Who is the average patient presenting with prostate cancer?

Trends, Sociodemographic and Hospital-Level Factors Associated with Palliative Care Utilization Among Metastatic Prostate Cancer Patients

Background: Several factors are reported to be associated with palliative care utilization among patients with various cancers, but literature is lacking on metastatic prostate cancer (MPC) specific factors. Early integration of palliative care in management of MPC patients could increase their quality of life and overall outcomes. Methods: Retrospective longitudinal analyses were conducted using the National Inpatient Sample (NIS) data (2010 - 2019). Prevalence trends in palliative care utilization were assessed, and sociodemographic and hospital-level factors associated with palliative care utilization in MPC patients were examined. Results: The overall prevalence of palliative care utilization was 13.1% with an increasing trend from 8490 to 15,231 per 100,000 MPC admissions (p-trend <.001). MPC patients aged 65 years and above had similar odds of receiving palliative care compared to younger patients. Relative to non-Hispanic Whites, other racial groups had similar likelihood to utilize palliative care services. Patients in higher median household national income quartiles had greater odds of utilizing palliative care relative to those in the first income quartile. Patients on Medicaid, private insurance and other insurance types had greater odds of palliative care use in comparison to those on Medicare. Other factors identified were hospital region, location and teaching status, patient disposition, admission type, length of stay, and number of comorbidities. Conclusion: Our findings underscore the significance of enhanced government policies and institutional support in improving palliative care use among hospitalized MPC patients. Health systems must be proactive in addressing barriers to optimization of palliative care utilization in this population.

Contrasting roles of the ABCG2 Q141K variant in prostate cancer

ABCG2 is a membrane transport protein that effluxes growth-promoting molecules, such as folates and dihydrotestosterone, as well as chemotherapeutic agents. Therefore it is important to determine how variants of ABCG2 affect the transporter function in order to determine whether modified treatment regimens may be necessary for patients harboring ABCG2 variants. Previous studies have demonstrated an association between the ABCG2 Q141K variant and overall survival after a prostate cancer diagnosis. We report here that in patients with recurrent prostate cancer, those who carry the ABCG2 Q141K variant had a significantly shorter time to PSA recurrence post-prostatectomy than patients homozygous for wild-type ABCG2 (P=0.01). Transport studies showed that wild-type ABCG2 was able to efflux more folic acid than the Q141K variant (P<0.002), suggesting that retained tumoral folate contributes to the decreased time to PSA recurrence in the Q141K variant patients. In a seemingly conflicting study, it was previously reported that docetaxel-treated Q141K variant prostate cancer patients have a longer survival time. We found this may be due to less efficient docetaxel efflux in cells with the Q141K variant versus wild-type ABCG2. In human prostate cancer tissues, confocal microscopy revealed that all genotypes had a mixture of cytoplasmic and plasma membrane staining, with noticeably less staining in the two homozygous KK patients. In conclusion, the Q141K variant plays contrasting roles in prostate cancer: 1) by decreasing folate efflux, increased intracellular folate levels result in enhanced tumor cell proliferation and therefore time to recurrence decreases; and 2) in patients treated with docetaxel, by decreasing its efflux, intratumoral docetaxel levels and tumor cell drug sensitivity increase and therefore patient survival time increases. Taken together, these data suggest that a patient's ABCG2 genotype may be important when determining a personalized treatment plan.

The Efficacy and Safety of Tadalafil 5 mg Once Daily in the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: 1-Year Follow-up

PURPOSE

To evaluate the efficacy and safety of tadalafil 5 mg once daily use in the treatment of erectile dysfunction (ED) after robot-assisted laparoscopic radical prostatectomy (RALP).

MATERIALS AND METHODS

The study retrospectively evaluated 92 patients who underwent RALP at Dong-A University Hospital. The patients were surveyed by use of the abridged five-item version of the International Index of Erectile Function (IIEF-5) questionnaire, which was self-administered before surgery and at 6 months and 1 year after surgery. The 92 patients were classified into the tadalafil group (n=47) and the non-tadalafil group (n=45). Each group was then classified depending on the nerve-sparing (NS) procedure used: bilateral NS or unilateral NS.

RESULTS

At 6 months, the total IIEF-5 scores of the tadalafil group and the non-tadalafil group were 10.0±3.4 and 7.0±4.0, respectively. At 1 year, the total IIEF-5 score in the tadalafil group was significantly greater than that in the non-tadalafil group (13.2±5.6 vs. 7.7±4.8, p<0.0001). Statistically significant improvements (p<0.05) were observed in the tadalafil group for all 5 domains of the IIEF-5 score, whereas in the non-tadalafil group there was no significant improvement in any of the domains at 1 year. The reported side effects were flushing (8.5%, n=4), headache (4.3%, n=2), and dizziness (2.1%, n=1).

CONCLUSIONS

In ED patients after NS RALP, a once-daily dose of tadalafil 5 mg was well tolerated and significantly improved EF compared with that in the non-tadalafil group.

Laparoscopic radical prostatectomy monotherapy, a more aggressive yet less invasive option, is oncologically effective in selected men with high-risk prostate cancer having only one D'Amico risk factor: experience from an Asian tertiary referral center

PURPOSE

To present oncologic results of laparoscopic radical prostatectomy (LRP) monotherapy for men with high-risk, localized prostate cancer, and to find factors associated with a good prognosis via surgery alone.

PATIENTS AND METHODS

Between 2002 and 2009, 241 men underwent LRP at an Asian tertiary referral center. Among them, we retrospectively identified 85 (35.3%) men who met the D'Amico's high-risk criteria: Prostate-specific antigen level >20 ng/mL, Gleason score of 8 to 10, or clinical stage ≥T2c. Perioperative parameters were analyzed against biochemical recurrence (BCR)-free survival.

RESULTS

At a median follow-up of 54 months, BCR developed in 28 (34.1%), with an actuarial BCR-free survival rate of 63.3% at 5 years. Pathologically, 37.6% of the men had organ-confined (OC) disease. Positive surgical margins (PSM) were identified in 49.4% of the patients. A favorable pathologic outcome, defined as OC(+)PSM(-), was observed in 24 patients and associated with a 5-year BCR-free survival rate of 87.0%, compared with 100%, 54.0%, and 46.4% in men with OC(+)PSM(+), OC(-)PSM(-) and OC(-)PSM(+) disease (log-rank, P=0.008). The overall positive lymph node rate was 14.1%. Men (65.9%) with only one D'Amico risk factor had a 5-year BCR-free survival rate of 76.9%, compared with 34.6% in men (34.1%) with ≥2 risk factors (log-rank, P<0.001).

CONCLUSIONS

Radical prostatectomy monotherapy performed laparoscopically or robotically appears to be an option for high-risk prostate cancer, especially in men with a single D'Amico risk factor. Men with ≥2 risk factors are more prone for BCR to develop after surgery and may need second-line therapy.

Divorcing diagnosis from treatment: contemporary management of low-risk prostate cancer

Today, the majority of men with newly diagnosed prostate cancer will present with low-risk features of the disease. Because prostate cancer often takes an insidious course, it is debated whether the majority of these men require radical treatment and the accompanying derangement of quality of life domains imposed by surgery, radiation, and hormonal therapy. Investigators have identified various selection criteria for "insignificant disease," or that which can be monitored for disease progression while safely delaying radical treatment. In addition to the ideal definition of low risk, a lack of randomized trials comparing the various options for treatment in this group of men poses a great challenge for urologists. Early outcomes from active surveillance cohorts support its use in carefully selected men with low-risk disease features, but frequent monitoring is required. Patient selection and disease monitoring methods will require refinement that will likely be accomplished through the increased use of biomarkers and specialized imaging techniques.

The Prostate Cancer Intervention Versus Observation Trial: VA/NCI/AHRQ Cooperative Studies Program #407 (PIVOT): design and baseline results of a randomized controlled trial comparing radical prostatectomy with watchful waiting for men with clinically localized prostate cancer

Prostate cancer is the most common noncutaneous malignancy and the second leading cause of cancer death in men. In the United States, 90% of men with prostate cancer are more than age 60 years, diagnosed by early detection with the prostate-specific antigen (PSA) blood test, and have disease believed confined to the prostate gland (clinically localized). Common treatments for clinically localized prostate cancer include watchful waiting (WW), surgery to remove the prostate gland (radical prostatectomy), external-beam radiation therapy and interstitial radiation therapy (brachytherapy), and androgen deprivation. Little is known about the relative effectiveness and harms of treatments because of the paucity of randomized controlled trials. The Department of Veterans Affairs/National Cancer Institute/Agency for Healthcare Research and Quality Cooperative Studies Program Study #407:Prostate Cancer Intervention Versus Observation Trial (PIVOT), initiated in 1994, is a multicenter randomized controlled trial comparing radical prostatectomy with WW in men with clinically localized prostate cancer. We describe the study rationale, design, recruitment methods, and baseline characteristics of PIVOT enrollees. We provide comparisons with eligible men declining enrollment and men participating in another recently reported randomized trial of radical prostatectomy vs WW conducted in Scandinavia. We screened 13 022 men with prostate cancer at 52 US medical centers for potential enrollment. From these, 5023 met initial age, comorbidity, and disease eligibility criteria, and a total of 731 men agreed to participate and were randomized. The mean age of enrollees was 67 years. Nearly one-third were African American. Approximately 85% reported that they were fully active. The median PSA was 7.8ng/mL (mean 10.2ng/mL). In three-fourths of men, the primary reason for biopsy leading to a diagnosis of prostate cancer was a PSA elevation or rise. Using previously developed tumor risk categorizations incorporating PSA levels, Gleason histologic grade, and tumor stage, it was found that approximately 40% had low-risk, 34% had medium-risk, and 21% had high-risk prostate cancer based on local histopathology. Comparison to our national sample of eligible men declining PIVOT participation as well as to men enrolled in the Scandinavian trial indicated that PIVOT enrollees are representative of men being diagnosed and treated in the United States and quite different from men in the Scandinavian trial. PIVOT enrolled an ethnically diverse population representative of men diagnosed with prostate cancer in the United States. Results will yield important information regarding the relative effectiveness and harms of surgery compared with WW for men with predominately PSA-detected clinically localized prostate cancer.

Comparison of efficacy and satisfaction profile, between penile prosthesis implantation and oral PDE5 inhibitor tadalafil therapy, in men with nerve-sparing radical prostatectomy erectile dysfunction

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Erectile dysfunction after nerve-sparing radical retropubic prostatectomy constitutes a challenge to the urologist. The mainstay of medical treatment after radical prostatectomy to restore spontaneous erectile function remains phosphodiesterase (PDE5) inhibitors, despite the fact that data from animal studies suggesting that PDE5 inhibitors can prevent smooth muscle apoptosis and fibrosis have not yet been extrapolated to humans because of a lack of standardized protocols. If the above treatment fails, second-line therapies such as intraurethral prostaglandins, penile injection therapy and vacuum devices are offered. When less invasive therapies are ineffective, interventions that preserve sexual function such as penile prosthesis implantation become the treatment of choice. Our study reveals the alternative of penile prosthesis implantation as first-line treatment in erectile dysfunction after nerve-sparing radical prostatectomy. It also highlights its superiority to the oral PDE5 inhibitor treatment, regarding the erection, frequency, firmness, maintenance and penetration ability. This suggests that a concept of an early penile intervention in the future would be promising for those patients who wish to remain sexually active without depending on oral formulations with doubtful and delayed results.

OBJECTIVE

To evaluate the outcome of penile prosthesis surgery in comparison to oral phosphodiesterase type 5 (PDE5) inhibitor administration, in men with erectile dysfunction after nerve-sparing radical prostatectomy, as early penile intervention therapy.

PATIENTS AND METHODS

A total of 174 patients treated by nerve-sparing retropubic radical prostatectomy (RRP) for clinically localized prostate cancer, between January 2006 and September 2009 enrolled in the study, 153 patients fulfilled the inclusion criteria, and 69 (45%) patients presented with post-RRP erectile dysfunction 6 months after primary surgery. Fifty-four patients were disease-free and subdivided into two arms according to treatment modality, either tadalafil three times/week or penile prosthesis implantation. All patients were evaluated using the International Index of Erectile Function (IIEF) questionnaire preoperatively and at 6, 12 and 24 month postoperatively. Repeated measurements analysis of variance was conducted to evaluate the effect of time and group on IIEF total score.

RESULTS

There was a significant reduction in IIEF score from preoperative values to the first measurement after surgery in both treatment groups. The overall degree of change from the first time point immediately after surgery to 2 years was greater in the penile prosthesis group than the tadalafil group (20.4 ± 1.3 vs 8.1 ± 2.4, P < 0.001).

CONCLUSIONS

The efficacy and satisfaction results of both treatment types are considered acceptable. However, regarding the erection frequency, firmness, penetration ability, maintenance and erection confidence it seems that penile prosthesis implantation is superior to oral treatment. The concept of early penile intervention should be considered and is promising for all patients with post-RRP erectile dysfunction.

Identification of differentially expressed proteins in direct expressed prostatic secretions of men with organ-confined versus extracapsular prostate cancer

Current protocols for the screening of prostate cancer cannot accurately discriminate clinically indolent tumors from more aggressive ones. One reliable indicator of outcome has been the determination of organ-confined versus nonorgan-confined disease but even this determination is often only made following prostatectomy. This underscores the need to explore alternate avenues to enhance outcome prediction of prostate cancer patients. Fluids that are proximal to the prostate, such as expressed prostatic secretions (EPS), are attractive sources of potential prostate cancer biomarkers as these fluids likely bathe the tumor. Direct-EPS samples from 16 individuals with extracapsular (n = 8) or organ-confined (n = 8) prostate cancer were used as a discovery cohort, and were analyzed in duplicate by a nine-step MudPIT on a LTQ-Orbitrap XL mass spectrometer. A total of 624 unique proteins were identified by at least two unique peptides with a 0.2% false discovery rate. A semiquantitative spectral counting algorithm identified 133 significantly differentially expressed proteins in the discovery cohort. Integrative data mining prioritized 14 candidates, including two known prostate cancer biomarkers: prostate-specific antigen and prostatic acid phosphatase, which were significantly elevated in the direct-EPS from the organ-confined cancer group. These and five other candidates (SFN, MME, PARK7, TIMP1, and TGM4) were verified by Western blotting in an independent set of direct-EPS from patients with biochemically recurrent disease (n = 5) versus patients with no evidence of recurrence upon follow-up (n = 10). Lastly, we performed proof-of-concept SRM-MS-based relative quantification of the five candidates using unpurified heavy isotope-labeled synthetic peptides spiked into pools of EPS-urines from men with extracapsular and organ-confined prostate tumors. This study represents the first efforts to define the direct-EPS proteome from two major subclasses of prostate cancer using shotgun proteomics and verification in EPS-urine by SRM-MS.

Androgen deprivation therapy in combination with radiotherapy for high-risk clinically localized prostate cancer

Androgen deprivation therapy (ADT) has remained the main therapeutic option for patients with advanced prostate cancer (PCa) for about 70 years. Several reports and our findings revealed that aggressive PCa can occur under a low dihydrotestosterone (DHT) level environment where the PCa of a low malignancy with high DHT dependency cannot easily occur. Low DHT levels in the prostate with aggressive PCa are probably sufficient to propagate the growth of the tumor, and the prostate with aggressive PCa can produce androgens from the adrenal precursors more autonomously than that with non-aggressive PCa does under the low testosterone environment with testicular suppression. In patients treated with ADT the pituitary-adrenal axis mediated by adrenocorticotropic hormone has a central role in the regulation of androgen synthesis. Several experimental studies have confirmed the potential benefits from the combination of ADT with radiotherapy (RT). A combination of external RT with short-term ADT is recommended based on the results of phase III randomized trials. In contrast, the combination of RT plus 6 months of ADT provides inferior survival as compared with RT plus 3 years of ADT in the treatment of locally advanced PCa. Notably, randomized trials included patients with diverse risk groups treated with older RT modalities, a variety of ADT scheduling and duration and, importantly, suboptimal RT doses. The use of ADT with higher doses of RT or newer RT modalities has to be properly assessed.

Factors affecting health-related quality of life in prostate cancer patients

OBJECTIVE

Prostate cancer is the most common cancer among men in Lithuania. Quality of life (QoL) assessment plays a key role in the evaluation and treatment of cancer patients. The aim of this study was to evaluate factors affecting the QoL of patients with prostate cancer in Lithuania.

MATERIAL AND METHODS

A cross-sectional national-level study was performed. QoL was investigated with the EORTC QLQ-C30 questionnaire. Statistical analysis included descriptive statistics, interrelationship analysis between characteristics and multivariate logistic regression to estimate predictors and odds ratios (ORs) for each of the independent variables in the model.

RESULTS

The response rate was 74.8% (N = 486). One-quarter of respondents with prostate cancer indicated high QoL scores. Higher QoL scores were given for prostate cancer patients with lower education level [OR = 3.092, 95% confidence interval (CI) 1.007-9.491, p = 0.049], having lower monthly expenses for treatment (OR = 3.653, CI 1.318-10.128, p = 0.013), disease stage II (by patient conveyance) (OR = 10.053, CI 1.015-99.534, p = 0.048), disease stage I (by medical record) (OR = 2.19E + 08, CI 218514200.17-218514200.17, p < 0.001) and in those with undisclosed disease stage (OR = 9.220, CI 1.251-67.965, p = 0.029).

CONCLUSIONS

Significant predictors for higher QoL scores were education level, own monthly expenses for treatment and disease stage. Patients with undisclosed disease stage more often had higher QoL scores.

Surgery for high-risk localized prostate cancer

Treatment of men with high-risk prostate cancer (PCa) remains challenging for urologists. The complex natural history of high-risk PCa and the lack of specific and accurate definitions for high-risk disease impede treatment decision making. Historically, surgery in this patient group has been avoided based on the perception of ostensibly higher complication rates associated with inferior functional and oncological outcomes. To date, no randomized data comparing different therapy approaches have been made available. Several investigators have reported that continence rates in patients after radical prostatectomy (RP) for high-risk disease seem to be unaffected. Similarly, in a large proportion of these men, a nerve-sparing procedure can be performed without a significant negative impact on surgical margin rates and with comparable potency results. Moreover, extended pelvic lymph node dissection (EPLND) contributes to accurate pathological staging with a marginal effect on perioperative morbidity. With regards to the benefits of RP on local recurrence and cure rates, realistic expectations regarding the success of RP alone or in the context of a multimodal approach should be provided during patient counseling.

Impact of androgen deprivation on physical well-being in patients with prostate cancer: analysis from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) registry

BACKGROUND

As androgen deprivation therapy (ADT) becomes a standard of treatment for men with recurrent or metastatic prostate cancer, evaluation of adverse effects associated with this treatment is needed. In this study, the authors evaluated the effect of ADT administered as monotherapy and in combination with local treatment on physical well-being in a longitudinal sample of men with prostate cancer.

METHODS

Exposure to ADT was defined by 3 groups: local (local treatment only), combination (local treatment with adjuvant and/or neoadjuvant ADT), and primary ADT. Associations between exposure to ADT and physical well-being measured by self-reported health-related quality of life outcomes over time were evaluated by repeated measures analysis using mixed modeling. Estimates adjusted for various clinical and demographic variables are reported.

RESULTS

A total of 2922 men, who completed both pretreatment and follow-up health-related quality of life assessment, were identified from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) registry. During 24 months of follow-up, exposure to ADT was associated with worse physical well-being compared with local treatment at all time points (P < .001). Being exposed to ADT as primary therapy was associated with more severe declines compared with combination therapy.

CONCLUSIONS

The potential consequence of decline in physical well-being in patients exposed to ADT has to be included in treatment decision making.

Treatment strategies for high-risk locally advanced prostate cancer

High-risk prostate cancer can be defined by the assessment of pretreatment prognostic factors such as clinical stage, Gleason score, and PSA level. High-risk features include PSA >20 ng/ml, Gleason score 8-10, and stage T3 tumors. Patients with adverse prognostic factors have historically fared poorly with monotherapeutic approaches. Multimodal treatment utilizing combined androgen suppression and radiotherapy has improved survival rates for patients with high-risk prostate cancer. In addition, multiple randomized trials in patients treated with primary radical prostatectomy have demonstrated improved outcomes with the addition of adjuvant radiotherapy. Improved radiotherapy techniques that allow for dose escalation, and new systemic therapy approaches such as adjuvant chemotherapy, present promising future therapeutic alternatives for patients with high-risk prostate cancer.

Five year biochemical recurrence free survival for intermediate risk prostate cancer after radical prostatectomy, external beam radiation therapy or permanent seed implantation

OBJECTIVE

To compare biochemical recurrence-free survival (bRFS) for patients with intermediate-risk prostate cancer treated by retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), external beam radiation therapy (RT), or permanent seed implantation (PI).

METHODS

Patients treated for intermediate-risk prostate cancer per National Comprehensive Cancer Network guidelines from 1996 to 2005 were studied. Variables potentially affecting bRFS were examined using univariate and multivariate Cox regression analysis. Five-year bRFS rates were calculated by actuarial methods; bRFS was calculated using Kaplan-Meier analysis. Nadir +2 definition of biochemical failure was used for RT and PI patients; a PSA ≥ 0.4 ng/mL was used for radical prostatectomy (RP) patients. Time to initiation of salvage therapy was compared for each treatment group using the Kruskal-Wallis test.

RESULTS

Nine-hundred seventy-nine patients were analyzed with a median follow-up of 65 months. Five years bRFS rate was 82.8% for all patients (89.5% PI, 85.7% RT, 79.9% RRP, and 60.2% LRP). Patients treated by LRP had significantly worse bRFS than RT (P < .0001), PI (P < .0001), or RRP patients (P = .0038). Treatment modality (P < .0001) and average number of PSA tests per year (P < .0001) were the only independent predictors of bRFS on multivariate analysis. Median time to initiation of salvage therapy from time of treatment was 28.6 months for all patients (26.1 RP, 21.0 LRP, 47.4 PI, 47.8 RT; P < .0001).

CONCLUSIONS

Patients with intermediate-risk prostate cancer choosing PI, RT, or RRP appear to have improved 5-year bRFS and delayed salvage therapy compared with LRP.

Prognostic implications of an undetectable ultrasensitive prostate-specific antigen level after radical prostatectomy

BACKGROUND

The prognostic meaning of an undetectable ultrasensitive prostate-specific antigen (USPSA) level after prostatectomy remains unclear.

OBJECTIVE

To determine whether an undetectable USPSA level obtained after surgery is a predictor of biochemical recurrence (BCR)-free survival.

DESIGN, SETTING, AND PARTICIPANTS

From the Urologic Oncology Database at the University of California San Francisco, 525 men were identified who had a USPSA measurement 1-3 mo postoperatively with at least 2 yr of follow-up. All preoperative and pathologic criteria were recorded.

MEASUREMENTS

Patients were stratified based on their initial USPSA level. We defined an undetectable USPSA level at ≤0.05 ng/ml. Recurrence was defined as two consecutive prostate-specific antigen (PSA) levels ≥0.2 ng/ml or secondary treatment.

RESULTS AND LIMITATIONS

We found that 456 patients (87%) had undetectable USPSA and 69 patients (13%) had detectable USPSA immediately postprostatectomy. A 5-yr recurrence-free rate of 86% was found in the undetectable USPSA group compared with 67% in the detectable USPSA group (p<0.01). For patients with pT3 disease, men with an undetectable USPSA had a 5-yr BCR-free survival rate of 78% compared with 40% for men with a detectable USPSA (p<0.01). A multivariable analysis confirmed that patients with an undetectable USPSA were 67% less likely to recur (hazard ratio: 0.33; 95% confidence interval: 0.20-0.55). As the detection level of PSA is lowered, the false-positive rate of BCR necessarily increases. A limitation of the study is its retrospective nature.

CONCLUSIONS

An undetectable USPSA after radical prostatectomy is a prognostic indicator of BCR-free survival at 5 yr and may aid in predicting outcome in higher risk patients.

Combined low-dose flutamide plus finasteride vs low-dose flutamide monotherapy for recurrent prostate cancer: a comparative analysis of two phase II trials with a long-term follow-up

OBJECTIVE

To compare the efficacy and tolerability of peripheral androgen blockade using combined low-dose flutamide plus finasteride vs low-dose flutamide monotherapy for treating biochemical relapse after the definitive management of prostate adenocarcinoma.

PATIENTS AND METHODS

Fifty-six men treated for biochemical relapse of prostate cancer were enrolled prospectively in a phase II trial at the Walter Reed Army Medical Center from 1997 to 2001. Thirty-six men were treated with flutamide (125 mg twice daily) and finasteride (5 mg twice daily), and 20 men received low-dose flutamide only after biochemical recurrence (prostate-specific antigen, PSA, level > or =0.4 ng/mL). Cox proportional hazards analyses were used to compare the risk of progression between the groups.

RESULTS

Patients on combined and monotherapy had a median follow-up of 54 and 43.5 months, respectively. Seven men (19%) in the combined arm remain in the study with no progression, while five (25%) on monotherapy continue and are progression-free. Men on combined therapy had a greater decrease in their PSA level (P = 0.002). Multivariate analysis showed that men on combined therapy had significantly less risk of progression than men on monotherapy (hazard ratio 0.21, 95% confidence interval 0.07-0.63, P = 0.005). There was no significant difference in the frequency of side-effects between the groups. Toxicities were reported to be mild.

CONCLUSIONS

Our analysis suggests the therapeutic value of low-dose flutamide alone or combined with finasteride as first-line agents in a possible graduated approach for treating PSA-only recurrent prostate cancer. Due to unwanted metabolic effects associated with traditional hormonal agents, phase III trials comparing both regimens with current therapies are warranted.

The Prostate cancer Intervention Versus Observation Trial:VA/NCI/AHRQ Cooperative Studies Program #407 (PIVOT): design and baseline results of a randomized controlled trial comparing radical prostatectomy to watchful waiting for men with clinically localized prostate cancer

BACKGROUND

Prostate cancer is the most common noncutaneous malignancy and the second leading cause of cancer death in men. Ninety percent of men with prostate cancer are over aged 60 years, diagnosed by early detection with the prostate specific antigen (PSA) blood test and have disease believed confined to the prostate gland (clinically localized). Common treatments for clinically localized prostate cancer include watchful waiting surgery to remove the prostate gland (radical prostatectomy), external beam radiation therapy and interstitial radiation therapy (brachytherapy) and androgen deprivation. Little is known about the relative effectiveness and harms of treatments due to the paucity of randomized controlled trials. The VA/NCI/AHRQ Cooperative Studies Program Study #407: Prostate cancer Intervention Versus Observation Trial (PIVOT), initiated in 1994, is a multicenter randomized controlled trial comparing radical prostatectomy to watchful waiting in men with clinically localized prostate cancer.

METHODS

We describe the study rationale, design, recruitment methods and baseline characteristics of PIVOT enrollees. We provide comparisons with eligible men declining enrollment and men participating in another recently reported randomized trial of radical prostatectomy versus watchful waiting conducted in Scandinavia.

RESULTS

We screened 13,022 men with prostate cancer at 52 United States medical centers for potential enrollment. From these, 5023 met initial age, comorbidity and disease eligibility criteria and a total of 731 men agreed to participate and were randomized. The mean age of enrollees was 67 years. Nearly one-third were African-American. Approximately 85% reported they were fully active. The median prostate specific antigen (PSA) was 7.8 ng/mL (mean 10.2 ng/mL). In three-fourths of men the primary reason for biopsy leading to a diagnosis of prostate cancer was a PSA elevation or rise. Using previously developed tumor risk categorizations incorporating PSA levels, Gleason histologic grade and tumor stage, approximately 43% had low risk, 36% had medium risk and 20% had high-risk prostate cancer. Comparison to our national sample of eligible men declining PIVOT participation as well as to men enrolled in the Scandinavian trial indicated that PIVOT enrollees are representative of men being diagnosed and treated in the U.S. and quite different from men in the Scandinavian trial.

CONCLUSIONS

PIVOT enrolled an ethnically diverse population representative of men diagnosed with prostate cancer in the United States. Results will yield important information regarding the relative effectiveness and harms of surgery compared to watchful waiting for men with predominately PSA detected clinically localized prostate cancer.

What percentage of patients with newly diagnosed carcinoma of the prostate are candidates for surveillance? An analysis of the CaPSURE database

PURPOSE

Active surveillance is an option for men with clinically localized prostate cancer and may be suitable for those with very low risk disease. We determined the percentage of men in a large prostate cancer registry who met criteria predictive of latent prostate cancer. We also assessed the percentage of men meeting these criteria who chose surveillance.

MATERIALS AND METHODS

We conducted an observational study of 1,886 men diagnosed with clinically localized prostate cancer between 1999 and 2004 from the CaPSURE database. Outcomes were percent of men meeting Epstein surveillance criteria (prostate specific antigen less than 10 ng/ml, clinical T1 or T2a, prostate specific antigen density less than 0.15, fewer than 1 of 3 biopsy cores positive, and absence of Gleason pattern 4 and 5 on biopsy) and percent selecting surveillance stratified by risk group.

RESULTS

Of 1,886 men with all 5 criteria documented 16.4% (310 of 1,886) met all 5 surveillance criteria and 9.0% (28 of 310) of men in this very low risk category actually chose surveillance compared with 4.3% (68 of 1,576) of patients in other risk groups (p <0.01). On multivariable analysis of the entire cohort older age was the only demographic predictor of surveillance. Being in the very low risk group was also a predictor of surveillance.

CONCLUSIONS

Of men presenting with localized prostate cancer 16% met the criteria for very low risk disease. However, only a small subset of eligible men chose active surveillance, suggesting that it may be underused in the management of very low risk prostate cancer.

Prostate specific antigen recurrence after definitive therapy

PURPOSE

We estimate that approximately 70,000 men yearly have prostate specific antigen-only recurrence after failed definitive therapy. The ideal salvage therapy for these men is not clear. Treatment must be individualized based on the patient risk of progression, the likelihood of success and the risks involved with the therapy. However, to do so the risks and benefits of the various options must be known. Therefore, we provide a comprehensive overview of the natural history and treatment options for men with prostate specific antigen-only recurrence.

MATERIALS AND METHODS

A literature review and overview of prostate specific antigen-only recurrence after failed definitive therapy was done.

RESULTS

The natural history after prostate specific antigen-only recurrence is long but variable. Median time from prostate specific antigen-only recurrence after radical prostatectomy to prostate cancer death exceeds 16 years, although some men die within 1 year after PSA recurrence. Rapid prostate specific antigen doubling time is the best prognostic factor for poor outcome. Salvage radiation therapy after radical prostatectomy results in a 45% 4-year prostate specific antigen response rate, although long-term outcomes appear poor. To our knowledge the effect on survival is not known. Salvage radical prostatectomy is rarely performed but in the highly selected patient it may provide some benefit. There are no randomized studies of early vs late hormonal therapy for men with prostate specific antigen-only recurrence. A retrospective study suggested delayed metastasis when therapy was begun early but only in men at high risk. This mirrors other data suggesting that men at high risk may derive significant benefits from early hormonal therapy, whereas men at low risk are unlikely to benefit and may be harmed by hormonal therapy.

CONCLUSIONS

Prostate specific antigen-only recurrence is the most common form of advanced prostate cancer. Optimal salvage treatments and timing of these treatments remain controversial.

Health-insurance status is a determinant of the stage at presentation and of cancer control in European men treated with radical prostatectomy for clinically localized prostate cancer

OBJECTIVE

To determine whether health-insurance status might result in more localized stage at presentation, more favourable stage at surgery and in a lower rate of biochemical recurrence (BCR), in patients diagnosed with prostate cancer and treated with radical prostatectomy (RP), as despite uninhibited access to healthcare, private and public health insurance are available in most European countries.

PATIENTS AND METHODS

In all, 4442 consecutive men had RP in two large European centres, of whom 2372 had public and 2070 had private health insurance. The groups were compared for several variables according to insurance status (private vs public). Means and proportions tests were complemented with logistic regression or Kaplan-Meier analyses.

RESULTS

Serum prostate-specific antigen level (P < 0.001), clinical stage (P < 0.001), pathological Gleason sum (P = 0.02), positive surgical margin rate (18.4% vs 25.4%, P < 0.001), extracapsular extension rate (17.7% vs 20.0%, P = 0.047) and seminal vesicle invasion rate (9.6% vs 11.6%, P = 0.04) were more favourable in privately insured patients. Conversely, the rate of lymph-node involvement was higher in those with private than public insurance (4.4% vs 3.3%, P = 0.045). In univariate analyses addressing pathological variables, private insurance was invariably protective (all P < 0.05). The Kaplan-Meier analyses showed that privately insured patients had a lower rate of BCR after RP (log-rank P = 0.017).

CONCLUSION

Despite uninhibited access to healthcare, insurance status represents a rate-limiting variable, which affects stage at presentation and the outcome of cancer control.

Death in patients with recurrent prostate cancer after radical prostatectomy: prostate-specific antigen doubling time subgroups and their associated contributions to all-cause mortality

PURPOSE

Among patients with biochemical recurrence after radical prostatectomy, we found previously that postoperative prostate-specific antigen doubling time (PSADT) was associated with risk of prostate cancer death. However, given the small number of patients in the highest risk PSADT subgroup, it is unclear which PSADT subgroups contribute the greatest to prostate cancer-specific death and how this influences all-cause mortality.

PATIENTS AND METHODS

This study was a retrospective analysis of 379 patients treated with radical prostatectomy between 1982 and 2000 who had a biochemical recurrence and PSADT data available. Mean and median follow-up after surgery was 11.4 (standard deviation, 5.4) and 11.0 years, respectively (range, 1.6 to 23.0 years).

RESULTS

Shorter PSADT was significantly associated with prostate cancer-specific and all-cause mortality (P < .001). Although patients with a PSADT less than 3 months were at the greatest risk of death, because of the limited number of patients in this group, they accounted for only 13% of prostate cancer deaths at 15 years after biochemical recurrence, whereas patients with an intermediate PSADT (3.0 to 8.9 months) accounted for 58% of all prostate cancer deaths. Among patients with a PSADT less than 15 months, prostate cancer accounted for 90% of all deaths. Only patients in the slowest PSADT subgroup (> or = 15 months) had a greater risk of competing-causes mortality compared with that from prostate cancer.

CONCLUSION

Among a select cohort of young, healthy patients with PSA recurrence after radical prostatectomy and a PSADT less than 15 months, prostate cancer accounted for an estimated 90% of all deaths by 15 years after recurrence. The majority of prostate cancer deaths occurred among patients with an intermediate PSADT (3.0 to 8.9 months).

Uncertainty and quality of life among men undergoing active surveillance for prostate cancer in the United States and Ireland

BACKGROUND

Prostate cancer continues to be the most common site of male cancers, particularly among older men in Europe and the United States, and the second most common male cancer worldwide. Active surveillance involves the use of no local or systemic therapy once prostate cancer has been diagnosed. A description of uncertainty and quality of life among men undergoing active surveillance in samples from both the United States and Ireland has the potential to enhance global health care delivery.

METHODS

The specific aim of this study is to enhance the understanding of the experience of active surveillance for prostate cancer among Irish and American men by measuring quality of life and levels of uncertainty among men over the age of 65 in receipt of the active surveillance management option for prostate cancer. A quantitative, descriptive survey design was used.

RESULTS

Twenty-nine men completed questionnaires. The results reveal that men undergoing active surveillance in the United States have slightly higher levels of uncertainty. Primary appraisal, opportunity, and danger appraisal were consistent between samples from both countries. Total affective and health-related quality-of-life scores were similar among active surveillance participants in both countries, but subscale scores identified both similarities and differences. Irish men had lower mean role and social function than U.S. men, and higher general health and energy. Irish men reported more urine bother and less sexual bother than U.S. men.

CONCLUSION

To assist men with prostate cancer who are treated with the active surveillance management option, health care professionals must develop an awareness of how prostate cancer affects the man's physical and psychological health care outcomes.