Prostate cancer mortality in northern Sweden, with special reference to tumor grade and patient age

CYP17 polymorphisms and prostate cancer outcomes

OBJECTIVE

Cytochrome P450 17alpha-hydroxylases-C-(17,20)-lyase (CYP17) is a key enzyme involved with the androgen biosynthesis pathway and has recently been targeted for therapy in men with advanced prostate cancer (PCa). However, studies relating prostate cancer outcomes with CYP17 gene variants have conflicting results. In this study we analyzed Single Nucleotide Polymorphisms (SNPs) spanning the CYP17 gene for association with PCa survival.

METHODS

The cohort was comprised of Caucasian men, aged 40-64, diagnosed with PCa between 1993 and 1996 in King County, Washington who participated in a population-based case-control study. CYP17 SNPs were selected to capture variation across the gene and known regulatory regions. PCa-specific mortality (PCSM) was obtained by linking to the SEER cancer registry. Recurrence/progression of PCa was determined from patient survey data and medical records. Cox proportional hazards regression analysis was used to generate hazard ratios for patient outcomes.

RESULTS

Genotypes were available for 598 cases. With a median follow-up of 13.2 years, 44 PCa deaths were observed. Recurrence/progression events were observed in 30% of subjects. No genetic association with disease progression were identified. However, men with the variant A allele in rs10883783 had a 56% risk reduction in PCSM (HR 0.44, 95% CI 0.21-0.98).

CONCLUSION

These data suggest that genetic variation in the CYP17 gene in Caucasian men is associated with PCa survival.

Prognostic grouping of metastatic prostate cancer using conventional pretreatment prognostic factors

OBJECTIVE

To develop three prognostic groups for disease specific mortality based on the binary classified pretreatment variables age, haemoglobin concentration (Hb), erythrocyte sedimentation rate (ESR), alkaline phosphatase (ALP), prostate-specific antigen (PSA), plasma testosterone and estradiol level in hormonally treated patients with metastatic prostate cancer (PCa).

MATERIAL AND METHODS

The present study comprised 200 Finnprostate 6 study patients, but data on all variables were not known for every patient. The patients were divided into three prognostic risk groups (Rgs) using the prognostically best set of pretreatment variables. The best set was found by backward stepwise selection and the effect of every excluded variable on the binary classification cut-off points of the remaining variables was checked and corrected when needed.

RESULTS

The best group of variables was ALP, PSA, ESR and age. All data were known in 142 patients. Patients were given one risk point each for ALP > 180 U/l (normal value 60-275 U/l), PSA > 35 microg/l, ESR > 80 mm/h and age < 60 years. Three risk groups were formed: Rg-a (0-1 risk points), Rg-b (2 risk points) and Rg-c (3-4 risk points). The risk of death from PCa increased statistically significantly with advancing prognostic group.

CONCLUSION

Patients with metastatic PCa can be divided into three statistically significantly different prognostic risk groups for PCa-specific mortality by using the binary classified pretreatment variables ALP, PSA, ESR and age.

Correlations between age, Charlson score and outcome in clinical unilateral T3a prostate cancer

According to the European Association of Urology (EAU) guidelines, a life expectancy of > 10 years is considered an important factor in the treatment of prostate cancer. The Charlson score is used to predict mortality based on comorbidities. The purpose of this study was to investigate the relationship between age, Charlson score and outcome in patients with cT3a prostate cancer. Between 1987 and 2004, 200 patients, who were with clinical T3a prostate cancer and who underwent radical prostatectomy (RP), were previously detected by digital rectal examination (DRE). Patients were categorized into two age groups (< 65 and >or= 65 years old). Patients were also divided into two groups according to Charlson score ( = 0 and >or= 1). Both age and Charlson score were analyzed regarding their predictive power of patients' outcomes. The mean follow-up period was 70.6 months, and the mean age of patients was 63.3 years. In all, 106 patients were < 65 years old and 94 patients were >or= 65 years old. Age was a significant predictor of overall survival (OS). A Charlson score of 0 was found in 110 patients, and of >or= 1 in 90 patients. Charlson score was not a significant predictor of biochemical progression-free survival (BPFS), clinical progression-free survival (CPFS) or OS. Cox multivariate analysis showed that margin status was a significant independent factor in BPFS, and cancer volume was a significant independent factor in CPFS. Charlson score does not influence the outcome in patients with clinical locally advanced prostate cancer. Age may influence OS. RP can be performed in motivated healthy older patients. However, the patients need to be counseled regarding possible surgery-related side effects, such as urinary incontinence and erectile dysfunction, which are age- and comorbidity-dependent.

Current perspectives in the treatment of advanced prostate cancer

Prostate cancer (PC) continues to be an important world health problem for men. Patients with locally confined PC are treated with either radiotherapy or surgery. However, treatment of more advanced stages of the disease is problematic. Initially, androgen deprivation offers a period of clinical stability, which is however invariably followed by progression to non-responsiveness to hormonal manipulation. Current management of patients with androgen-independent prostate cancer (AIPC) displays modest response rates and achieves only short-term benefit. Recently, knowledge in the complex pathophysiology of advanced PC has led to the identification of mechanisms and target molecules permitting the introduction of new therapies. Consequently, many investigational treatments are ongoing for AIPC in Phase-II and Phase-III trials aiming at the combination of chemotherapeutic regimens along with immunotherapy targeting PC-associated antigens. Other attractive options are gene therapy, as well as the targeting of survival signaling, differentiation, and apoptosis of the malignant PC cells. Further treatment modalities are directed against the tumor microenvironment, bone metastasis, or both. Collectively, the aforementioned efforts introduce a new era in the management of advanced PC. Novel pharmaceutical compounds and innovative approaches, integrated into the concept of individualized therapy will hopefully, during the next decade, improve the outcome and survival for hundreds of thousands of men worldwide.

Epidemiology of Prostate Cancer

Prostate cancer is one of the most important cancers in men. With a worldwide incidence of 25.3 per 100,000 it is the second most common cancer in men, with large differences between countries. Important clues on risk factors remain to be found. Age, genetic factors and environmental influences have been studied. Incidence has been increasing over the last few decades, largely due to early detection procedures. The mortality rate of 8.1 per 100,000 mainly affects men at older ages; increases in this rate over time and differences between countries are markedly smaller than for incidence. For the future, prostate cancer will remain an important and--through evolutions in incidence and demography--growing health problem.

Early prostate cancer: clinical decision-making

Prostate cancer is one of the most common malignant diseases for which health-care intervention is sought worldwide, and in many developed countries it is the most common. Some patients with early-stage prostate cancer, especially those who are elderly and have comorbidities, can be observed without treatment. Surgery (radical prostatectomy) and radiotherapy (external-beam radiotherapy, brachytherapy, or both) are the most widely accepted curative options for patients with early-stage disease who need intervention. All these local treatments have been refined, resulting in comparable cure rates; however, they all have different side-effect profiles. Adjuvant systemic treatments (hormones or chemotherapy), which are effective for advanced-stage disease, might have a greater role in early-stage disease. Selecting the best option for individuals from the available options is challenging--the decision on whether and how to treat is based on many disease and patient factors. Here, we review the major treatment options, discuss their relative advantages and disadvantages, and provide a general approach to management of patients with early-stage prostate cancer.

Conditional median survival of patients with advanced carcinoma: surveillance, epidemiology, and end results data

BACKGROUND

Conditional survival is clinically useful, particularly for patients with malignant disease who have a poor prognosis. However, there are no published data on the conditional median survival of patients with advanced carcinoma on a population basis.

METHODS

Data on 217,573 patients with breast, colorectal, lung, or prostate carcinoma who were newly diagnosed with distant disease between 1973 and 1995 and who were followed through the end of 1997 were extracted from the Surveillance, Epidemiology, and End Results (SEER) data base of the National Cancer Institute. The Kaplan-Meier method was employed to estimate conditional median survival and 95% confidence intervals at 0-5 years after the initial diagnosis.

RESULTS

The conditional median survival increased as time elapsed after the initial diagnosis. The increase was slowest and almost leveled off among patients with prostate carcinoma. The median survival of patients with breast carcinoma increased relatively linearly with time, i.e., 5-6 months per year. Conversely, there was a rapid increase in the conditional median survival according to the amount of time since diagnosis for patients with lung and colorectal carcinoma. The trend was most pronounced for patients with colorectal carcinoma. At 5 years after the initial diagnosis, the remaining median survival was longest for patients with colorectal carcinoma, almost 6 years (71.5 months), followed by patients with lung carcinoma (52.5 months), breast carcinoma (42.5 months), and prostate carcinoma (34.5 months). Although race was a correlate with initial survival, gender and age had more impact on late conditional survival.

CONCLUSIONS

The conditional median survival provides useful and encouraging information for patients who survive with advanced disease and for healthcare professionals who treat these patients. However, the information should be used carefully, taking the limitations of these data into account.

Observation in the management of localized prostate cancer

Background

The widespread use of the prostate-specific antigen test, the availability of ultrasound, and improved techniques for prostate biopsy have led to the diagnosis of organ-confined prostate cancers at an earlier stage. An unknown number of these cancers will be incidental and will not impact the patient's quality or length of life.

Methods

The most recent published reports and decision analysis studies on observation management were reviewed. We also analyzed our own series of observed patients.

Results

Three contemporary series on observation and three reports on decision analysis for treatment of early prostate cancer define a group of patients who may be treated with observation. Our own preliminary experience, however, demonstrates that a significant number undergo definitive treatment within 3 years from diagnosis. The optimal treatment for men with early prostate cancer is currently unknown.

Conclusions

A subset of patients with newly diagnosed prostate cancer may be managed by observation. Standard protocols for selection and follow-up of patients on observation need to be developed.

No difference in survival between sporadic, familial and hereditary prostate cancer

OBJECTIVE

To estimate the survival of men with familial prostate cancer and compare them with prostate cancer cases unselected for family history.

PATIENTS AND METHODS

The overall and prostate cancer-specific survival was calculated in two large (249 and 304 men, respectively) population-based cohorts of men with familial prostate cancer. The tumour grade at diagnosis was also obtained in one of the cohorts.

RESULTS

There were no significant differences in either overall or prostate cancer-specific survival between familial and sporadic cases. The spectrum of tumour grades at diagnosis in familial cases did not differ from that in a population with prostate cancer unselected for family history.

CONCLUSION

No differences in treatment between men with or without a positive family history of prostate cancer are justified, based on the result from this study.

An analysis of watchful waiting for clinically localized prostate cancer

PURPOSE

We reviewed recent series of watchful waiting for prostate cancer to place this management strategy in appropriate perspective

MATERIALS AND METHODS

We reviewed the literature and analyzed the 9 articles on watchful waiting published in leading medical journals in the last decade.

RESULTS

Watchful waiting is probably the best treatment option for men with well and perhaps moderately differentiated, low volume prostate cancer who have a life expectancy of less than 10 years. However, the conclusions derived from watchful waiting studies of older men cannot and should not be applied to younger, healthier men or to those with more advanced or aggressive disease. If treated ineffectively, many of these men will die of prostate cancer.

CONCLUSIONS

Most men with prostate cancer who have a life expectancy greater than 10 to 15 years should be treated with curative intent.