Active Surveillance of Very-low-risk Prostate Cancer in the Setting of Active Treatment of Benign Prostatic Hyperplasia With 5α-reductase Inhibitors

Five-alpha reductase inhibitors in men undergoing active surveillance for prostate cancer: impact on treatment and reclassification after 6 years follow-up

OBJECTIVES

To evaluate the impact of 5-alpha reductase inhibitors (5-ARIs) on definitive treatment (DT) and pathological progression (PP) in patients on active surveillance (AS) for prostate cancer.

METHODS

We identified 361 consecutive patients, from an IRB-approved database, on AS for prostate cancer with minimum 2 years follow-up. Patients were grouped into two cohorts, those using 5-ARIs (5-ARI; n = 119) or not using 5-ARIs (no 5-ARI; n = 242). Primary and secondary endpoints were treatment-free survival (TFS) and PP-free survival (PPFS), which were evaluated by Kaplan-Meier analysis. Univariate and multivariable cox regression analysis were used to identify predictors for PP and DT. A p value < 0.05 was considered statistically significant.

RESULTS

Baseline characteristics and the prostate biopsy rate were similar between the two groups. Median (range) follow-up was 5.7 (2.0-17.2) years. Five-year and 10-year TFS was 92% and 59% for the 5-ARI group versus 80% and 51% for the no 5-ARI group (p = 0.005), respectively. Five-year and 10-year PPFS was 77% and 41% for the 5-ARI group versus 70% and 32% for the no 5-ARI group (p = 0.04), respectively. Independent predictors for treatment and PP were not taking 5-ARIs (p = 0.005; p = 0.02), entry PSA > 2.5 ng/mL (p = 0.03; p = 0.01) and Gleason pattern 4 on initial biopsy (p < 0.001; p < 0.001), respectively. The main limitation is the retrospective study design.

CONCLUSIONS

5-ARIs reduces reclassification and cross-over to treatment in men on active surveillance for prostate cancer. Further, taking 5-ARIs was an independent predictor for prostate cancer progression and definitive treatment.

Long-term use of 5-alpha-reductase inhibitors is safe and effective in men on active surveillance for prostate cancer

BACKGROUND

Although 5-alpha-reductase inhibitors (5ARIs) have been shown to benefit men with prostate cancer (PCa) on active surveillance (AS), their long-term safety remains controversial. Our objective is to describe the long-term association of 5ARI use with PCa progression in men on AS.

MATERIALS/SUBJECTS AND METHODS

The cohort of men with low-risk PCa was derived from a prospectively maintained AS database at the Princess Margaret (1995-2016). Pathologic, grade, and volume progression were the primary end points. Kaplan-Meier time-to-event analysis was performed and Cox proportional hazards regression was used to determine predictors of progression where 5ARI exposure was analyzed as a time-dependent variable. Patients who came off AS prior to any progression events were censored at that time.

RESULTS

The cohort included 288 men with median follow-up of 82 months (interquartile range: 37-120 months). Among non-5ARI users (n = 203); 114 men (56.2%) experienced pathologic progression compared with 24 men (28.2%) in the 5ARI group (n = 85), (p < 0.001). Grade and volume progression were higher in the non-5ARI group compared with the 5ARI group (n = 82; 40.4% vs. n = 19; 22.4% respectively, p = 0.003 for grade progression; n = 87; 43.1% and n = 15; 17.7%, respectively for volume progression p < 0.001). Lack of 5ARI use was independently positively associated with pathologic progression (HR: 2.65; CI: 1.65-4.24), grade progression (HR: 2.75; CI: 1.49-5.06), and volume progression (HR: 3.15; CI: 1.78-5.56). The frequency of progression to high-grade (Grade Group 4-5) tumors was not significantly different between the groups.

CONCLUSIONS

Use of 5ARIs diminished both grade and volume progression without an increased risk of developing Grade Groups 4-5 disease.

Pre-radiotherapy PSA progression is a negative prognostic factor in prostate cancer patients using 5‑alpha-reductase inhibitors

OBJECTIVE

To investigate the impact of 5‑alpha-reductase inhibitor (5-ARI) use on radiotherapy outcomes for localized prostate cancer.

PATIENTS AND METHODS

We included 203 patients on a 5-ARI from our institutional database comprising over 2500 patients who had been treated with either external beam radiotherapy (EBRT) or brachytherapy for localized prostate cancer. Patients received a 5-ARI for urinary symptoms or active surveillance. Cancer progressions at the time of definitive treatment were analyzed according to the following criteria: (a) progression of Gleason score or increase in cancer volume on biopsy, (b) first biopsy positive for cancer after being treated for urinary symptoms with a 5-ARI, and (c) prostate-specific antigen (PSA) progression with or without a previous cancer diagnosis. Biochemical failure (BF) was defined by the Phoenix definition. Log-rank test was used for survival analysis.

RESULTS

At a median follow-up of 38.2 months (standard deviation 22.2 months), 10 (4.9%) patients experienced BF. Concerning prostate cancer progression criteria, 52% of men demonstrated none, 37% showed only one criterion, and 11% showed two. Using univariate analysis, PSA progression (p = 0.004) and appearance of a positive biopsy (p < 0.001) were significant predictive factors for BF, while Gleason progression (p = 0.3) was not. In multivariate analysis adjusted for cancer aggressiveness, rising PSA (hazard ratio, HR, 5.7; 95% confidence interval, CI, 1.1-28.8; p = 0.04) and the number of cancer progression factors (HR 2.9, 95% CI 1.2-7.0, p = 0.02) remained adverse risk factors.

CONCLUSION

PSA progression experienced during 5‑ARI treatment before radiotherapy is predictive of worse biochemical outcome. Such details should be considered when counseling men prior to radiation therapy.

5-Alpha reductase inhibitors in active surveillance

PURPOSE OF REVIEW

Active surveillance is now one of the recommended treatment options for low-risk prostate cancer (PCa). However, about 10-30% of men on active surveillance will progress and require definitive therapy. In this review, we examine the role of 5-alpha reductase inhibitors (5-ARIs) in secondary prevention among men with low-risk PCa who opted to be managed by active surveillance.

RECENT FINDINGS

Three retrospective studies and one randomized controlled trial have evaluated the role of 5-ARIs in preventing clinical progression among men followed by active surveillance. These studies largely support the role of 5-ARIs for secondary chemoprevention, although the drugs do not have an indication for this setting.

SUMMARY

5-ARIs have been shown to play an important role in preventing clinical progression among men with low-risk PCa on active surveillance. However, in light of the US Food and Drug Administration recommendation against 5-ARIs for primary chemoprevention, these findings should be interpreted with caution. Patients should be made aware of this warning label before starting the drug.

International Urology Journal Club via Twitter: 12-month experience

BACKGROUND

Online journal clubs have increasingly been utilised to overcome the limitations of the traditional journal club. However, to date, no reported online journal club is available for international participation.

OBJECTIVE

To present a 12-mo experience from the International Urology Journal Club, the world's first international journal club using Twitter, an online micro-blogging platform, and to demonstrate the viability and sustainability of such a journal club.

DESIGN, SETTING, AND PARTICIPANTS

#urojc is an asynchronous 48-h monthly journal club moderated by the Twitter account @iurojc. The open invitation discussions focussed on papers typically published within the previous 2-4 wk. Data were obtained via third-party Twitter analysis services.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Outcomes analysed included number of total and new users, number of tweets, and qualitative analysis of the relevance of tweets. Analysis was undertaken using GraphPad software, Microsoft Excel, and thematic qualitative analysis.

RESULTS AND LIMITATIONS

The first 12 mo saw a total of 189 unique users representing 19 countries and 6 continents. There was a mean of 39 monthly participants that included 14 first-time participants per month. The mean number of tweets per month was 195 of which 62% represented original tweets directly related to the topic of discussion and 22% represented retweets of original posts. A mean of 130 832 impressions, or reach, were created per month. The @iurojc moderator account has accumulated >1000 followers. The study is limited by potentially incomplete data extracted by third-party Twitter analysers.

CONCLUSIONS

Social media provides a potential for enormous international communication that has not been possible in the past. We believe the pioneering #urojc is both viable and sustainable. There is unlimited scope for journal clubs in other fields to follow the example of #urojc and utilise online portals to revitalise the traditional journal club while fostering international relationships.