Analysis of prognostic factors in men with metastatic prostate cancer. Uro-Oncology Group of Northern Alberta

Prognostic impact of serum testosterone in metastatic hormone-naive prostate cancer: a systematic review and meta-analysis

PURPOSE OF REVIEW

In daily practice, there is an unmet medical need for biomarkers that facilitate therapeutic decision-making in the metastatic hormone sensitive prostate cancer (mHSPC) scenario. Although recent studies have highlighted the potential of testosterone as a prognostic and predictive marker in prostate cancer, the evidence is controversial. The objective of this review was to summarize and analyze the scientific evidence regarding the prognostic role of basal testosterone levels in patients with mHSPC.

METHODS

A systematic review was performed. Three authors selected the articles from Web of Science, PubMed, Scopus, and Cochrane Library electronic databases. Risk of bias was assessed by the Newcastle Ottawa Scale.

RECENT FINDINGS

Most of the selected articles suggest that low testosterone levels before starting hormonal blockade imply a worse prognosis for patients with mHSPC. However, the quality of the evidence is poor, the studies are heterogeneous, and it is not possible to meta-analyze most of the published results.

SUMMARY

Testosterone is an accessible and affordable biomarker. If it were correctly demonstrated that it harbors a prognostic and/or predictive role in the mHSPC setting, it could represent an advance in decision-making in these patients. Well designed prospective studies are needed to correctly answer this question.

Advances in local and ablative treatment of oligometastasis in prostate cancer

Oligometastasis is a state of limited metastatic disease that may be amenable to aggressive local therapy to achieve long-term survival. This review aims to explore the role of ablative radiotherapy and surgical management of prostate cancer (CaP) patients with oligometastasis. We performed a systematic review of the literature from November 2003 to November 2013 in the PubMed and EMBASE databases using structured search terms. From our literature search, we identified 13 cases of oligometastatic CaP managed by surgery. The longest disease-free survival documented was 12 years following pulmonary metastasectomy. We also found 12 studies using radiotherapy to treat oligometastatic CaP with median follow-up ranging from 6 to 43 months. Local control rates and overall survival at 3 years range from 66 to 90% and from 54 to 92%, respectively. Most patients did not report any significant toxicity. The limited current literature suggests oligometastatic CaP may be amenable to more aggressive local ablative therapy to achieve prolonged local control and delay to androgen deprivation therapy (ADT). There is a larger body of evidence supporting the use of radiotherapy than surgery in this disease state. However, no direct comparison with ADT is available to suggest an improvement in overall survival. Further studies are required to determine the role of aggressive-targeted local therapy in oligometastatic CaP.

CCL2 increases αvβ3 integrin expression and subsequently promotes prostate cancer migration

BACKGROUND

Chemokine ligand 2 (CCL2), also known as monocyte chemoattractant protein-1 (MCP-1), belongs to the CC chemokine family which is associated with the disease status and outcomes of cancers. Prostate cancer is the most commonly diagnosed malignancy in men and shows a predilection for metastasis to the bone. However, the effect of CCL2 on human prostate cancer cells is largely unknown. The aim of this study was to examine the role of CCL2 in integrin expression and migratory activity in prostate cancers.

METHODS

Prostate cancer migration was examined using Transwell, wound healing, and invasion assay. The PKCδ and c-Src phosphorylations were examined by using western blotting. The qPCR was used to examine the mRNA expression of integrins. A transient transfection protocol was used to examine AP-1 activity.

RESULTS

Stimulation of prostate cancer cell lines (PC3, DU145, and LNCaP) induced migration and expression of integrin αvβ3. Treatment of cells with αvβ3 antibody or siRNA abolished CCL2-increased cell migration. CCL2-increased migration and integrin expression were diminished by CCR2 but not by CCR4 inhibitors, suggesting that the CCR2 receptor is involved in CCL2-promoted prostate cancer migration. CCL2 activated a signal transduction pathway that includes PKCδ, c-Src, and AP-1. Reagents that inhibit specific components of this pathway each diminished the ability of CCL2 to effect cell migration and integrin expression.

CONCLUSIONS

Interaction between CCL2 and CCR2 enhances migration of prostate cancer cells through an increase in αvβ3 integrin production.

GENERAL SIGNIFICANCE

CCL2 is a critical factor of prostate cancer metastasis.

D-pinitol inhibits prostate cancer metastasis through inhibition of αVβ3 integrin by modulating FAK, c-Src and NF-κB pathways

Prostate cancer is the most commonly diagnosed malignancy in men and shows a predilection for metastasis to the bone. D-pinitol, a 3-methoxy analogue of d-chiro-inositol, was identified as an active principle in soy foods and legumes, and it has been proven to induce tumor apoptosis and metastasis of cancer cells. In this study, we investigated the anti-metastasis effects of D-pinitol in human prostate cancer cells. We found that D-pinitol reduced the migration and the invasion of prostate cancer cells (PC3 and DU145) at noncytotoxic concentrations. Integrins are the major adhesive molecules in mammalian cells and have been associated with the metastasis of cancer cells. Treatment of prostate cancer cells with D-pinitol reduced mRNA and cell surface expression of αvβ3 integrin. In addition, D-pinitol exerted its inhibitory effects by reducing focal adhesion kinase (FAK) phosphorylation, c-Src kinase activity and NF-κB activation. Thus, D-pinitol may be a novel anti-metastasis agent for the treatment of prostate cancer metastasis.

CCN3 increases cell motility and ICAM-1 expression in prostate cancer cells

Nephroblastoma overexpressed (NOV or CCN3) is a secreted matrix-associated protein that belongs to the CCN gene family and is involved in many cellular functions, including growth, differentiation and adhesion. The effect of CCN3 on human prostate cancer cells, however, is unknown. Here, we have shown that CCN3 increased cell migration and intercellular adhesion molecule-1 (ICAM-1) expression in prostate cancer cells. In addition, expression of CCN3 was positively correlated with both cell migration and ICAM-1 expression in human prostate cancer cells. CCN3 activated a signal transduction pathway that included αvβ3 integrin, integrin-linked kinase (ILK), Akt and nuclear factor-kappaB (NF-κB). Reagents that inhibit specific components of this pathway each diminished the ability of CCN3 to effect cell migration and ICAM-1 expression. Moreover, CCN3 increased binding of p65 to an NF-κB-binding element in the ICAM-1 promoter. Finally, knockdown of CCN3 expression markedly inhibited cell migration, tumor growth in bone and bone metastasis. Taken together, our results indicate that CCN3 enhances the migration of prostate cancer cells by increasing ICAM-1 expression through a signal transduction pathway that involves αvβ3 integrin, ILK, Akt and NF-κB. CCN3 thus represents a promising new target for treating prostate cancer.

Dasatinib combined with docetaxel for castration-resistant prostate cancer: results from a phase 1-2 study

BACKGROUND

To determine the potential efficacy of targeting both the tumor and bone microenvironment in patients with castration-resistant prostate cancer (PC), the authors conducted a phase 1-2 trial combining docetaxel with dasatinib, an oral SRC inhibitor.

METHODS

In phase 1, 16 men received dasatinib 50 to 120 mg once daily and docetaxel 60 to 75 mg/m(2) every 21 days. In phase 2, 30 additional men received dasatinib 100 mg once daily/docetaxel 75 mg/m(2) every 21 days. Efficacy endpoints included changes in prostate-specific antigen (PSA), measurable disease, bone scans, and markers of bone metabolism. Safety and pharmacokinetics were also studied.

RESULTS

Combination dasatinib and docetaxel therapy was generally well tolerated. Thirteen of 46 patients (28%) had a grade 3-4 toxicity. Drug-drug interactions and a maximum tolerated dose were not identified. Durable 50% PSA declines occurred in 26 of 46 patients (57%). Of 30 patients with measurable disease, 18 (60%) had a partial response. Fourteen patients (30%) had disappearance of a lesion on bone scan. In bone marker assessments, 33 of 38 (87%) and 26 of 34 (76%) had decreases in urinary N-telopeptide or bone-specific alkaline phosphatase levels, respectively. Twenty-eight patients (61%) received single-agent dasatinib after docetaxel discontinuation and had stabilization of disease for an additional 1 to 12 months.

CONCLUSIONS

The high objective response rate and favorable toxicity profile are promising and justify randomized studies of docetaxel and dasatinib in castration-resistant PC. Parallel declines in levels of PSA and bone markers are consistent with cotargeting of epithelial and bone compartments of the cancer. Treatment with single-agent dasatinib following docetaxel cessation warrants further study. Cancer 2012;. © 2011 American Cancer Society.

Prognostic factors in metastatic prostate cancer

OBJECTIVE

Aim of this study is to determine the prognostic value of age, serum alkaline phosphatase, pretreatment PSA level, Gleason score, and number of bone metastasis focuses.

PATIENTS AND METHODS

One hundred fifty-one patients who had been followed in our clinic between years 1989 and 2006 were investigated retrospectively.

RESULTS

As a result of this study, it has been detected that serum alkaline phosphatase, Gleason score, and intensity of bone metastasis are important and statistically significant prognostic factors, and affects time to progression and life time. But pretreatment PSA level, and age have been detected not to be effective in predicting time to progression and life time.

CONCLUSION

Metastatic prostate cancer provides a wide spectrum for risk of death from the disease, and clinicians have long sought methods to predict the outcome accurately in individual patients. In our study, we found that high serum alkaline phosphatase, high Gleason score, and intense bone metastasis (>6) has negative impact on progression and survival.

Prognostic and Predictive Factors in Patients with Androgen-Independent Prostate Cancer Treated with Docetaxel and Estramustine: A Single Institution Experience

OBJECTIVES

To investigate potential prognostic and predictive factors in patients with androgen-independent prostate cancer (AIPC) treated with docetaxel chemotherapy.

METHODS

This analysis included 94 consecutive AIPC patients who were treated between March 2001 and May 2006 with biweekly docetaxel 45 mg/m(2) (day 2) and estramustine 140 mg three dimes daily (days 1-3).

RESULTS

Prostate-specific antigen (PSA) responses were observed in 45 of 84 evaluable patients (53%), whereas objective responses were observed in 16 of 40 patients with measurable disease (40%). Median survival (OS) was 16.2 mo (95% confidence interval [CI], 12.9-19.4) and median time to PSA progression (TTP) 5.0 mo (95%CI, 3.6-7.1). OS was independently associated with pain score baseline PSA and weight loss. Patients with only extraosseous disease had higher PSA response rate (87% vs. 49%, p=0.014) and superior TTP compared with patients with bone metastases with or without extraosseous disease (7.3 vs. 4.3 vs. 4 mo, p=0.002). Concurrent bone and extraosseous metastases were associated with worse prognosis compared with each site alone (median OS: 12.3 vs.19 vs.18.3 mo, p=0.007).

CONCLUSIONS

Among patients with AIPC treated with biweekly docetaxel and estramustine, baseline PSA >100, existence of pain, weight loss, and simultaneous extraosseous and bone disease were associated with worse prognosis. Extraosseous metastases seem to be more sensitive than bone disease to this chemotherapy.

Plasma osteopontin in comparison with bone markers as indicator of bone metastasis and survival outcome in patients with prostate cancer

BACKGROUND

The study was undertaken to evaluate the diagnostic and prognostic value of plasma osteopontin (OPN) in comparison to bone markers as well as the relationships between the markers and clinico-pathological factors in prostate cancer (PCa) patients.

METHODS

OPN and the bone markers carboxyterminal-telopeptide of type I collagen, bone-specific alkaline phosphatase (bALP), and aminoterminal-propeptide of type I procollagen (PINP) were measured in 90 PCa patients with and without bone metastases, 35 patients with benign prostatic hyperplasia, and 29 healthy men.

RESULTS

OPN and bone markers were significantly elevated in patients with bone metastases compared to the other groups. Significant correlations were found between all four-bone markers (r(s) = 0.43-0.79, all P < 0.01). OPN correlated with tumor grade (r(s) = 0.23, P < 0.05). In receiver-operating characteristics (ROC) analyses, OPN and bone markers were effective in distinguishing PCa patients with and without bone metastases showing areas under the curve (AUC) between 0.80 and 0.88 (all P < 0.001). OPN had an AUC of 0.85 that increased in combination with bALP up to 0.93 providing at the point with the highest diagnostic accuracy both a sensitivity and specificity of about 90%. Kaplan-Meier analyses and Cox proportional hazards regression models showed decreased survival of patients with high OPN and bone marker levels, while only high OPN and PINP were independent negative prognostic factors for PCa-related death.

CONCLUSIONS

OPN alone or in combination with bone markers is useful as diagnostic marker in the detection of bone metastases and as prognosticator in the survival prediction in PCa patients.

Impact of IGF-I and CYP19 gene polymorphisms on the survival of patients with metastatic prostate cancer

PURPOSE

The prognosis of metastatic prostate cancer significantly differs among individuals. While various clinical and biochemical prognostic factors for survival have been suggested, the progression and response to treatment of those patients may also be defined by host genetic factors. In this study, we evaluated genetic polymorphisms as prognostic predictors of metastatic prostate cancer.

PATIENTS AND METHODS

One hundred eleven prostate cancer patients with bone metastasis at the diagnosis were enrolled in this study. Thirteen genetic polymorphisms were genotyped using polymerase chain reaction-restriction fragment length polymorphism or an automated sequencer with a genotyping software.

RESULTS

Among the polymorphisms, the long allele (over 18 [CA] repeats) of insulin-like growth factor-I (IGF-I) and the long allele (over seven [TTTA] repeats) of cytochrome P450 (CYP) 19 were significantly associated with a worse cancer-specific survival (P = .016 and .025 by logrank test, respectively). The presence of the long allele of either the IGF-I or CYP19 polymorphisms was an independent risk factor for death (P = .019 or .026, respectively). Furthermore, the presence of the long allele of both the IGF-I and CYP19 polymorphisms was a stronger predictor for survival (P = .001).

CONCLUSION

The prognosis of metastatic prostate cancer patients is suggested to be influenced by intrinsic genetic factors. The IGF-I (CA) repeat and CYP19 (TTTA) repeat polymorphisms may be novel predictors in prostate cancer patients with bone metastasis at the diagnosis.

Pretreatment Serum Testosterone Level as a Predictive Factor of Pathological Stage in Localized Prostate Cancer Patients Treated with Radical Prostatectomy

OBJECTIVE

Pretreatment serum level of testosterone (T) is a potential prognostic factor for prostate cancer. The present study was conducted to evaluate the clinical significance of pretreatment serum T level in patients with clinically localized prostate cancer.

MATERIALS AND METHODS

The subjects were 82 clinically localized prostate cancer patients treated with radical prostatectomy, whose pretreatment T levels were recorded. We investigated clinical and pathological factors such as pretreatment serum T level, age, pretreatment PSA or pathological Gleason score concerning the association with pathological stage and biochemical recurrence.

RESULTS

The mean pretreatment T level was significantly lower in patients with non-organ-confined prostate cancer (pT3-T4, N1; 3.44+/-1.19 ng/ml) than in patients with organ-confined cancer (pT2; 4.33+/-1.42 ng/ml) (p=0.0078). Multivariate analysis demonstrated that pathological Gleason score, pretreatment serum T level and pretreatment PSA were significant predictors of extraprostatic disease. When the patients were divided into high and low T level groups according to the median value, pretreatment T levels were not significantly associated with PSA recurrence rates (p=0.7973).

CONCLUSIONS

A lower pretreatment T level appears to be predictive of extraprostatic disease in patients with localized prostate cancer.

Comparison of 10 serum bone turnover markers in prostate carcinoma patients with bone metastatic spread: diagnostic and prognostic implications

Our aim was to assess the diagnostic accuracy of bone markers in serum of patients with prostate cancer (PCa) for early detection of bone metastases and their usefulness as predictors of PCa-caused mortality. In sera of 117 PCa patients (pN0M0, n = 39; pN1M0, n = 34; M1, n = 44), 35 healthy men and 35 patients with benign prostatic hyperplasia, bone formation markers [total and bone-specific alkaline phosphatase (tALP, bALP), amino-terminal procollagen propeptides of type I collagen (P1NP), osteocalcin (OC)], bone resorption markers [bone sialoprotein (BSP), cross-linked C-terminal (CTX) and cross-linked N-terminal (NTX) telopeptides of type I collagen, tartrate-resistant acid phosphatase isoenzyme 5b (TRAP)] and osteoclastogenesis markers [osteoprotegerin (OPG), receptor activator of nuclear factor kappaB ligand (RANKL)] were measured. tALP, bALP, BSP, P1NP, TRAP, NTX and OPG were significantly increased in PCa patients with bone metastases compared to patients without metastases. OPG showed the best discriminatory power to differentiate between these patients. Logistic regression analysis resulted in a model with OPG and TRAP as variables that predicted bone metastasis with an overall correct classification of 93%. Patients with concentrations of OPG, P1NP, tALP, bALP, BSP, NTX, TRAP and CTX above cut-off levels showed significantly shorter survival than patients with low marker concentrations. Multivariate Cox proportional hazards regression revealed that only OPG and BSP were independent prognostic factors for PCa-related death. Thus, the importance of serum OPG in detecting bone metastatic spread, alone or in combination with other bone markers, and predicting survival in PCa patients has been clearly demonstrated.

Analysis of biochemical bone markers as prognostic factors for survival in patients with hormone-resistant prostate cancer and bone metastases

OBJECTIVES

To investigate the prognostic value of some conventional bone markers and a number of other factors in terms of the survival of patients with hormone-resistant prostate cancer and bone metastases treated with chemotherapy.

METHODS

The data of 141 patients were analyzed to verify the influence of the following factors on survival: bone-alkaline phosphatase, type I collagen propeptide, the carboxyterminal telopeptide of type I collagen, the urinary calcium/creatinine ratio, patient age, Karnofsky performance status, pathologic grade, duration of response to primary hormonal therapy, prostate-specific antigen, hemoglobin, lactate dehydrogenase, and extent of bone disease.

RESULTS

When all the variables were simultaneously analyzed using the multivariate proportional hazard model, only Karnofsky performance status (P <0.005) and duration of response to primary hormonal therapy (P <0.0001) remained statistically significant.

CONCLUSIONS

The results of this study suggest that bone-alkaline phosphatase, type I collagen propeptide, the carboxyterminal telopeptide of type I collagen, and the urinary calcium/creatinine ratio are not prognostic of survival in patients with hormone-resistant prostate cancer and bone metastases treated with chemotherapy.

Clinical significance of pulmonary metastases in stage D2 prostate cancer patients

Several prognostic factors such as the extent of bone metastases (EOD) in advanced prostate cancer (PCa) have been reported. Metastasis of the lung is rarely a significant clinical factor in the management of prostate cancer. The present study evaluates the clinical significance of lung metastases. We retrospectively reviewed the PCa database to identify patients with pulmonary metastases at initial diagnosis. The medical records of the patients were examined with respect to age, histologic grade, EOD score, marker response to endocrine therapy and clinical outcome. We then compared several potential clinical factors between patients with and without pulmonary metastases. Next, we retrospectively reviewed autopsy records of 60 Japanese patients who died of hormone-refractory metastatic PCa with particular focus upon metastatic profiles. A comparative study of stage D(2) patients with (n=20) and without (n=77) pulmonary metastases found no significant differences in EOD score, performance status, marker response and survival. Only tumor grade was better in the group with, than without pulmonary metastases (P=0.0120, chi-square analysis). In the series of autopsies, we found pulmonary metastases in 38 cases (63%), following metastases of the bone (57 cases, 95%) and lymph nodes (52 cases, 87%). A retrospective analysis of survival showed that patients with bone or lymph node metastases had a positive relative risk. In contrast, lung metastasis could be a positive prognostic indicator, although the findings were not statistically significant. These data suggest that the presence of pulmonary metastasis has no ominous impact on clinical course and disease outcome even in patients with disseminated prostate cancer.

Percentage of the positive area of bone metastasis is an independent predictor of disease death in advanced prostate cancer

We addressed in this study whether quantifying the extent of disease on bone scans can predict the disease death of patients with advanced prostate cancer using computer-assisted image analysis. Pretreatment radionuclide bone scans were reviewed in 56 patients with bone metastases from prostate cancer, and the percentage of the positive area on a bone scan (%PABS) was quantified automatically using a personal computer with the NIH Image program for estimation of the accurate extent of metastatic bone lesions on a bone scan. The significance of the %PABS as well as the other known prognostic factors was evaluated using univariate and multivariate Cox proportional hazards analysis. In univariate regression analysis, the %PABS (P=0.0155), serum alkaline phosphatase (P=0.0272), the tumour grade based on biopsy (P=0.044) and the number of bone lesions on bone scans (P=0.0388) were well associated with disease-specific survival. In multivariate analysis, the %PABS (P=0.0155, relative risk ratio 2.603), but not the other factors, was the independent predictor of the disease death. These results suggest that the %PABS is a novel parameter for predicting the prognosis of patients with advanced prostatic cancer.

Metastatic prostate carcinoma to bone: clinical and pathologic features associated with cancer-specific survival

BACKGROUND

The objective of this study was to examine the clinical and pathologic features of metastatic prostate carcinoma to bone in a large cohort of men, and the associations of these features with outcome.

METHODS

Sixty-eight men who underwent surgery for metastatic prostate carcinoma to bone for stabilization of a pathologic fracture or impending fracture were studied. Clinical characteristics included the type of treatment for the primary and metastatic prostate carcinoma, age and serum prostate specific antigen (PSA) at the diagnosis of the metastatic prostate carcinoma, radiographic findings of the metastasis (osteoblastic, osteolytic, or mixed), and the number of metastatic sites at the time of the surgery for the metastasis. Pathologic features examined included Gleason score of the metastatic prostate carcinoma. Immunohistochemical stains for MIB-1, cytokeratin, PSA, synaptophysin, chromogranin A, serotonin, estrogen receptor, progesterone receptor, and androgen receptor were performed for all cases. The Kaplan-Meier method was used to estimate cancer-specific survival. The duration of follow-up was defined as the interval from the date of surgery for the metastasis to the date of death or last follow-up. Univariate and multivariate Cox proportional hazards models were fit to assess the features that were associated with death from prostate carcinoma.

RESULTS

The average (standard deviation) time from the surgery for the metastasis to death from prostate carcinoma was 1.5 (1.9) years, ranging from 0 days to 10 years, with a median of 1 year. The estimated cancer-specific survival rates at 1 year, 2 years, and 3 years were 54.3%, 28.8%, and 22.9%, respectively. Median cancer-specific survival occurred at 1.1 years. After 4 years of follow-up, there were only seven patients left at risk for death from prostate carcinoma. Features that were found to be significantly associated with death from prostate carcinoma univariately included the interval between the diagnosis of metastasis and the surgery for metastasis (P < 0.001), androgen deprivation therapy before surgery for the metastasis (P = 0.002), presentation with metastasis (P = 0.003), the number of metastatic sites (P = 0.034), Gleason score of the metastasis (P = 0.002), and tumor positivity for chromogranin A (P = 0.041). On multivariate analysis, the interval between the diagnosis of metastasis and the surgery for metastasis (P < 0.001), Gleason score of the metastasis (P < 0.001), and tumor positivity for chromogranin A (P = 0.009) were associated significantly with death from prostate carcinoma.

CONCLUSIONS

Although cancer-specific survival for patients after surgery for prostate carcinoma metastatic to bone is poor, assessments of tumor differentiation of the metastasis and chromogranin A positivity provide prognostic information.

Prognostic factor analysis in patients with advanced prostate cancer treated by castration plus anandron or placebo: a final update

PURPOSE

Different outcome results have been published in trials comparing maximal androgen blockade (MAB) with chemical or surgical castration alone. The conflicting results could be explained by the fact that patients were included with different prognostic factors. In this new analysis of the Anandron European Study, independent prognostic factors have been evaluated in order to identify those which could influence the study outcome and the impact of the treatment.

MATERIAL AND METHODS

399 out of 457 patients recruited in this study were divided in a good or poor prognostic group depending on the presence of two or more poor prognostic factors, these were pain requiring treatment, >5 bone metastases, hydronephrosis, and alkaline phosphatase >2 ULN.

RESULTS

When expressed as a percentage, the improvement in time to progression, overall and cancer specific survival in the Anandron treated patients was identical in both groups. In absolute terms this improvement, however, was greater in the good prognostic group.

CONCLUSION

In comparison with surgical castration MAB using Anandron, in patients with metastatic prostate cancer improves the time to objective progression, overall and cancer specific survival, irrespective of certain poor prognostic factors.

CAG polymorphic repeat lengths in androgen receptor gene among Japanese prostate cancer patients: potential predictor of prognosis after endocrine therapy

BACKGROUND

Several investigators have examined the clinical significance of the length of the CAG repeat at the N-terminal region of the androgen receptor in the pathogenesis of prostate cancer. Because the clinical significance of CAG repeat length during the course of prostate cancer in Japanese patients is unknown, the present study analyzed CAG repeat length in relation to several potential clinical factors.

MATERIALS AND METHODS

A total of 88 Japanese patients with prostate cancer and a control group of 53 patients with benign prostatic disease were enrolled in this study. The length of the CAG repeat was determined by PCR sequencing and analyzed in relation to several clinical factors.

RESULTS

The length of the CAG repeat did not significantly differ between prostate cancer and benign prostatic disease. Although not statistically different with regard to clinical stage and serum PSA level, the CAG repeat length was associated with histological grade and age at diagnosis. In addition, the CAG repeat length in CR and in non CR patients significantly differed at 22.1 +/- 2.4 and 24.4 +/- 3.0, respectively (P = 0.0264), suggesting that the CAG repeat length can act as a molecular marker with which to predict response to endocrine therapy in stage D prostate cancer patients.

CONCLUSIONS

A shorter CAG repeat length appears to predict a response to endocrine therapy, showing a positive prognostic value and indicating good prognosis in the metastatic stage of prostate cancer patients.

Is obesity a risk factor for prostate cancer, and does it even matter? A hypothesis and different perspective

Measurement of obesity is not as simple as its definition. Currently, several methods of measuring obesity are used in clinical studies. Skinfold thickness, crude weight, lean body mass (LBM), body mass index (BMI), and waist-to-hip ratio (WHR) are some of the more popular methods, but each contains its inherent strengths and flaws. In general, the results of the largest studies on prostate cancer and obesity have not been conclusive. One of the largest studies found an inverse relation to prostate cancer in the youngest age groups. The age and duration of obesity or any rapid changes in weight gain, along with other unhealthy exposures, may have some relation to prostate cancer incidence and mortality. Early intrinsic or extrinsic exposure to estrogen or estrogenlike compounds may provide a protective effect. The timing and duration of a higher estrogen and/or lower testosterone exposure may have a beneficial or detrimental impact on the prognosis of an established prostate tumor. Negative exposures over time such as low levels of sex hormone-binding globulin (SHBG), a greater exposure to growth factors, elevated insulin levels, greater sympathetic activity, higher cholesterol levels, immune system dysfunction, inadequate diets, smoking status, and other factors may be associated with an increased risk of prostate cancer and other diseases. Obesity may also be associated with other cancers for similar and different reasons. For example, morbidity and mortality from postmenopausal breast cancer, colon, kidney, and other cancers are potentially associated with obesity. Other comorbidities such as cataracts, coronary heart disease, diabetes, erectile dysfunction, hypertension, and others are also associated with obesity. The 2 largest prospective studies on BMI and overall mortality have also demonstrated the substantial negative impact of excess weight on society. Prostate cancer risk and obesity need further research to establish if a true association exists, but at this time, does it really matter? Overall, the profound adverse effect of being obese on general health is dramatic, and this is what clinicians and patients need to remember.

Low serum testosterone level predicts worse response to endocrine therapy in Japanese patients with metastatic prostate cancer

Patients with prostate cancer generally respond to androgen withdrawal therapy, but progression to androgen-independence is frequently observed later. To examine whether pretreatment serum androgen status could predict disease progression in metastatic prostate cancer, pretreatment serum testosterone, histological grade, extent of bony metastasis, serum prostate-specific antigen (PSA) response to hormone therapy, and prognosis of the 40 patients with untreated metastatic prostate cancer who received endocrine therapy were evaluated. Although there were no differences in age, pretreatment PSA level, extent of bony disease and histological grade between patients with normal testosterone and those with low testosterone, PSA response after endocrine therapy was better in normal testosterone group. There was a significantly longer interval to disease progression in patients with normal testosterone than in those with low testosterone. The patients with metastatic prostate cancer with low serum testosterone were in the high risk group of worse response to endocrine therapy. Additional therapy might be considered in those patients.

[Prognostic value of DNA ploidy in prostatic cancer]

OBJECTIVE

To asses the prognostic value of deoxyribonucleic acid (DNA) ploidy in a group of patients with prostate cancer treated with adrogenic blockade.

MATERIALS AND METHODS

A retrospective study on 136 patients with prostatic cancer having undergone androgenic blockade was carried out. The prognostic influence of age, T and M categories, Gleason score and flow cytometry-determined DNA ploidy from survival analyses. Univariate survival analysis was carried out following Kaplan-Meier's method, while for multivariate survival analysis Cox's proportional hazard model was used.

RESULTS

The univariante analysis showed that T and M categories, Gleason score and DNA ploidy have prognostic value. The Cox's regression analysis identified DNA ploidy, metastasis and Gleason score as independent variables having prognostic potential.

CONCLUSIONS

DNA ploidy has independent prognostic value in prostate cancer treated with androgenic blockade and improves the predictive potential of classical prognostic factors.

The value of serum prostate specific antigen and other parameters in detecting bone metastases in prostate cancer

The cut-off value of serum prostate-specific antigen (PSA) level in prediction of bone metastases and the correlation of serum PSA with the clinical stage, grade, score and the rate of bone metastases have been investigated in cases of prostate cancer (PCa). The study population consisted of 160 patients with histologically proven PCa between April, 1993 and August, 1996. The negative predictive value and the sensitivity were the highest (94%) in patients with a serum PSA value less than 10 ng/ml. We claim that in patients with PSA values less than 10 ng/ml whole body bone scan is not necessary.

The prognostic value of different forms of prostate specific antigen and their ratios in patients with prostate cancer

OBJECTIVE

To assess the prognostic value for patient survival of different forms of PSA and ratios thereof, before treatment for prostate cancer, by considering the forms and ratios both as independent markers and by comparing them with other commonly used prognostic markers, e.g. tumour grade, local stage (T-stage) and absence or presence of skeletal metastases (M-stage).

PATIENTS AND METHODS

Blood samples were collected consecutively from men diagnosed with prostate cancer at our department in 1988. From this group, 66 men were followed until death, or for >/=9 years. Twenty-five patients died from their prostate cancer and 21 from other causes during the follow-up period. Forty-eight patients received hormonal treatment, whereas 18 remained untreated or received no treatment for their cancer before they died from other causes. Assays measuring the serum levels of free prostate specific antigen (fPSA), PSA complexed to alpha1-antichymotrypsin (PSA-ACT), and total PSA (tPSA) were used to calculate the percentage of free to total PSA (f/tPSA) fPSA/ACT and ACT/tPSA at diagnosis. Based on the initial levels or ratios of the PSA forms, the patients were divided into three numerically comparable groups (tertiles) for survival analysis. Prognostic factors predicting patient survival were evaluated using univariate (Kaplan-Meier life-tables with the log-rank test) and multivariate techniques (Cox proportional hazards regression model).

RESULTS

Univariate analysis using the log-rank test showed that the serum level of each molecular form of PSA, i.e. tPSA (P=0.001), PSA-ACT (P<0.001) and fPSA (P<0.001), as well as grade (P<0.001), T-stage (P=0.00355) and M-stage (P<0.001), provided statistically significant prognostic information. Log-rank tests showed that none of the ratios, i.e. f/tPSA, fPSA/ACT and ACT/tPSA, were informative of prognosis (P>0.05). However, in a multivariate analysis regression model, not only M-stage (risk ratio 4.2; P=0. 026) and grade (risk ratio 2.6; P=0.022), but also f/tPSA (risk ratio 1.8; P=0.037), provided significant prognostic information.

CONCLUSION

The values of tPSA, fPSA and PSA-ACT, as well as grade and T- and M-stage, are all independent prognostic factors of prostate cancer survival. In a multivariate analysis, not only M-stage and grade but also f/tPSA provided significant prognostic information.

Pattern of progression and survival in hormonally treated metastatic prostate cancer

BACKGROUND

Patients with prostate cancer generally respond to androgen ablation therapy, but progression to androgen-independence is frequently observed. To further evaluate disease progression, the pattern of progression and survival in hormonally treated metastatic prostate cancer was examined.

METHODS

One hundred and ninety-three patients with untreated metastatic prostate cancer (TxNxM ) who received endocrine therapy between 1986 and 1995 were included in the present study. The pattern of progression was evaluated in these patients.

RESULTS

One hundred and eighteen of the 193 patients (61.1%) had disease progression: 33 had local progression, 73 had distant progression and 12 had distant with local progression. Patients with only local progression had a longer interval to disease progression and longer survival than those with distant progression. The interval from disease progression to death in patients with local progression was longer than in those with distant progression. The patients whose prostate-specific antigen (PSA) had not been normalized 3 months after the start of endocrine therapy had a tendency to progression either into the prostate or into distant sites. Patients with extent of disease (EOD) scores of 3 and 4 progress, especially to distant sites, after endocrine treatment.

CONCLUSIONS

In untreated metastatic prostate cancer, patients with a poor response of PSA levels and patients with a high volume of bone metastasis (i.e. EOD 3, 4) were in the high-risk group for progression, especially to distant sites. Progression into distant sites was a poor prognostic factor for patients with recurrence to endocrine therapy.

Use of bone turnover marker, pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (ICTP), in the assessment and monitoring of bone metastasis in prostate cancer

BACKGROUND

We investigated whether a new marker of bone turnover, pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (ICTP), could be useful in the assessment of bone metastasis and in monitoring of the response to treatment in patients with prostate cancer with bone metastasis.

METHODS

In all, 58 patients with prostate cancer (25 with bone metastasis and 33 without bone metastasis) and 52 patients with benign prostate hypertrophy who were treated between June 1994-August 1997 were included in this study. All patients were newly diagnosed.

RESULTS

Serum ICTP levels in patients with prostate cancer with bone metastasis were significantly higher than those in patients with prostate cancer without bone metastasis (P<0.0001) or with benign prostate hypertrophy (P<0.0001). No significant differences were observed in serum ICTP levels between patients with prostate cancer without bone metastasis and those with benign prostate hypertrophy. Serum ICTP levels correlated significantly with Soloway's grading system for bone scans. Serum ICTP levels in patients with bone metastasis showed a significant downward trend in response to hormonal treatment.

CONCLUSIONS

The determination of serum ICTP levels is useful in the assessment of bone metastasis and in monitoring the response of bone metastasis to treatment to prostate cancer.

Inability of bone turnover marker as a strong prognostic indicator in prostate cancer patients with bone metastasis: comparison with the extent of disease (EOD) grade

BACKGROUND

Although clinical investigations of bone turnover markers in prostate cancer patients have been conducted, the relationships of pretreatment levels of the markers to the prognosis of patients with bone metastasis has not been fully examined.

METHODS

The serum levels of carboxy-terminal propeptide of type I procollagen (PICP) and carboxy-terminal telopeptide of type I collagen (ICTP), alkaline phosphatase (ALP), and prostate-specific antigen (PSA) were examined in 48 untreated prostate cancer patients with bone metastasis, and the prognoses of the patients were evaluated using univariate and multivariate analyses.

RESULTS

The patients with low PICP or ALP values had significantly better outcomes in terms of cause-specific survival compared to the patients with high PICP or ALP values. There was no significant difference in survival between patients with high and low ICTP or PSA values. The multivariate analysis of PICP, ICTP, ALP, PSA, and extent of disease (EOD) grade revealed that only the EOD grade was an important prognostic indicator for survival.

CONCLUSIONS

These results demonstrate that the extent of bone metastasis evaluated by bone scintigrams is a more important prognostic indicator than are the serum biochemical markers of bone turnover.

A worse prognosis for men with testicular atrophy at therapeutic orchiectomy for prostate carcinoma

BACKGROUND

The significance of testicular atrophy at the time of therapeutic orchiectomy for prostate carcinoma has not been examined even though pretreatment hypogonadism has been associated with poor prognosis during chemical androgen ablation for these tumors.

METHODS

Survival after therapeutic orchiectomy was determined for 78 men with prostate carcinoma and related to the histologic severity of testicular atrophy. Included in analysis were the presence or absence of prior radiation therapy, tumor grade and stage at diagnosis, host age, obesity, and smoking habits.

RESULTS

Among 35 men who underwent therapeutic orchiectomy for progressive disease after primary radiation therapy to the prostate bed, the 25 men with testicular atrophy had worse 5-year, tumor specific, postorchiectomy survival than the 10 men without testicular atrophy (30% vs. 89%) (P=0.02). These 25 men had tumors of more advanced stage and greater undifferentiation at the time of diagnosis an average of 45 months before orchiectomy, but neither characteristic was related to postorchiectomy survival. Among 25 men with Stage D2 disease (American Urologic Association staging system) with orchiectomy as the primary treatment, the 7 men with testicular atrophy more often had undifferentiated tumors and had lower 2-year tumor specific survival than the 18 men without atrophy (43% vs. 72% ) (P > 0.10).

CONCLUSIONS

Testicular atrophy at the time of therapeutic orchiectomy for prostate carcinoma is associated with poor postorchiectomy prognosis in men with prior prostate bed radiation therapy and perhaps in men without prior radiation. The association may reflect a high frequency of inherently more aggressive tumors (often relatively nonandrogen-dependent) among those tumors that are progressing in hypogonadal men.

Testicular atrophy in therapeutic orchiectomy specimens from men with prostate carcinoma: association with prior prostate bed radiation and older age

BACKGROUND

The significance of testicular atrophy at the time of therapeutic orchiectomy for prostate carcinoma has not been examined even though hypogonadism may occur after prostate bed radiation therapy for these tumors, may itself be symptomatic, and also may be associated with poor tumor prognosis.

METHODS

Therapeutic orchiectomy specimens from 78 men with prostate carcinoma and no preceding hormonal therapy were evaluated histologically for atrophy. Observations were related to prior radiation therapy, tumor grade and stage diagnosis, host age, obesity, and smoking habits.

RESULTS

Thirty-five men who previously received radiation therapy to the prostate bed had testicular atrophy more frequently than 43 men without prior radiation (71% vs. 28%) (P < 0.001). In men without prior radiation, atrophy was less common in specimens from those age < 70 years than in specimens from men age > 70 years (7% vs. 38%) (P < 0.04). In men with prior radiation, prominent atrophy occurred with similar frequency in specimens from both younger and older men, and was more frequent in specimens obtained within 3 years after radiation therapy than in specimens obtained after longer postradiation intervals (89% vs. 53%) (P < 0.001).

CONCLUSIONS

Testicular atrophy at the time of therapeutic orchiectomy for men with prostate carcinoma is much more common in patients with prior prostate bed radiation therapy. Available evidence suggests that this association may reflect both radiation-induced testicular injury and more frequent early tumor recurrence in men with atrophy preceding their radiation therapy.

Prognostic factors in patients with metastatic (stage D2) prostate cancer: experience from the Scandinavian Prostatic Cancer Group Study-2

PURPOSE

Nuclear texture reflects the overall structures of the chromatin organization. We recently reported the principles and prognostic importance of image analysis of nuclei from metastatic prostate cancer. Immunohistochemical up regulation of the adhesion molecule sialyl Lewis(x) is also reported to be a prognostic parameter. Presently we analyzed statistically the prognostic impact of these 2 new parameters compared to well-known clinical parameters in metastatic prostate cancer.

MATERIALS AND METHODS

Prognostic factors, such as sedimentation rate, alkaline and acid phosphatases, hemoglobin, testosterone, performance status, pain due to metastasis, T category, histological grade and patient age, were included in a multivariate Cox proportional hazards regression analysis based on 262 patients from the Scandinavian Prostatic Cancer Group Study-2. Extent of bone lesions, deoxyribonucleic acid ploidy, texture analysis and sialyl Lewis(x) molecules based on subsets of these 262 patients were also analyzed in the same multivariate model.

RESULTS

This test identified chromatin texture as the most important factor (p < 0.001), followed by reaction of the oligosaccharide sialyl Lewis(x) (p < 0.01). Among the routine clinical and laboratory data, sedimentation rate, alkaline phosphatase and hemoglobin (p < 0.05) showed prognostic importance. Performance status, pain due to metastasis and extent of bone lesions showed prognostic value in the univariate analysis (p < 0.05).

CONCLUSIONS

These data indicate that computerized nuclear texture analysis as well as up regulation of sialyl Lewis(x) molecules may be new important prognostic factors in metastatic prostate cancer. Furthermore the prognostic importance of sedimentation rate, alkaline phosphatase and hemoglobin was confirmed.

Pretherapeutic erythrocyte polyamine spermine levels discriminate high risk relapsing patients with M1 prostate carcinoma

BACKGROUND

Androgen deprivation is currently the standard treatment for patients with metastatic prostate carcinoma. Few reliable prognostic markers are able to select, at diagnosis, patients who will respond favorably and durably to hormone ablation. Circulating polyamines, markers of cell proliferation that are elevated in prostate carcinoma, have been evaluated as a prognostic tool.

METHODS

Eighty-eight patients with untreated, M1 classified prostate carcinoma who received endocrine therapy between 1988 and 1993 were included in this study. Performance status, hemoglobin, alkaline phosphatases, prostate specific antigen, Gleason tumor grade, extent of disease by bone scan, and circulating erythrocyte spermidine and spermine were correlated with observed progression free and cause-specific survivals. Multiple correspondence analysis and ascending hierarchical classification were performed to determine significant pretreatment prognostic factors.

RESULTS

Pretreatment performance status, alkaline phosphatase, hemoglobin, and erythrocyte spermine levels were correlated with progression, with hemoglobin and erythrocyte spermine level being the most significant independent variables (P < 0.00001 and P < 0.0001, respectively). With regard to cause specific survival, only hemoglobin and spermine erythrocyte levels were significant independent variables (P < 0.0001 and P < 0.0005, respectively). Patients with spermine levels of less than 9 nmol/8.10(9) had a statistically better outcome than patients with 9 nmol/8.10(9) or more erythrocytes. Erythrocyte spermine was the best sole determinant of progression. A test combining spermine with performance status or hemoglobin improved each variable's predictive values.

CONCLUSIONS

Circulating erythrocyte spermine levels, extracted from a blood sample, can discriminate, at diagnosis, patients with hormone-refractory from those with hormone-responsive metastatic prostate carcinoma.

The effect of Buserelin versus conventional antiandrogenic treatment in patients with T2-4NXM1 prostatic cancer. A prospective, randomized multicentre phase III trial. The "Danish Buserelin Study Group"

A prospective, randomized multicentre phase III trial was undertaken to compare the effectiveness and safety of Buserelin, a gonadotropin-releasing hormone analogue (GnRHa), with conventional antiandrogenic treatment in patients with painful metastases from T2-4NXM1 prostatic cancer. Seventy-two patients received Buserelin, 22 received estrogens and 46 were subjected to orchiectomy. The trial was completed one year after allocation of the patients. No significant differences as regards suppression of testosterone or survival were found in favour of one of the three treatment modalities. The performance index improved significantly both during the first months of treatment with Buserelin and following orchiectomy. No detectable improvement of performance index was seen during treatment with estrogens. Treatment with estrogens also failed to alleviate pain or general symptoms of cancer. Tolerability, safety and compliance of Buserelin was although administered intranasally clearly evidenced as palliation of advanced symptomatic cancer and the efficacy and sideeffects were fully comparable to those following orchiectomy.

How is androgen-dependent metastatic prostate cancer best treated?

The principles of management of newly diagnosed metastatic prostate cancer have changed little since the time of Huggins and his colleagues. Modern clinicians have many more weapons in their therapeutic armamentarium than those pioneers, but little progress has been made in improving the survival of men with this disease. The results of androgen deprivation are comparable using any one of a number of different monotherapy approaches. The use of combined androgen blockade may improve survival in men with minimal disease but at considerable economic cost and with significant impairment of quality of life. The benefit of this therapy for men with more extensive disease is uncertain. New modalities such as intermittent androgen blockade or combination therapies are exciting, but unproven.

Histopathological grading and DNA ploidy as prognostic markers in metastatic prostatic cancer

The present study compares the prognostic potential of tumour grade and DNA ploidy status in patients with advanced-stage prostatic cancer. Two outcome groups were selected on the basis of time to progression and survival after orchiectomy. A poor-outcome group consisted of 32 therapy-resistant patients who experienced disease progression during the first year after orchiectomy and subsequently death due to prostatic cancer during the following year. A good-outcome group consisted of 27 therapy-responsive patients who showed disease regression and no signs of progression during a 3 year follow-up. The primary tumours were graded twice according to WHO and Gleason classification systems by two pathologists. Final agreement between the pathologists was obtained after a consensus meeting. The analysis revealed no prognostic importance of the two histological classification systems (P = 0.62 and P = 0.70) and disclosed weak inter- and intra-observer reproducibility (kappa < 0.70). DNA ploidy analyses were performed by image cytometry on formalin-fixed, paraffin-embedded samples of the primary tumours. Overall, 48% of the tumours were diploid, 20% tetraploid and 32% anueploid. DNA ploidy status did not discriminate between the two outcome groups (P = 0.46). Histological grade and DNA ploidy showed no prognostic importance in patients with prostatic cancer and skeletal metastases.

Prostate-specific antigen and prognosis in patients with metastatic prostate cancer--a multivariable analysis of prostate cancer mortality

OBJECTIVE

To analyse the prognostic significance of pre- and post-treatment serum prostate-specific antigen (PSA) levels, together with a variety of other factors, in a multivariable analysis of survival in men with stage D2 prostate cancer.

PATIENTS AND METHODS

Cox's proportional hazards model was used to compare survival in 134 men with stage D2 metastatic prostate cancer followed prospectively over a 4 year period, using both univariable and multivariable models. The influence of the following factors on survival was analysed: pre- and post-treatment PSA (both absolute and percentage values), age, treatment, testosterone, pre- and post-treatment alkaline phosphatase (absolute and percentage values), acid phosphatase, haemoglobin, symptom score and performance status and extent of disease on bone scan.

RESULTS

Pre-treatment PSA levels did not significantly influence survival. Similarly, a low absolute post-treatment PSA level at 3 months after the start of treatment conferred no survival advantage relative to patients with a high PSA level at this time. A post-treatment percentage PSA of < 10% at 2, 3 and 6 months after commencement of treatment was associated with prolonged survival. Low pre-treatment alkaline phosphatase (less than the upper limit of normal) and high pre-treatment testosterone levels (> or = 10 nmol/L) were similarly associated with prolonged survival.

CONCLUSIONS

The strong influence of post-treatment percentage PSA on survival in patients with stage D2 prostate cancer suggests that the percentage change in bulk of metastatic deposits is more important in determining survival than the absolute volume of tumour. Pre-treatment alkaline phosphatase seems to be a better indicator of tumour activity than pre-treatment PSA. These findings have important implications for the design and analysis of clinical trials of new therapies in men with stage D2 prostate cancer and for the future selection of alternative treatments for patients with this stage of the disease.

Symptomatology of metastatic prostate cancer: prognostic significance

OBJECTIVE

To identify the various presenting symptoms in patients with metastatic prostate cancer, quantify the metastatic load for each symptom group and compare their case-specific survival.

PATIENTS AND METHODS

A prospective and consecutive series of 279 men with metastatic cancer of the prostate was analysed. Based on the symptom at presentation, six different groups were identified: bladder outflow obstruction, bone pain, anaemia, weight loss, paraplegia and alteration of bowel habit.

RESULTS

Significant variations were observed in their metastatic load (Kruskal-Wallis test, P = 0.0035) and in case-specific survival (log-rank test, P = 0.0038).

CONCLUSION

Bladder outflow obstruction, bone pain and anaemia not only dictate treatment selection but we provide evidence that each of these symptoms has considerable prognostic significance in patients with metastatic cancer of the prostate.

Prognostic factors in metastatic prostate cancer

Androgen deprivation therapy is the initial treatment choice for metastatic disease. When enrolling patients into androgen deprivation trials, it is important to consider stratification of enrollees based on prognostic factors that have been identified as important in determining the likelihood of response. Prognostic factors are also helpful in identifying which patients are less likely to respond to treatment; this information also would help to counsel patients. Performance status is an important prognostic factor; however, its impact is minimal because the great majority of men who receive treatment for advanced disease have a normal performance status. Hemoglobin, alkaline phosphatase, and a semiquantitative grading scale for the number of metastatic foci on the bone scan are useful prognostic factors. The pretreatment serum testosterone level is a powerful prognostic factor. Patients with a low serum testosterone level have a shorter progression-free survival than men whose pretreatment serum testosterone level is above normal. The prognostic importance of pretreatment serum testosterone level has been evaluated in studies using treatment methods that lower this level to castrate levels. Recently, we found that serum testosterone level was not a prognostic factor for men taking the nonsteroidal antiandrogen, Casodex (Zeneca, Wilmington, DE), which does not alter the serum testosterone level. The pretreatment serum prostatic-specific antigen also is a prognostic factor. This antigen may be the best single method for monitoring patients in regard to response to or progression following therapy. The return of the prostatic-specific antigen level to normal (< 4 ng/ml), or the decline in the prostatic-specific antigen level of > 90% indicates a prolonged progression-free survival. In the future, it will be interesting to incorporate both the initial prognostic factors as well as monitor the prostatic-specific antigen into a multivariate analysis, which will be highly predictive of a man's response to treatment.

Prognostic factors in stage D2 prostate cancer treated with a pure nonsteroidal antiandrogen

BACKGROUND

Prognostic factors have been shown to be important when stratifying patients with prostate cancer into randomized trials and counseling the individual patient regarding his chances of response to treatment. However, there are no reports on prognostic factors in patients with Stage D2 prostate cancer treated with a pure antiandrogen as monotherapy.

METHODS

The authors studied a variety of possible prognostic factors among 150 patients with metastatic prostate cancer treated with an antiandrogen (Casodex, Imperial Chemical Industries, Wilmington, DE).

RESULTS

In a univariate analysis, performance status; extent of disease (EOD); pretreatment hemoglobin, alkaline phosphatase, prostate-specific antigen (PSA), and prostatic acid phosphatase (PAP) levels; and extent of disease (EOD) on bone scan all were found to be significant prognostic factors (P < 0.05). Pretreatment serum testosterone levels, identified as one of the most important prognostic factors, was not identified as significant in the current study.

CONCLUSIONS

Although the pretreatment testosterone level was shown to be an important prognostic factor in previous studies, using other modes of androgen ablation (reducing testosterone to below castrate levels), the current study suggest it may not be a helpful factor if the therapy used is antiandrogens as monotherapy. This may relate to the different mode of action of antiandrogens, which do not reduce serum testosterone levels.

Antiandrogenic agents as monotherapy in advanced prostatic carcinoma

Pure antiandrogens have a quality-of-life advantage over other androgen ablation methods in the treatment of patients with prostatic cancer because they do not reduce the serum testosterone and therefore do not have a marked inhibitory effect on libido and potency. The long half-life of two of the three currently studied pure antiandrogens permits once-a-day administration, which should enhance patient compliance. With continued administration, there is a gradual rise in serum testosterone, and the clinical impact of this requires additional study using randomized Phase III trials. Proper stratification of patients at entry into such studies with documentation of various prognostic factors will add statistical value and enable physicians to draw better conclusion on the relative efficacy of these agents.