabolic consequences of ADT. In this review, we explore the relationship between ADT and cardiometabolic effects. Current literature on this complex relationship remains conflicting, due to a variety of factors, including study design (randomized vs. observational), treatment decision-making, and patient factors. Looking to the future, a combination of well-designed, randomized controlled trials and high-quality, real-world evidence are needed to definitely establish any ADT cardiovascular safety signal and to evaluate the efficacy of potential screening and therapeutic interventions. Furthermore, a collaborative, integrated approach among all health care professionals is critical to accurately delineate patients' potential risk/benefit treatment options.

Impact of Cerebrovascular Disease on Survival Benefits from Local Treatment in Patients with De Novo Metastatic Hormone-Sensitive Prostate Cancer

PURPOSE

Local treatment has become a treatment option for patients with de novo metastatic hormone-sensitive prostate cancer (mHSPC). Subgroup analyses based on a history of cerebrovascular disease (CVD) were performed to evaluate the impact thereof on overall survival (OS) after local treatment.

MATERIALS AND METHODS

A retrospective analysis was performed for 879 patients with de novo mHSPC between August 2003 and November 2016. Patients were stratified according to prior CVD history and the type of initial treatment: androgen-deprivation therapy (ADT) alone versus local treatment consisting of radical prostatectomy (RP) or radiation therapy (RT) with ADT, with or without metastasis-directed therapy. The primary outcome was OS assessed by Kaplan-Meier analysis and Cox-regression models.

RESULTS

Of 879 patients, 660 (75.1%) men underwent ADT alone, and 219 (24.9%) men underwent RP or RT with ADT, with or without metastasis-directed therapy. The median follow-up was 38 months. Multivariable analysis showed CVD history to be associated with a higher risk of overall mortality (p=0.001). In the overall cohort and in patients without a history of CVD, patients who underwent local treatment exhibited higher OS than men who received ADT alone (all p<0.001). However, the survival benefit conferred by local treatment was not seen in patients with a history of CVD (p=0.324). OS was comparable between patients who received RP and RT (p=0.521).

CONCLUSION

Local treatment with or without metastasis-directed therapy may provide OS advantages for mHSPC patients without a history of CVD. Further prospective studies are needed to address these important concerns.

Androgen Deprivation Therapy and the Risk of Stroke in Patients with Prostate Cancer: An Updated Systematic Review and Meta-Analysis

BACKGROUND

The aim of this article was to review the association between androgen deprivation therapy (ADT) and the risk of stroke in patients with prostate cancer (PC). Thus, we performed this study to understand the impact of ADT on the incidence of stroke in PC patients.

METHODS

A comprehensive literature search was performed in June 2019 based on PubMed, EMBASE, and Web of science databases. Pooled rate ratio (RR), hazard ratio (HR), and their 95% confidence intervals (95% CIs) were calculated with a DerSimonian and Laird random effects.

RESULT

A total of 239,099 patients from 10 studies were included in this analysis. There was no significant association in pooled RR analysis. Pooled HR analysis showed that ADT treatment increased the risk of stroke (HR = 1.129, 95% CI: 1.019-1.251, p = 0.02). In a subgroup analysis of RR results, we found that different ADT treatments had no significant effect on increasing the risk of stroke. And in the subgroup analysis of HR results, only PC patients treated with gonadotropin-releasing hormone (GnRH) agonists, orchiectomy, or oral antiandrogen had significantly higher risk of stroke. In addition, we observed the result from another comparison that PC patients treated with GnRH agonists combined with oral antiandrogens might have a lower risk of stroke compared with using GnRH agonists alone.

CONCLUSION

Our results showed that GnRH agonists, orchiectomy, or oral antiandrogen might play an important role in the incidence of stroke. We still need further studies to clarify the role of ADT in the increased risk of stroke.

Is androgen deprivation therapy for prostate cancer associated with cardiovascular disease? A meta-analysis and systematic review

BACKGROUND

Androgen deprivation therapy (ADT) is widely being applied in men who suffered from prostate cancer. Whether androgen deprivation therapy (ADT) is associated with an increased risk of developing cardiovascular-related disease is poorly defined.

OBJECTIVES

The aim of the present meta-analysis is to explore the relationship between ADT and the risk of cardiac events. MATERIALS AND METHODS: For this systematic review and meta-analysis, we searched databases from inception to April 2019 for randomized controlled trials (RCT) or observational studies that reported data on ADT administration and cardiac event incidence. The connection was evaluated through estimating relative risk ratio (RR) and 95% confidence intervals (CIs).

RESULTS

A significantly increased acute myocardial infarction (AMI) was detected in the ADT group compared with the control group (RR = 1.19, 95% confidence interval (CI), 1.02-1.39, P < .05). A significant difference between cardiovascular disease (CVD) and ADT was also observed, with summary RR = 1.25, 95% CI, 1.11-1.40, P < .05. Furthermore, our study also suggested ADT was not related to increased incidence of sudden cardiac death (SCD) (RR = 1.13, 95% CI, 0.92-1.38, P = .24); AMI and CVD were not connected with the duration of ADT (AMI: RR = 1.31; 95% CI, 0.66-2.63, P = .44, for > 5 year group; CVD: RR = 1.12, 95% CI, 0.97-1.30, P = .12, for > 5 year group). In addition, the RR for risk of CVD was 1.28 (95% CI, 1.01-1.62, P < .05) for men with PCa on new hormonal agents.

DISCUSSION

Various ADT modalities have different impact on cardiovascular disease risk in different level. Long-term application of ADT is not associated with increased risk of AMI and CVD. Both abiraterone and enzalutamide could significantly increase the incidence of cardiac events in patients who suffered from prostate cancer. Cautions and periodic cardiovascular elevation are necessary for patients before the ADT starting.

CONCLUSIONS

Androgen deprivation therapy is associated with increased risk of AMI, CHD, in contrast, this association is not detected in SCD.

Obesity is a predictor in prostate cancer patients receiving prostatectomy after neoadjuvant hormonal therapy

OBJECTIVE

This study aimed to investigate the relationship between obesity and pathologic features and biochemical recurrence in patients with prostate cancer (PCa) undergoing radical prostatectomy (RP) after neoadjuvant hormonal therapy (NHT).

METHODS

A total of 422 consecutive patients with clinically localized PCa who received NHT before RP were retrospectively analyzed. Unconditional multiple logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) regarding probability. A receiver operating characteristic (ROC) curve was used to assess the efficacy of the predictive variables. Castration resistance free survival curves were obtained using the Kaplan-Meier method, and were compared using the log-rank test.

RESULTS

Being overweight was associated with an increased risk of positive margins (OR 2.281; 95% CI 1.292-4.028) after adjusting for potential confounders. The area under the ROC curve for overweight patients was larger than that for patients in the normal weight range. There was no significant difference between the overweight and normal weight groups regarding castration resistance free survival.

CONCLUSIONS

Being overweight was associated with positive margins in patients with PCa undergoing RP after NHT.

Is androgen deprivation therapy associated with cerebral infarction in patients with prostate cancer? A Korean nationwide population-based propensity score matching study

Purpose

Previous studies have suggested that androgen deprivation therapy (ADT) is associated with cerebral infarction. However, conflicting results have been reported by other researchers. The aim of this study was to evaluate the association between ADT and cerebral infarction in patients with prostate cancer (PC) using big data.

Materials and Methods

Using information from the National Health Insurance Service database representative of the entire Korean adult PC population (n = 206 735), data regarding ADT and cerebral infarction between 2009 and 2016 were analyzed. Adjusted hazard ratios for cerebral infarction associated with ADT were estimated using propensity score‐matched Cox proportional hazards models and Kaplan‐Meier survival analyses.

Results

The final cohort comprised 36 146 individuals with PC, including 24 069 men (66.6%) who underwent ADT. During the mean follow‐up of 4.1 years, 2792 patients were newly diagnosed with cerebral infarction. In the unmatched cohort, there was a significant difference in the annual incidence of cerebral infarction between the ADT and non‐ADT groups (22.8 vs 14.6 per 1000 person‐years, respectively). However, there was no significant difference between the ADT and non‐ADT groups in the matched cohort (14.9 vs 14.6 per 1000 person‐years). The adjusted hazard ratio for cerebral infarction for PC patients who underwent ADT was 1.045 (95% CI 0.943‐1.159; P = 0.401) compared with those who did not undergo ADT. In addition, the cumulative duration of ADT was also not associated with an increased risk for cerebral infarction. However, older age, hypertension, diabetes, myocardial infarction, congestive heart failure, peripheral vascular disease, renal disease, dementia, and atrial fibrillation were revealed to be factors contributing to cerebral infarction.

Conclusion

This nationwide population‐based study revealed that ADT was not associated with cerebral infarction after adjusting for potential confounders.

Cardiovascular Safety and Possible Benefit of a 5-Alpha Reductase Inhibitor among Benign Prostatic Hyperplasia Patients, A Nationally Representative Cohort of Korean Men

Several studies suggest that 5-alpha reductase inhibitors (5ARIs) may be associated with elevated risk of cardiovascular disease (CVD). We investigated the association of 5ARI exposure and CVD incidence using the National Health Insurance Service-Health Screening Cohort, a nationally representative population-based sample of Koreans. We calculated the 4-year cumulative exposure to 5ARI for 215,003 men without prior 5ARI use. Participants were followed from January 1st, 2008 to December 31st, 2015. A subcohort of newly diagnosed benign prostatic hyperplasia (BPH) patients during 2004–2010 was also analyzed. The primary study outcome was CVD and secondary outcomes were myocardial infarction (MI) or stroke. Hazard ratios (HRs) were estimated using Cox proportional hazards models adjusted for conventional risk factors. In both the main cohort and BPH subcohort, the use of any 5ARI did not increase the risk of cardiovascular disease (HR = 1.06; 95% CI = 0.91–1.23; HR = 0.95; 95% CI = 0.88–1.03; respectively). Furthermore, as an unexpected finding, a dose-analysis among the BPH subcohort showed that the highest tertile of 5ARI exposure reduced the risk of CVD (HR = 0.82; 95% CI = 0.72–0.92; p-trend = 0.001), MI (HR = 0.69; 95% CI = 0.50–0.95), and stroke (HR = 0.84; 95% CI = 0.72–0.98) compared to non-users. Among men and BPH patients, 5ARI did not increase the risk of CVD. Among BPH patients, 5ARI use may reduce the risk CVD.

Risk of cardiovascular events in men treated for prostate cancer compared with prostate cancer-free men

Background

The effect of lifestyle, anthropometry and cardiovascular risk factors on cardiovascular disease in men with prostate cancer (PCa) remains unclear.

Methods

Using a population-based cohort of 25,436 Danish, cancer-free men aged 50–64 years, we obtained information on self-reported pre-cancer lifestyle, objectively measured anthropometry and cardiovascular risk factors, and linked them to national health registers for information on major cardiovascular outcomes. We assessed hazard ratios (HRs) of incident acute myocardial infarction (MI), ischaemic stroke (IS) and heart failure (HF) among 1546 men diagnosed with PCa treated with first-line active surveillance, watchful waiting, intended curative or palliative treatment compared with PCa-free men during 18 years of follow-up.

Results

Men who received first-line palliative treatment had higher rates of IS and HF with adjusted HRs of 2.09 (95% CI 1.49–2.93) and 2.05 (95% CI 1.43–2.94), respectively, compared with PCa-free men. The risks were increased from start of treatment. We did not find the same relation for men in any other treatment group. No differences between men treated for PCa and cancer-free controls were observed for MI after adjustment for lifestyle, anthropometry, and cardiovascular risk factors.

Conclusion

Pre-diagnosis lifestyle, anthropometry or cardiovascular risk factors did not explain the risk of IS and HF in PCa patients receiving palliative treatment. The results emphasise the need for balancing disease management and monitoring of cardiovascular health in this patient group.

Stroke and thromboembolic events in men with prostate cancer treated with definitive radiation therapy with or without androgen deprivation therapy

BACKGROUND

There is conflicting evidence regarding the association between androgen deprivation therapy (ADT) for prostate cancer (PC) and the risk of developing stroke and thromboembolic events. Our study evaluated the association between ADT use and development of stroke, transient ischemic attack (TIA), deep vein thrombosis (DVT), and pulmonary embolism (PE) in a homogenous group of men with PC treated with definitive radiation therapy (RT) after controlling for multiple sources of confounding.

METHODS

Observational cohort study of patients diagnosed with PC at the US Department of Veterans Affairs between 1 January 2001 and October 31, 2015 and treated with definitive RT. Exposure was initiation of ADT within 1 year of PC diagnosis. Primary outcomes were development of stroke, TIA, DVT, or PE.

RESULTS

44,246 men with median follow-up of 6.8 years. The overall cumulative incidences of stroke, TIA, DVT, and PE at 10 years were 6.0, 3.0, 3.4, and 1.9%, respectively. In the multivariable competing risks model, there was a significant association between ADT and stroke (subdistribution hazard ratio (SHR) = 1.19, 95% CI = 1.09-1.30, p < 0.01), TIA (SHR = 1.24, 95% CI = 1.08-1.41, p < 0.01), and DVT (SHR = 1.18, 95% CI = 1.04-1.34, p < 0.01). ADT was only associated with PE in men receiving ADT for > 1 year (SHR = 1.34, 95% CI = 1.06-1.69, p-value = 0.03).

CONCLUSION

We observed an increase in the risk of stroke, TIA, and DVT in men receiving ADT and an increased risk of PE in men receiving long-term ADT. These results highlight concerns regarding long-term risks of ADT on stroke and thromboembolic events in the treatment of PC.

Effect of Androgen Deprivation Therapy on Other-Cause of Mortality in Elderly Patients with Clinically Localized Prostate Cancer Treated with Modern Radiotherapy: Is There a Negative Impact?

The influence of androgen deprivation therapy (ADT) on other-cause of mortality (OCM) was investigated in patients with localized prostate cancer treated with modern high-dose radiotherapy. A retrospective review was conducted on 1125 patients with localized prostate cancer treated with high-dose radiotherapy, including image-guided, intensity-modulated radiotherapy or brachytherapy with a median follow-up of 80.7 months. Overall survival rate was no different between ADT (+) and ADT (−) group in high-, intermediate-, and low-risk groups. OCM was found in 71 patients, consisting of 4% (10/258) in the ADT (−) group and 7% (61/858) in the ADT (+) group (p = 0.0422). The 10-year OCM-free survival rate (OCMFS), if divided by the duration of ADT (ADT naïve (ADT (−)), ADT <2-year, and ADT ≥2-year groups), showed statistical significance, and was 90.7%, 88.2%, and 78.6% (p = 0.0039) for the ADT (−), ADT <2-year, and ADT ≥2-year groups, respectively. In patients aged ≥75 years, 10-year OCMFS for ADT (−), ADT <2-, and ADT ≥2-year groups was 93.5% (at 115.6 months), 85.6%, and 60.7% (p = 0.0189), respectively, whereas it was 90.7%, 89.9%, and 89.0% (p = 0.4716), respectively, in their younger counterparts. In localized prostate cancer patients, treatment with longer ADT for ≥2 years potentially increases the risk of OCM, especially in patients aged ≥75 years.

Population-based estimate of the use of intermittent androgen deprivation therapy in prostate cancer patients in Catalonia, Spain

PURPOSE

To estimate the use of intermittent androgen deprivation (IAD) therapy in patients with prostate cancer (PCa).

METHODS

Retrospective, non-interventional study based on electronic pharmacy dispensation data of luteinizing hormone-releasing hormone (LHRH) analogs and anti-androgens in Catalonia (Spain). Intermittency was defined as the percentage of time off treatment (%IAD), which was calculated for the whole sample by dividing the sum of all off-IAD periods by the total time on any LHRH analog regimen. The prevalence of patients on an IAD regimen (P_IAD ) was also estimated. A small validation study based on data from clinical records confirmed the excellent sensitivity and specificity of this approach.

RESULTS

A total of 515 803 prescriptions for LHRH analog were dispensed over a 5-year period (2008 to 2012) to 35 089 PCa patients. The mean age (±SD) was 77 years (±9). The %IAD in the cohort was 1.7% whereas the 5-year prevalence (P_IAD ) was 4.2%. Only 2.5% of patients on IAD were on IAD for >6 months. Of the physicians (n = 1638) who prescribed hormonal treatment, 24% used IAD at least once. Total expenditures for LHRH analogs were 1.2% of total drug expenditure in this population.

CONCLUSIONS

This study confirms the validity of the method developed to estimate IAD use based on electronic pharmacy dispensation data. Given the large potential clinical and economic benefits that greater use of IAD could provide, future studies are needed to confirm these findings and to identify new strategies to increase the use of IAD.

Cancer-associated stroke: Pathophysiology, detection and management (Review)

Numerous types of cancer have been shown to be associated with either ischemic or hemorrhagic stroke. In this review, the epidemiology and pathophysiology of stroke in cancer patients is discussed, while providing vital information on the diagnosis and management of patients with cancer and stroke. Cancer may mediate stroke pathophysiology either directly or via coagulation disorders that establish a state of hypercoagulation, as well as via infections. Cancer treatment options, such as chemotherapy, radiotherapy and surgery have all been shown to aggravate the risk of stroke as well. The clinical manifestation varies greatly depending upon the underlying cause; however, in general, cancer‑associated strokes tend to appear as multifocal in neuroimaging. Furthermore, several serum markers have been identified, such as high D‑Dimer levels and fibrin degradation products. Managing cancer patients with stroke is a delicate matter. The cancer should not be considered a contraindication in applying thrombolysis and recombinant tissue plasminogen activator (rTPA) administration, since the risk of hemorrhage in cancer patients has not been reported to be higher than that in the general population. Anticoagulation, on the contrary, should be carefully examined. Clinicians should weigh the benefits and risks of anticoagulation treatment for each patient individually; the new oral anticoagulants appear promising; however, low‑molecular‑weight heparin remains the first choice. On the whole, stroke is a serious and not a rare complication of malignancy. Clinicians should be adequately trained to handle these patients efficiently.

Cardiovascular safety of oncologic agents: a double-edged sword even in the era of targeted therapies - Part 2

INTRODUCTION

Patients with cancer are subject to the cardiotoxic effects of cancer therapy. Improved cancer treatments lead to more cancer-survivors, who though are exposed to various forms of cardiovascular (CV) disease (CVD) as they age. Aging patients are at increased risk of developing both malignancy and CVD or they may have survived some form of CVD as a result of effective CV treatments. Furthermore, patients with CVD may develop cancer and require treatment (and vice versa), all contributing to increased morbidity and mortality. The prevalence of both malignancy and CVD will increase due to the trend toward a longer lifespan.

AREAS COVERED

In part 2 of this review, the discussion of the CV effects of specific oncology drugs is completed with inclusion of additional immunological agents, current hormonal and other agents. Early detection and monitoring of cardiotoxicity, use of biomarkers and other imaging and diagnostic methods and prevention and treatment options are also discussed.

EXPERT OPINION

As outlined in part 1 of this review, oncologists need to be aware of the CV adverse-effects of their treatments and make careful and expectant clinical decisions, especially in patients with preexisting CVD or CV risk factors. Similarly, cardiologists should consider a detailed previous history of treatment for malignant disease, including prior chemotherapy exposure, dose(s) received, and/or combined modality therapy with chest radiotherapy. Both specialists should collaborate in order to minimize the impact of these two ubiquitous diseases (cancer and CVD) and mitigate the adverse effects of treatment modalities.

Risks of Major Long-Term Side Effects Associated with Androgen-Deprivation Therapy in Men with Prostate Cancer

STUDY OBJECTIVE

To examine the risks and compare the occurrences of major long-term side effects (sexual dysfunction, bone fractures, diabetes, cardiovascular morbidity, acute myocardial infarction [MI], and dementia) in patients with prostate cancer who received androgen-deprivation therapy (ADT) with those who did not.

DESIGN

Propensity score-matched retrospective cohort study using Medicare claims data.

DATA SOURCE

National Cancer Institute's Surveillance, Epidemiology, and End Results Program-Medicare linked database.

PATIENTS

A total of 201,797 patients 66 years or older who were diagnosed with any stage of prostate cancer between 1992 and 2009; of these, 94,528 patients received ADT; 107,269 patients did not.

MEASUREMENTS AND MAIN RESULTS

We identified receipt of ADT and number of claims for ADT, and ascertained the long-term treatment-related side effects that occurred during 19 years of follow-up, from 1992-2010, from Medicare claims data. Cox proportional hazards models were used to estimate the incidences and hazard ratios (HRs) of newly developed side effects. Among all potential long-term side effects, the risk of bone fractures was highest (HR 1.39, 95% confidence interval [CI] 1.35-1.43), followed by diabetes (HR 1.21, 95% CI 1.18-1.24), dementia (HR 1.16, 95% CI 1.13-1.20), coronary heart disease (HR 1.12, 95% CI 1.09-1.14), and acute MI (HR 1.11, 95% CI 1.08-1.15) in those who received ADT compared with those who did not. The HRs for bone fractures and diabetes increased steadily as the number of ADT doses increased, indicating a linear trend in the dose-response relationship. Compared with patients who received active surveillance, ADT was associated with a 12% increased risk of sexual dysfunction (HR 1.12, 95% CI 1.05-1.20). The HR for sexual dysfunction increased to 1.68 (95% CI 1.59-1.77) when ADT was combined with radiation therapy and to 3.54 (95% CI 3.26-3.85) when ADT was combined with radiation and surgery.

CONCLUSION

The results of this study demonstrated that in men with prostate cancer, receipt of ADT was associated with higher risks of bone fractures, diabetes, dementia, coronary heart disease, acute MI, and sexual dysfunction than in those who did not receive ADT.

Intermittent androgen deprivation therapy: recommendations to improve the management of patients with prostate cancer following the GRADE approach

PURPOSE

The purpose of this study was to provide evidence-based recommendations of intermittent androgen deprivation therapy (IADT) compared with continuous androgen deprivation therapy (CADT) for men with prostate cancer (PCA).

METHODS

We conducted a comprehensive search in MEDLINE, EMBASE, The Cochrane Library, CINAHL, and ECONLIT, from the database inception to December 2017. We adhered to the Grading of Recommendations, Assessment, Development and Evaluation framework to assess the quality of the evidence and to formulate recommendations.

RESULTS

We included one systematic review with 15 trials as well as three additional studies that assessed IADT versus CADT, all of them focused on PCA patients in advanced stages. The findings did not show differences for critical and important outcomes, including adverse events. Trials reported the benefits of IADT in terms of selected domains of health-related quality of life, although with high heterogeneity. Evidence quality was considered moderate or low for most of the assessed outcomes. We identified a patient preference study reporting a high preference for IADT, due to issues related to quality of life, general well-being, and side effects, among others. We did not identify economic studies comparing these regimes. We formulate four recommendations: one no-recommendation, one conditional recommendation, and two good practice points.

CONCLUSION

For men in early stages of PCA, it is not possible to make any recommendation about the preferable use of IADT or CADT due to the lack of available evidence. For men in advanced stages of the disease, an IADT should be considered as soon as clinically reasonable (weak recommendation and low certainty of the evidence). Clinicians should discuss the risks and benefits of IADT and CADT with their patients, taking into account their values and preferences.

The risk of prostate cancer mortality and cardiovascular mortality of nonmetastatic prostate cancer patients: A population-based retrospective cohort study

PURPOSE

To assess the risk of prostate cancer (PCa) specific mortality (PCSM) compared to cardiovascular disease mortality (CVDM), or other-cause mortality (OCM) of men with nonmetastatic PCa according to PCa risk groups, primary treatment, and age.

PATIENTS AND METHODS

This retrospective population-based cohort study identified 1,908 nonmetastatic PCa patients in the cancer registry Zurich and Zug, diagnosed between 2000 and 2009 living in the City of Zurich. Multiple imputation methods were applied to handle missing PCa information. Fine and Gray competing risk regression analysis was used to estimate subdistribution hazard ratios for the outcomes PCSM, CVDM, or OCM RESULTS: Ten years after diagnosis the cumulative probability of PCSM and CVDM was 16.4% and 10.0%, respectively. We observed an increased adjusted risk of PCSM in men treated with androgen deprivation therapy (ADT) compared to surgery, but could not observe an association between ADT and CVDM. The probability of PCSM was significantly higher for patients on active surveillance or watchful waiting, compared to surgery. Age and PCa risk categories were positively associated with risk of PCSM, whereas there was no evidence for an association with CVDM or OCM based on risk groups.

CONCLUSIONS

Overall, men with PCa were more likely to die from non-PCa related outcomes. Nevertheless, the analyses showed a high proportion of PCSM among men on ADT, older men and men with a high-risk tumor. However, further research is needed to understand comprehensively the benefits of the respective treatments.