Impact of biochemical failure on overall survival after radiation therapy for localized prostate cancer in the PSA era

Hybrid magnetic resonance and PET imaging for prostate cancer recurrence

PURPOSE OF REVIEW

Recurrence post definitive local therapy by prostatectomy or radiation therapy is often detected via rise in serum prostate-specific antigen (PSA) levels; however, PSA rise does not localize the disease. Distinguishing local versus distant recurrence guides whether to choose subsequent local versus systemic therapy. The purpose of this article is to review imaging for prostate cancer recurrence post local therapy.

RECENT FINDINGS

Among imaging modalities, multiparametric MRI (mpMRI) is commonly used to assess for local recurrence. New radiopharmaceuticals target prostate cancer cells and enable whole-body imaging. These tend to be more sensitive for lymph node metastases than MRI or computed tomography (CT) and for bone lesions than bone scan at lower PSA levels but can be limited for local prostate cancer recurrence. Given greater soft tissue contrast, similar criteria for lymph nodes, and greater sensitivity for prostate bone metastases, MRI is advantageous to CT. MRI of the whole body and mpMRI are now feasible within a reasonable time frame and complementary to PET imaging, enabling whole-body and pelvis-focused PET-MRI, which should be advantageous in the setting of recurrent prostate cancer.

SUMMARY

Hybrid PET-MRI with prostate cancer targeted radiopharmaceuticals and whole body with local multiparametric MRI can be complementary for detecting local and distant recurrence to guide treatment planning.

The impact of the apparent diffusion coefficient for the early prediction of the treatment response after definitive radiotherapy in prostate cancer patients

PURPOSE

We assessed early changes in apparent diffusion coefficient (ADC) and serum prostate specific antigen (PSA) values after definitive radiotherapy (RT) without androgen deprivation treatment in low- and intermediate-risk prostate cancer (PC) patients.

MATERIALS AND METHODS

The clinical data and ADC parameters of 229 PC patients were retrospectively evaluated. Pre-treatment and post-treatment serum PSA and primary tumor ADC values were calculated. Post-treatment DW-MRI was performed median 4.1 months after completion of definitive RT. The prognostic factors predicting freedom from biochemical failure (FFBF) and progression-free survival (PFS) were analyzed using univariable and multivariable analyses.

RESULTS

With a median follow-up time of 80.8 months, the 5-year FFBF and PFS rates were 95.9% and 89.3%, respectively. Eleven patients (4.8%) had PSA relapse, with a median of 34.4 months after the completion of RT. A statistically significant difference in post-treatment ADC values was noted between patients with and without recurrence (0.94 ± 0.07 vs. 1.10 ± 0.20 × 10^-3 mm²/sec; p < 0.001). Patients with a Gleason score (GS) of 6 and low-risk disease had significantly higher post-treatment tumor ADC and PSA levels than patients with a GS of 7 and intermediate-risk disease. The 5-year FFBF rate in patients with tumor ADC ≤ 0.96 × 10^-3 mm²/sec was significantly lower than patients with tumor ADC > 0.96 × 10^-3 mm²/sec (85.5% vs. 100; p < 0.001). In the multivariable analysis, a lower ADC value, GS 4 + 3 and intermediate-risk disease were independent predictors of worse FFBF. In the multivariate analysis, a lower post-treatment ADC value and a GS of 4+3 were significant prognostic factors for a lower PFS.

CONCLUSION

These findings suggest that the post-treatment tumor ADC value could be used for early treatment response evaluation after definitive RT in PC patients.

Introduction of salvage prostatectomy in Denmark: the initial experience

OBJECTIVE

To introduce salvage prostatectomy in Denmark. Prior to this, no national curative treatment for recurrent prostate cancer following radiation therapy existed in Denmark. This pilot study represent our initial experiences and the feasibility of performing salvage robot-assisted radical prostatectomy for true local, high-risk recurrence after initial therapy with external beam radiation for high-risk prostate cancer.

RESULTS

Five patients underwent sRARP between April 2020 and July 2021. All patients were discharged within 48 h and no major complications were observed within 3 months. All patients had unmeasurable PSA (< 0.1 ng/ml) at follow-up 6 months after surgery. One patient with longer follow-up than 6 months experienced biochemical recurrence. At 3-months follow-up all patients reported considerable incontinence, at 6-month follow-up, pad usage decreased to 1 or 2 pads daily. Based on our initial results, the idea to introduce sRARP as a nationwide option remains and further patients will be included to establish the true role of sRARP in patients with recurrence after primary radiotherapy for PCa.

Operative and Midterm Oncological Outcome of Focal Salvage Cryotherapy for Localized Prostate Cancer

BACKGROUND

Local recurrence after radiation therapy for prostate cancer is a major clinical issue. Various local treatments are available with mitigated functional and oncological outcomes. The aim of the present study was to evaluate perioperative and oncological results of salvage cryotherapy (CT) as treatment of local recurrence of prostate cancer.

METHODS

We retrospectively reviewed all patients treated with hemi-prostatic salvage CT for local recurrence of prostate cancer in 1 academic hospital between November 2011 and April 2019. Local recurrence was defined according to the Phoenix criteria (prostate-specific antigen [PSA] nadir + 2 ng/mL), associated with a prostatic MRI target lesion and confirmed by biopsy. Perioperative and functional complications were collected. Cox regression was conducted to assess factors associated with time to initiation of androgen deprivation therapy (ADT). Statistical analyses were conducted using R Studio.

RESULTS

A total of 29 patients were treated with an average follow-up of 37.6 months. Median age at CT was 77 years. Median PSA before CT was 5.1 ng/mL (min-max: 2.74-18). 17.2% of patients displayed a high D'Amico risk group. Median hospital stay was 1.4 days. Four patients (13.8%) experienced postoperative acute urinary retention. Nineteen patients (65.5%) experienced late functional complications (3 erectile dysfunctions, 3 stress incontinence, and 13 urinary frequency). Fourteen patients displayed recurrence after salvage treatment (48.2%). Median time to introduction of ADT was 15.1 months. ADT-free survival at 1 and 2 years was, respectively, 74% and 61%. In multivariate analysis, ISUP score 4 and PSA nadir <1 ng/mL after CT were significantly associated with time to ADT initiation.

CONCLUSIONS

Salvage focal CT may delay the use of ADT in locally recurrent prostate cancer after RT and offers an alternative for eligible patients. The technique was feasible with acceptable perioperative morbidity and acceptable midterm oncological outcome.

Evolution of Disparities in Prostate Cancer Treatment: Is This a New Normal?

Despite notable screening, diagnostic, and therapeutic advances, disparities in prostate cancer incidence and outcomes remain prevalent. Although commonly discussed in the context of men of African descent, disparities also exist based on socioeconomic level, education level, and geographic location. The factors in these disparities span systemic access issues affecting availability of care, provider awareness, and personal patient views and mistrust. In this review, we will discuss common themes that patients have noted as impediments to care. We will review how equitable access to care has helped improve outcomes among many different groups of patients, including those with local disease and those with metastatic castration-resistant prostate cancer. Even with more advanced presentation, challenges with recommended screening, and lower rates of genomic testing and trial inclusion, Black populations have benefited greatly from various modalities of therapy, achieving comparable and at times superior outcomes with certain types of immunotherapy, chemotherapy, androgen receptor-based inhibitors, and radiopharmaceuticals in advanced disease. We will also briefly discuss access to genomic testing and differences in patterns of gene expression among Black patients and other groups that are traditionally underrepresented in trials and genomic cohort studies. We propose several strategies on behalf of providers and institutions to help promote more equitable care access environments and continued decreases in prostate cancer disparities across many subgroups.

Prostate Cancer: Community Education and Disparities in Diagnosis and Treatment

Prostate cancer remains the leading diagnosed cancer and the second leading cause of death among American men. Despite improvements in screening modalities, diagnostics, and treatment, disparities exist among Black men in this country. The primary objective of this systematic review is to describe the reported disparities in screening, diagnostics, and treatments as well as efforts to alleviate these disparities through community and educational outreach efforts. Critical review took place of retrospective, prospective, and socially descriptive data of English language publications in the PubMed database. Despite more advanced presentation, lower rates of screening and diagnostic procedures, and low rates of trial inclusion, subanalyses have shown that various modalities of therapy are quite effective in Black populations. Moreover, patients treated on prospective clinical trials and within equal-access care environments have shown similar outcomes regardless of race. Additional prospective studies and enhanced participation in screening, diagnostic and genetic testing, clinical trials, and community-based educational endeavors are important to ensure equitable progress in prostate cancer for all patients. IMPLICATIONS FOR PRACTICE: Notable progress has been made with therapeutic advances for prostate cancer, but racial disparities continue to exist. Differing rates in screening and utility in diagnostic procedures play a role in these disparities. Black patients often present with more advanced disease, higher prostate-specific antigen, and other adverse factors, but outcomes can be attenuated in trials or in equal-access care environments. Recent data have shown that multiple modalities of therapy are quite effective in Black populations. Novel and bold hypotheses to increase inclusion in clinical trial, enhance decentralized trial efforts, and enact successful models of patient navigation and community partnership are vital to ensure continued progress in prostate cancer disparities.

Biochemical Recurrence in Prostate Cancer: The European Association of Urology Prostate Cancer Guidelines Panel Recommendations

Biochemical recurrence (BCR) after primary treatment of localized prostate cancer does not necessarily lead to clinically apparent progressive disease. To aid in prognostication, the European Association of Urology prostate cancer guidelines panel undertook a systematic review and successfully developed a novel BCR risk stratification system (groups with a low risk or high risk of BCR) based on disease and prostate-specific antigen characteristics. PATIENT SUMMARY: Following treatment to cure prostate cancer, some patients can develop recurrence of disease identified via a prostate-specific antigen blood test (ie, biochemical recurrence, or BCR). However, not every man who experiences BCR develops progressive disease (symptoms or evidence of disease progression on imaging). We conducted a review of the literature and developed a classification system for predicting which patients might progress to optimize treatment decisions.

Prognostic Value of Biochemical Recurrence Following Treatment with Curative Intent for Prostate Cancer: A Systematic Review

CONTEXT

In men with prostate cancer (PCa) treated with curative intent, controversy exists regarding the impact of biochemical recurrence (BCR) on oncological outcomes.

OBJECTIVE

To perform a systematic review of the existing literature on BCR after treatment with curative intent for nonmetastatic PCa. Objective 1 is to investigate whether oncological outcomes differ between patients with or without BCR. Objective 2 is to study which clinical factors and tumor features in patients with BCR have an independent prognostic impact on oncological outcomes.

EVIDENCE ACQUISITION

Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. For objective 1, prospective and retrospective studies comparing survival outcomes of patients with or without BCR following radical prostatectomy (RP) or radical radiotherapy (RT) were included. For objective 2, all studies with at least 100 participants and reporting on prognostic patient and tumor characteristics in patients with BCR were included. Risk-of-bias and confounding assessments were performed according to the Quality in Prognosis Studies tool. Both a narrative synthesis and a meta-analysis were undertaken.

EVIDENCE SYNTHESIS

Overall, 77 studies were included for analysis, of which 14 addressed objective 1, recruiting 20 406 patients. Objective 2 was addressed by 71 studies with 29 057, 11 301, and 4272 patients undergoing RP, RT, and a mixed population (mix of patients undergoing RP or RT as primary treatment), respectively. There was a low risk of bias for study participation, confounders, and statistical analysis. For most studies, attrition bias, and prognostic and outcome measurements were not clearly reported. BCR was associated with worse survival rates, mainly in patients with short prostate-specific antigen doubling time (PSA-DT) and a high final Gleason score after RP, or a short interval to biochemical failure (IBF) after RT and a high biopsy Gleason score.

CONCLUSIONS

BCR has an impact on survival, but this effect appears to be limited to a subgroup of patients with specific clinical risk factors. Short PSA-DT and a high final Gleason score after RP, and a short IBF after RT and a high biopsy Gleason score are the main factors that have a negative impact on survival. These factors may form the basis of new BCR risk stratification (European Association of Urology BCR Risk Groups), which needs to be validated formally.

PATIENT SUMMARY

This review looks at the risk of death in men who shows rising prostate-specific antigen (PSA) in the blood test performed after curative surgery or radiotherapy. For many men, rising PSA does not mean that they are at a high risk of death from prostate cancer in the longer term. Men with PSA that rises shortly after they were treated with radiotherapy or rapidly rising PSA after surgery and a high tumor grade for both treatment modalities are at the highest risk of death. These factors may form the basis of new risk stratification (European Association of Urology biochemical recurrence Risk Groups), which needs to be validated formally.

Evolution of definitive external beam radiation therapy in the treatment of prostate cancer

PURPOSE

Although the clinical significance of a diagnosis of prostate cancer for some men is debated, for many men it leads to significant morbidity and mortality. Radical treatment of clinically localized prostate cancer has been shown to improve survival in men with intermediate or high-risk disease. There is no high level evidence to support the superiority of radical prostatectomy, with or without adjuvant or salvage external beam radiotherapy in comparison to definitive radiotherapy with or without androgen deprivation, and the choice should be individualized. External beam radiation therapy practices are in constant evolution, and numerous strategies have been investigated to improve either efficacy or reduce toxicity, or both.

METHODS

Randomized controlled trials investigating strategies to improve efficacy, reduce toxicity, or both of external beam radiotherapy have been reviewed in men with prostate cancer without nodal or distant metastases. These strategies include the use of neo-adjuvant and adjuvant androgen deprivation, dose-escalation, hypofractionation, whole pelvic radiation therapy, incorporation of improved imaging, image- guided radiation therapy, and adjuvant systemic therapy. The evidence to date for these strategies is discussed, noting limitations in applying the results of reported trials to men treated in contemporary settings.

RESULTS

A number of strategies have shown improvements in biochemical control using external beam radiotherapy. To date, only with the use of androgen deprivation therapy has this translated into improvements in disease specific and overall survival. This may reflect the long natural history of prostate cancer and high incidence of competing risks. Technological advances have enabled dose escalation with reduced toxicity, of paramount importance given the long natural history.

RESULTS

The use of external beam radiation therapy in prostate cancer is evolving with numerous strategies incorporated to improve outcomes. The optimum dose and fractionation and use of androgen deprivation or systemic adjuvants for each man is unclear based on current evidence and prognostic and predictive parameters. Patient preferences play an important role in chosen therapy. It is hoped that future studies better capture all prostate cancer- and treatment- related morbidity to clarify the optimal therapy choices for each man with prostate cancer.

Management of recurrent prostate cancer after radiotherapy: long-term results from CALGB 9687 (Alliance), a prospective multi-institutional salvage prostatectomy series

BACKGROUND

To evaluate efficacy and morbidity prospectively in a contemporary multi-institutional salvage radical prostatectomy (SRP) series.

METHODS

Forty-one men were enrolled between 1997 and 2006, who suffered biopsy-proven recurrent prostate cancer (CaP) after receiving ≥ 60c Gy radiation as primary treatment for cT_1-2N_XM₀ disease. Surgical morbidity, quality of life, biochemical progression-free survival (BPFS) and overall survival (OS) were evaluated.

RESULTS

Twenty-four men had undergone external beam radiotherapy, 11 brachytherapy, and six both. Median time between radiation and SRP was 64 months. Median age at SRP was 64 years. Pathologic staging revealed 44% pT2, 54% pT3, and 3% pT4. Surgical margins were positive in 17 and 88% were pN0. Twenty-two percent required intraoperative blood transfusion. Three rectal and one obturator nerve injuries occurred. Seventeen of 38 evaluable patients (45%) had urinary incontinence ( ≥ 3 pads/day) prior to SRP; 88% reported urinary incontinence at 6 months, 85% at 12 months, 63% at 24 months after SRP. Furthermore, 37% of men reported impotence prior to SRP; 78% reported impotence at 6 months, 82% at 12 months, and 44% at 24 months after SRP. The 2-, 5- and 10-year BPFS rates were 51, 39, and 33% respectively; the 2-, 5- and 10-year OS rates were 100, 89, and 52%, respectively, at median follow-up 91 months.

CONCLUSIONS

Modern surgical techniques continue to be associated with significant peri-operative complication rates. Nevertheless, SRP may benefit carefully selected patients through durable oncologic control.

[Salvage cryotherapy of prostate cancer after failed external radiotherapy and brachytherapy: Morbidity and mid-term oncological results]

OBJECTIVE

To study the oncologic and functional results of salvage cryotherapy after failure of external radiotherapy and brachytherapy.

MATERIALS AND METHODS

Patients treated by total salvage cryotherapy (3rd generation) in 2 centers (Groupe Hospitalier Saint-Joseph in Paris and Clinique Jule-Verne Nantes) in between January 2008 and April 2016 were included. The biochemical recurrence-free survival (BRFS) was calculated using the Phoenix criteria (PSA>nadir+2ng/mL). The functional results were assessed clinically.

RESULTS

Ninety-seven patients with an average follow up of 39.4months were evaluated retrospectively. The 5-year biochemical recurrence-free survival (5y-BRFS) among all patients was 58.1% (IC à 95% [45.9-68.5]). Low and intermediate risk patients (d'Amico classification) were less prone to biochemical recurrence than high risk (81.05% (IC à 95% [64.1-90.5]) 5y-BRFS as opposed to 35.09% (IC à 95% [20.1-50.4]) respectively) (P<0.0001). As were patients with a Gleason score≤7 75.35% (IC à 95% [59.7-85.6]) compared to 32.31% (IC à 95% [16.5-49.2]) for higher Gleason (>7 scores [P=0.0002]). A Gleason score>7 (OR=6.9; P=0.002), PSA nadir>1ng/mL (OR=25.8; P=0.0026) and peri-urethral invasion (OR=35.8; P<0.001) were major risk factors for local recurrence in univariate analysis. In multivariate analysis, only PSA nadir>1ng/mL (OR=12.9; P=0.042) and peri-urethral invasion (OR=21.6; P=0.0003) remain major risk factors for recurrence. About 13 (16.46%) patients were incontinent of which 3 (3.79%) required placement of an artificial urinary sphincter. Erectile dysfunction was present in 66 (83.5%) patients. Recto-urethral fistula was uncommon in 1 patient (1.27%).

CONCLUSION

Salvage cryotherapy after failure of external radiotherapy and brachytherapy is a reliable and reproducible technique with promising oncological and functional results. Study of prognostic factors will help better select eligible patients in the future.

LEVEL OF EVIDENCE

4.

Long-Term Results of a Randomized Trial Comparing Iridium Implant Plus External Beam Radiation Therapy With External Beam Radiation Therapy Alone in Node-Negative Locally Advanced Cancer of the Prostate

PURPOSE

To determine the impact on long-term survival from the addition of brachytherapy to external beam radiation therapy (EBRT) in patients with prostate cancer.

METHODS AND MATERIALS

Between 1992 and 1997, 104 men with cT2-3, surgically staged node-negative prostate cancer were randomized to receive either EBRT (40 Gy/20 fractions) with iridium implant (35 Gy/48 hours) or EBRT alone (66 Gy/33 fractions) to the prostate. According to T stage, Gleason score, and prostate-specific antigen level, 60% of patients had high-risk disease. Substantial improvements in biochemical control at 8 years have previously been reported. Additional follow-up was collected on deaths and metastases.

RESULTS

Median follow-up was 14 years. Five patients were lost to follow-up. All other patients have been followed a minimum of 13 years. There have been 75 deaths, including 21 from prostate cancer and 25 from second cancers. No patients developing a second cancer have died from prostate cancer. There was no difference in overall survival between the 2 treatment groups: 34 deaths (67%) in the implant arm and 41 (77%) in the EBRT arm (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.63-1.59). Similarly, there was no difference in prostate cancer-specific deaths: 9 (18%) patients in the implant arm compared with 12 (23%) in the EBRT arm (HR 0.79, 95% CI 0.34-1.87). There was no statistically significant difference in the number of patients developing metastatic disease: 10 (20%) in the implant arm and 15 (28%) in the EBRT arm (HR 0.70, 95% CI 0.32-1.57). Improvements in biochemical control were maintained (HR 0.53, 95% CI 0.31-0.88).

CONCLUSIONS

Despite a dramatic reduction of biochemical recurrence rates, the addition of iridium implant to EBRT did not translate into improved overall survival or prostate cancer-specific survival.

Race Does Not Affect Tumor Control, Adverse Effects, or Quality of Life after Proton Therapy

Purpose

To compare 5-year biochemical control, toxicity, and patient-reported quality of life (QOL) outcomes for African American and White patients treated with proton therapy (PT) for prostate cancer.

Materials and Methods

We reviewed the medical records of 1,066 men with clinically localized prostate cancer. Patients were treated with definitive PT between 2006 and 2010. Patients received a median radiation dose of 78 Gy (RBE) with conventional fractionation (1.8- 2 Gy [RBE] per fraction). Sixty-eight (6.4%) men self-identified as African American and 998 (93.6%) self-identified as White. Five-year rates of biochemical control, grade 3 genitourinary and gastrointestinal toxicity, and patient-reported QOL are reported and compared between African American and White patients.

Results

Median biochemical follow-up was 5.0 years for both African American and White patients. Median follow-up for toxicity was 5.0 and 5.2 years, respectively. On multivariate analysis, race was not a significant predictor for 5-year freedom from biochemical failure (HR 0.8, p=0.55). No significant association was found between race and grade 3 genitourinary toxicity on multivariate analysis at 5 years (HR 2.5, p=0.10). Patient-reported QOL using median EPIC bowel, urinary incontinence, and irritative summaries scores were not significantly different between the groups. African Americans had higher median sexual summary scores at 2 years than White patients (75 vs. 54, p=0.01) but by 5+ years, the sexual summary scores were no longer significantly different (63 vs. 53, p=0.35).

Conclusion

With a median follow-up of 5 years, there were no racial disparities in biochemical control, grade 3 toxicity, or patient-reported QOL after PT for prostate cancer.

The Role of α1-Adrenoceptor Antagonists in the Treatment of Prostate and Other Cancers

This review evaluates the role of α-adrenoceptor antagonists as a potential treatment of prostate cancer (PCa). Cochrane, Google Scholar and Pubmed were accessed to retrieve sixty-two articles for analysis. In vitro studies demonstrate that doxazosin, prazosin and terazosin (quinazoline α-antagonists) induce apoptosis, decrease cell growth, and proliferation in PC-3, LNCaP and DU-145 cell lines. Similarly, the piperazine based naftopidil induced cell cycle arrest and death in LNCaP-E9 cell lines. In contrast, sulphonamide based tamsulosin did not exhibit these effects. In vivo data was consistent with in vitro findings as the quinazoline based α-antagonists prevented angiogenesis and decreased tumour mass in mice models of PCa. Mechanistically the cytotoxic and antitumor effects of the α-antagonists appear largely independent of α 1-blockade. The proposed targets include: VEGF, EGFR, HER2/Neu, caspase 8/3, topoisomerase 1 and other mitochondrial apoptotic inducing factors. These cytotoxic effects could not be evaluated in human studies as prospective trial data is lacking. However, retrospective studies show a decreased incidence of PCa in males exposed to α-antagonists. As human data evaluating the use of α-antagonists as treatments are lacking; well designed, prospective clinical trials are needed to conclusively demonstrate the anticancer properties of quinazoline based α-antagonists in PCa and other cancers.

The dilemma of a rising prostate-specific antigen level after local therapy: what are our options?

Prostate cancer is the most common solid tumor diagnosed in men in the United States and Western Europe. Primary treatment with radiation or surgery is largely successful at controlling localized disease. However, a significant number (up to one third of men) may develop biochemical recurrence (BR), defined as a rise in serum prostate-specific antigen (PSA) level. A general presumption is that BR will lead to overt progression in patients over subsequent years. There are a number of factors that a physician must consider when counseling and recommending treatment to a patient with a rising PSA. These include the following (1) various PSA-based definitions of BR; (2) source of PSA (ie, local or distant disease, residual benign prostate); (3) available modalities to treat the disease with the least morbidity; and (4) timing of therapy. In this article we review the current and future factors that clinicians should consider in the diagnosis and treatment of recurrent prostate cancer.

Systematic review of hypofractionated radiation therapy for prostate cancer

Prostate cancer is the second most prevalent solid tumor diagnosed in men in the United States and Western Europe. Conventionally fractionated external beam radiation therapy (1.8-2.0 Gy/fraction) is an established treatment modality for men in all disease risk groups. Emerging evidence from experimental and clinical studies suggests that the α/β ratio for prostate cancer may be as low as 1.5 Gy, which has prompted investigators around the world to explore moderately hypofractionated radiation therapy (2.1-3.5 Gy/fraction). We review the impetus behind moderate hypofractionation and the current clinical evidence supporting moderate hypofractionated radiation therapy for prostate cancer. Although hypofractionated radiation therapy has many theoretical advantages, there is no clear evidence from prospective, randomized, controlled trials showing that hypofractionated schedules have improved outcomes or lower toxicity than conventionally fractionated regimens. Currently, hypofractionated schedules should only be used in the context of clinical trials. High dose rate brachytherapy and stereotactic body radiation therapy (fraction size 3.5 Gy and greater) are alternative approaches to hypofractionation, but are beyond the scope of this report.

Impact of the adaptor protein GIPC1/Synectin on radioresistance and survival after irradiation of prostate cancer

PURPOSE

Studies have shown that GIPC1/Synectin is an essential adaptor protein of receptors that play an important role in cancer progression and therapy resistance. This is the first study to explore the role of GIPC1/Synectin in radioresistance of prostate cancer and as a possible predictive marker for outcome of primary radiation therapy.

MATERIALS AND METHODS

The effect of RNA interference-mediated GIPC1/Synectin depletion on clonogenic cell survival after irradiation with 0, 2, 4, or 6 Gy was assayed in two different GIPC1/Synectin-expressing human prostate cancer cell lines. The clinical outcome data of 358 men who underwent radiotherapy of prostate cancer with a curative intention were analyzed retrospectively. Uni- and multivariate analysis was performed of prostate-specific antigen recurrence-free survival and overall survival in correlation with protein expression in pretreatment biopsy specimens. Protein expression was evaluated by standard immunohistochemistry methods.

RESULTS

In cell culture experiments, no change was detected in radiosensitivity after depletion of GIPC1/Synectin in GIPC1/Synectin-expressing prostate cancer cell lines. Furthermore, there was no correlation between GIPC1/Synectin expression in human pretreatment biopsy samples and overall or biochemical recurrence-free survival after radiotherapy in a retrospective analysis of the study cohort.

CONCLUSION

Our results do not show a predictive or prognostic function of GIPC1/Synectin expression for the outcome of radiotherapy in prostate cancer. Furthermore, our in vitro results do not support a role of GIPC1 in the cellular radiation response. However, the role of GIPC1 in the progression of prostate cancer and its precursors should be subject to further research.

A Review on the Clinical Utility of PSA in Cancer Prostate

Prostate cancer has come to share the oncological centrestage among male cancers. The availability of Serum Prostate Specific Antigen, PSA, as a marker has encouraged it's use to diagnose both cancer and cancer recurrence. Some clarity is required about its precise role in clinical practice. The available literature on Prostate Specific Antigen was reviewed; Articles were reviewed for content, applicability to the problem at hand, availability of data about sensitivity and specificity of values, refinements in measurements and finally for impact of screening programmes using these values on survival and quality of life. The data in the literature was critically re-evaluated and analysed to draw reasonable conclusions. Serum PSA measurements show variable reliability when it comes to diagnosis of Prostate cancer, given the dynamics of PSA physiology. Surrogate measures like PSA density, PSA velocity, free-to-complexed PSA ratio, percentage Pro-PSA, etc., have been used to improve the predictive utility of this assay for Prostate cancer. The ability of PSA to detect those cancers that will cost life, and thereby permit early curative treatment, is as yet unclear. It's most definitive role appears to be in diagnosing recurrences after adequate surgical treatment, and in evaluating response to treatment.

Impact of race on biochemical disease recurrence after prostate brachytherapy

BACKGROUND

Understanding racial differences in disease presentation and response to therapy is necessary for the effective treatment and control of prostate cancer. In this study, the authors examined the influence of race on biochemical disease-free survival (BDFS) among men who received prostate brachytherapy.

METHODS

In total, 2301 men were identified who had a minimum follow-up of 24 months and had received low-dose-rate brachytherapy for prostate cancer at the Mount Sinai Medical Center from June 1990 to October 2008. Patient factors, with specific emphasis on patient race, were analyzed with respect to freedom from biochemical failure (FFbF). Kaplan-Meier analyses, life-tables, and log-rank tests were used to identify variables that were predictive of 10-year FFbF.

RESULTS

In this series, a total of 2268 patients included 81% Caucasians, 12% African Americans, 6% Hispanics, and 1% Asians. The 10-year actuarial FFbF rate was 70% for AA men and 84% for all others (P = .002). Between Caucasian men and AA men, the 10-year FFbF rate was 83% versus 70%, respectively (P = .001).There was no significant difference in 10-year FFbF between Caucasian men and Hispanic men (83% vs 86%, respectively; P = .6). The 10-year FFbF rate for Hispanic men and AA men was 86% versus 70%, respectively (P = .062). A greater percentage of AA men presented with higher prostate-specific antigen levels (PSA) (>10 ng/mL; 44% vs 21%; P < .001) and, thus, with higher risk disease (24% vs 15%; P < .001) compared with Caucasian men. Among the men with low-risk disease, the 10-year FFbF rate was 90% for Caucasian men and 76% for AA men (P = .041). The 10-year BDFS rate for patients who received brachytherapy alone was 86% for Caucasian men and 61% for AA men (P = .001); however, this difference was not observed when brachytherapy was combined with androgen-deprivation therapy(ADT) with or without supplemental external-beam radiotherapy (EBRT). Multivariate analysis revealed that PSA (P = .024), Gleason score (P < .001), the biologic effective dose (P < .001), EBRT (P = .002), ADT (P = .03), and AA race (P = .037) were significant predictors of 10-year FFbF. No significant differences was observed in overall survival, cause-specific survival, or distant metastasis-free survival between racial groups.

CONCLUSIONS

AA race appeared to be an independent negative predictor of BDFS after prostate brachytherapy, and this result may highlight the need for more aggressive therapy in this patient population.

Why are pretreatment prostate-specific antigen levels and biochemical recurrence poor predictors of prostate cancer survival?

BACKGROUND

The value of pretreatment (initial) prostate-specific antigen (iPSA) and biochemical recurrence (BR) as prognostic factors for survival remains unclear. The authors sought to determine why using randomized trial data with 7-year minimum follow-up.

METHODS

In the Trans-Tasman Radiation Oncology Group 96.01 trial, 802 men with T2b, T2c, T3, or T4 N0 prostate cancer (PC) were randomized to radiotherapy alone or with 3 or 6 months neoadjuvant androgen deprivation between 1996 and 2000. Cox modeling was used to identify outcome predictors at follow-up landmark points.

RESULTS

Higher iPSA was found to be a potent predictor of BR-free survival (P < .01) but was not prognostic for prostate cancer-specific survival (PCSS) from randomization. Patients experiencing BR had unfavorable initial prognostic factors compared with patients who did not. After BR, these factors were not prognostic for PC death in models adjusted for time to BR (TTBR). In these models, TTBR predicted PCSS more satisfactorily than the occurrence of BR itself. Survival probability 5 years after BR exceeded 90% for men with TTBR >/=4 years; however, it dropped to 44% +/- 6% for men with TTBR <1 year. After BR, rapid PSA doubling time (DT), low iPSA, and short TTBR were identified as the most important predictors of inferior PCSS.

CONCLUSIONS

When BR occurs, prognostic factors for survival change. Low iPSA, short TTBR, and rapid PSA DT take over at this point, providing reasons why iPSA and occurrence of BR alone predict PCSS unsatisfactorily.

18F-fluorocholine PET-guided target volume delineation techniques for partial prostate re-irradiation in local recurrent prostate cancer

BACKGROUND AND PURPOSE

We evaluate the contribution of (18)F-choline PET/CT in the delineation of gross tumour volume (GTV) in local recurrent prostate cancer after initial irradiation using various PET image segmentation techniques.

MATERIALS AND METHODS

Seventeen patients with local-only recurrent prostate cancer (median=5.7 years) after initial irradiation were included in the study. Rebiopsies were performed in 10 patients that confirmed the local recurrence. Following injection of 300 MBq of (18)F-fluorocholine, dynamic PET frames (3 min each) were reconstructed from the list-mode acquisition. Five PET image segmentation techniques were used to delineate the (18)F-choline-based GTVs. These included manual delineation of contours (GTV(man)) by two teams consisting of a radiation oncologist and a nuclear medicine physician each, a fixed threshold of 40% and 50% of the maximum signal intensity (GTV(40%) and GTV(50%)), signal-to-background ratio-based adaptive thresholding (GTV(SBR)), and a region growing (GTV(RG)) algorithm. Geographic mismatches between the GTVs were also assessed using overlap analysis.

RESULTS

Inter-observer variability for manual delineation of GTVs was high but not statistically significant (p=0.459). In addition, the volumes and shapes of GTVs delineated using semi-automated techniques were significantly higher than those of GTVs defined manually.

CONCLUSIONS

Semi-automated segmentation techniques for (18)F-choline PET-guided GTV delineation resulted in substantially higher GTVs compared to manual delineation and might replace the latter for determination of recurrent prostate cancer for partial prostate re-irradiation. The selection of the most appropriate segmentation algorithm still needs to be determined.

Retrospective comparison of external beam radiotherapy and radical prostatectomy in high-risk, clinically localized prostate cancer

PURPOSE

Because of the lack of conclusive and well-conducted randomized studies, the optimal therapy for prostate tumors remains controversial. The aim of this study was to retrospectively compare the results of radical surgery vs. a conservative approach such as external beam radiotherapy (EBRT) plus androgen deprivation therapy using an intent-to-treat analysis on two pretreatment defined, concurrently treated, high-risk patient populations.

METHODS AND MATERIALS

Between January 2003 and December 2007, 162 patients with high-risk prostate cancer underwent an EBRT plus androgen deprivation therapy program at the RT department of our institute. In the same period, 122 patients with the same high-risk disease underwent radical prostatectomy (RP) at the urologic department of our institute. Patients with adverse pathologic factors also underwent adjuvant EBRT with or without androgen deprivation therapy. The primary endpoint was freedom from biochemical failure.

RESULTS

The two groups of high-risk patients were homogeneous in terms of freedom from biochemical failure on the basis of the clinical T stage, biopsy Gleason score, and initial prostate-specific antigen level. The median follow-up was 38.6 and 33.8 months in the EBRT and RP groups, respectively. The actuarial analysis of the freedom from biochemical failure showed a 3-year rate of 86.8% and 69.8% in the EBRT and RP group, respectively (p = .001). Multivariate analysis of the whole group revealed the initial prostate-specific antigen level and treatment type (EBRT vs. RP) as significant covariates.

CONCLUSION

This retrospective intention-to-treat analysis showed a significantly better outcome after EBRT than after RP in patients with high-risk prostate cancer, although a well-conducted randomized comparison would be the best procedure to confirm these results.

MVA-MUC1-IL2 vaccine immunotherapy (TG4010) improves PSA doubling time in patients with prostate cancer with biochemical failure

PURPOSE

TG4010 is a recombinant MVA vector expressing the tumor-associated antigen MUC1 and IL2. We explored the effect two schedules of TG4010 on PSA in men with PSA progression.

PATIENTS AND METHODS

A randomized phase II trial was conducted in 40 patients with PSA progression. Patients had PSA doubling times less than 10 months, with no overt evidence of disease. Patients received either weekly subcutaneous injection (sc) of TG4010 10(8) pfu for 6 weeks, then one injection every 3 weeks or sc injection of TG4010 10(8) pfu every 3 weeks.

RESULTS

The primary endpoint of a 50% decrease in PSA values from baseline was not observed. Nevertheless, 13 of 40 patients had a more than two fold improvement in PSA doubling time. Ten patients had their PSA stabilized for over 8 months. Therapy was well tolerated.

CONCLUSIONS

Although the primary endpoint was not achieved, there is evidence of biologic activity of TG4010 in patients with PSA progression, further investigation in prostate cancer is warranted.

The Phoenix definition of biochemical failure predicts for overall survival in patients with prostate cancer

BACKGROUND

The American Society for Therapeutic Radiology and Oncology (ASTRO) definition of biochemical failure (BF) incorporates backdating, resulting in an artificial flattening of Kaplan-Meier curves and overly favorable estimates when follow-up is short. The nadir + 2 ng/mL (Nadir + 2; Phoenix) definition reduces these artifacts. The objective of the current study was to compare ASTRO and Phoenix BF estimates as determinants of distant metastasis (DM), cause-specific mortality (CSM), and overall mortality (OM).

METHODS

A total of 1831 patients with T1-4N0M0 prostate cancer were treated with external beam radiotherapy (RT) using conventional or three-dimensional conformal methods to at least 60 grays (Gy). The median follow-up was 71 months and the median RT dose was 72 Gy (range, 60-79 Gy). Cox regression models incorporating BF as a time-dependent covariate were used for both univariate and multivariate analyses. Other covariates included in the analyses were T classification, Gleason score, neoadjuvant/adjuvant androgen deprivation, age, RT dose, and pretreatment prostate-specific antigen.

RESULTS

BF was observed in 389 men (21%) using the Phoenix definition and 460 men (25%) using the ASTRO definition. DM was observed in 84 patients (5%), 48 patients (3%) patients died of prostate cancer, and 404 patients (22%) died of any cause. The Phoenix definition of BF was found to be a significant predictor of DM, CSM, and OM, after controlling for other significant covariates. The ASTRO definition was found to be associated with CSM and DM, but not OM.

CONCLUSIONS

The Phoenix definition of BF is a more robust determinant of patient outcome compared with the ASTRO definition. The correlation with mortality, including OM, and the independence of this correlation from the use of neoadjuvant/adjuvant androgen deprivation, supports the use of Nadir + 2 in prostate cancer clinical trials of RT with or without androgen deprivation.

Development of a set of nomograms to predict acute lower gastrointestinal toxicity for prostate cancer 3D-CRT

PURPOSE

To predict acute Radiation Therapy Oncology Group (RTOG)/European Organization for Research and Treatment of Cancer (EORTC) and Subjective Objective Signs Management and Analysis/Late Effect of Normal Tissue (SOMA/LENT) toxicities of the lower gastrointestinal (LGI) syndrome in patients with prostate cancer undergoing three-dimensional conformal radiotherapy using a tool (nomogram) that takes into account clinical and dosimetric variables that proved to be significant in the Italian Association for Radiation Oncology (AIRO) Group on Prostate Cancer (AIROPROS) 0102 trial.

METHODS AND MATERIALS

Acute rectal toxicity was scored in 1,132 patients by using both the RTOG/EORTC scoring system and a 10-item self-assessed questionnaire. Correlation between clinical variables/dose-volume histogram constraints and rectal toxicity was investigated by means of multivariate logistic analyses. Multivariate logistic analyses results were used to create nomograms predicting the symptoms of acute LGI syndrome.

RESULTS

Mean rectal dose was a strong predictor of Grade 2-3 RTOG/EORTC acute LGI toxicity (p = 0.0004; odds ratio (OR) = 1.035), together with hemorrhoids (p = 0.02; OR = 1.51), use of anticoagulants/antiaggregants (p = 0.02; OR = 0.63), and androgen deprivation (AD) (p = 0.04; OR = 0.65). Diabetes (p = 0.34; OR = 1.28) and pelvic node irradiation (p = 0.11; OR = 1.56) were significant variables to adjust toxicity prediction. Bleeding was related to hemorrhoids (p = 0.02; OR = 173), AD (p = 0.17; OR = 0.67), and mean rectal dose (p = 0.009; OR = 1.024). Stool frequency was related to seminal vesicle irradiation (p = 0.07; OR = 6.46), AD administered for more than 3 months (p = 0.002; OR = 0.32), and the percent volume of rectum receiving more than 60 Gy (V60Gy) V60 (p = 0.02; OR = 1.02). Severe fecal incontinence depended on seminal vesicle irradiation (p = 0.14; OR = 4.5) and V70 (p = 0.033; OR = 1.029).

CONCLUSIONS

To the best of our knowledge, this work presents the first set of nomograms available in the literature specific to symptoms of LGI syndrome and provides clinicians with a tailored probability of the specific outcome. Validation of the tool is in progress.

10-Year Survival and Quality of Life in Patients With High-Risk PN0 Prostate Cancer Following Definitive Radiotherapy

PURPOSE

To evaluate long-term overall survival (OS), cancer-specific survival (CSS), clinical progression-free survival (cPFS), and health-related quality of life (HRQoL) following definitive radiotherapy (RT) given to T(1-4p)N(0)M(0) prostate cancer patients provided by a single institution between 1989 and 1996.

METHODS AND MATERIALS

We assessed outcome among 203 patients who had completed three-dimensional conformal RT (66 Gy) without hormone treatment and in whom staging by lymphadenectomy had been performed. OS was compared with an age-matched control group from the general population. A cross-sectional, self-report survey of HRQoL was performed among surviving patients.

RESULTS

Median observation time was 10 years (range, 1-16 years). Eighty-one percent had high-risk tumors defined as T(3-4) or Gleason score (GS) > or =7B (4+3). Among these, 10-year OS, CSS, and cPFS rates were 52%, 66%, and 39%, respectively. The corresponding fractions in low-risk patients (T(1-2) and GS < or =7A [3+4]) were 79%, 95%, and 73%, respectively. Both CSS and cPFS were predicted by GS and T-classification; OS was associated with GS only. High-risk, but not low-risk, patients had reduced OS compared with the general population (p < 0.0005). When pelvis-related side effects were included in multivariate analyzes together with physical function and pain, sexual, urinary, and bowel function were not independently associated with self-reported global quality of life.

CONCLUSIONS

Despite surgically proven (p)N(0), RT with dosage <70 Gy as monotherapy does not give satisfactory CSS rates after 10 years in patients with T(3-4) or GS > or =7B.

High dose rate brachytherapy in combination with external beam radiotherapy in the radical treatment of prostate cancer: initial results of a randomised phase three trial

BACKGROUND AND PURPOSE

A randomised phase III trial has compared external beam radiotherapy alone with a dose escalated schedule using high dose rate brachytherapy. Patients with histologically confirmed prostate cancer, no evidence of metastases, a PSA <50, no previous TURP and fit for general anaesthetic were included.

METHODS

Patients were randomised to receive either standard radiotherapy 55 Gy in 20 fractions treating Monday to Friday over 4 weeks or a combined schedule comprising external beam treatment delivering 35.75 Gy in 13 fractions treating daily Monday to Friday over 2.5 weeks followed by a temporary high dose rate afterloading implant delivering 17 Gy in two fractions over 24h.

RESULTS

A total of 220 patients were randomised, balanced for important prognostic parameters including tumour stage, presenting PSA, Gleason score and use of adjuvant anti-androgens. With a median follow up of 30 months (range 3-91) a significant improvement in actuarial biochemical relapse-free survival is seen in favour of the combined brachytherapy schedule (p=0.03). A lower incidence of acute rectal discharge was seen in the brachytherapy group (p=0.025) and other acute and late toxicities were equivalent. Patients randomised to brachytherapy had a significantly better FACT-P score at 12 weeks (p=0.02).

CONCLUSIONS

The use of high dose rate brachytherapy in combination with external beam radiotherapy resulted in an improved biochemical relapse-free survival compared to external beam radiotherapy alone with less acute rectal toxicity and improved quality of life in this randomised trial.

Implications of Prostate-Specific Antigen Doubling Time as Indicator of Failure after Surgery or Radiation Therapy for Prostate Cancer

OBJECTIVES

To review the methodology of PSA doubling time (PSA DT) calculations and the implications of PSA DT for the follow-up of prostate cancer patients curatively treated with surgery or radiation therapy.

METHODS

A literature search of the most recent articles on PSA DT (those published after 2000) led to the selection of six studies with the largest and best-documented cohorts of patients treated with surgery or irradiation with curative intent.

RESULTS

PSA kinetics, in the form of PSA DT, is the most effective parameter for identifying patients at significant risk for mortality specific to prostate cancer. Thresholds of 3, 6, and 12 mo have shown prognostic significance both in surgical and radiation series, notwithstanding differences in treatment selection, definition of biochemical recurrence, and methods of DT calculation.

CONCLUSIONS

In retrospective studies, PSA DT is a reliable predictor of prognosis; however, prospective validation studies are needed to determine the cut points of PSA DT. Optimal time intervals for calculation and optimal thresholds are still to be determined.

Radiation therapy for prostate cancer: the role for dose escalation

Recent technological advances in radiation treatment delivery have allowed relatively higher doses of radiation to be delivered safely to the prostate. Emerging data suggest improvements in disease control with higher doses of radiation in subsets of patients with prostate cancer.

Radiation dose escalation combined with hormone therapy improves outcome in localised prostate cancer

We present the impact of systematic radiation dose escalation from 64 Gy to 66 Gy to 70 Gy on the outcome after radiation therapy (RT) alone or combined with hormonal treatment (HT) in a series of 494 consecutive localised prostate cancer patients treated during 1990-1999. Prognostic factors for prostate-specific antigen (PSA) failure, overall survival (OS) and prostate cancer specific survival (CSS) were investigated using multivariate analysis. T stage, pre-treatment PSA, grade, radiation dose and HT were found to be independent predictors of PSA failure. T stage, grade and HT were also independent predictors of both OS and CSS, while radiation dose was a significant predictor for OS and indicated a trend (p = 0.07) for CSS. A dose of 70 Gy combined with hormonal treatment improves PSA failure free survival and survival in localised prostate cancer compared with doses of 64-66 Gy.

Salvage radical prostatectomy for radiorecurrent prostate cancer: Indications and results

AIMS

A rise in the incidence of radiorecurrent prostate cancer is to be expected, since approximately one third of early prostate cancer cases are nowadays treated with a radiotherapy modality. One possibility in treating radiorecurrent prostate cancer is salvage prostatectomy. Our objective was to look into our own experience with salvage radical prostatectomy and to analyse outcome and morbidity.

METHODS

A computer search through our hospital database identified 11 patients who underwent a salvage radical prostatectomy for radiorecurrent cancer over the last 15 years. All data were retrospectively analysed and confronted with the literature.

RESULTS

Although the surgery was mostly difficult, there were no intraoperative complications. Bladder neck stricture is the most common postoperative complication (18%). Continence rates are worse than in classical radical prostatectomy. All patients lost potency, since no attempt was made to spare the neurovascular bundles. With a mean follow-up of 6.9 years, biochemical disease-free survival rates was 55%, while overall and cancer-specific survival was 91%.

CONCLUSION

While most patients with radiorecurrent prostate cancer will be treated by many experts with hormonal therapy, a salvage radical prostatectomy can give a second chance for cure in carefully selected patients.

Estimating the risk of long-term erectile, urinary and bowel symptoms resulting from prostate cancer treatment

Reports on long-term complications resulting from treatment for localized prostate cancer are very inconsistent. In order to estimate the risks of long-term erectile dysfunction, urine symptoms and bowel symptoms following prostatectomy (RP), external conventional or conformal beam radiation (ERT or CRT) and brachytherapy (BRT), 98 papers from the PubMed and Cochrane Clinical Trial databases were selected, reviewed and critically evaluated. The majority of papers were institution-based retrospective and prospective follow-up studies; only two of these studies measured the risk of developing more than one treatment complication. Due to differences in study designs and populations, it is difficult to directly compare studies and not meaningful to calculate summary estimates. In addition to focusing on randomized clinical trials and well-designed population based studies, future research should adopt standardized methodologies and should measure the risk of developing more than one treatment complication.

Prostate-specific antigen doubling time predicts clinical outcome and survival in prostate cancer patients treated with combined radiation and hormone therapy

PURPOSE

To determine whether prostate-specific antigen (PSA) doubling time predicts clinical outcomes in patients with prostate cancer that has been treated with combined radiation and hormone therapy.

METHODS AND MATERIALS

We reviewed the medical records of 621 men with nonmetastatic prostate cancer treated with radiation therapy and hormone therapy between 1989 and 2003. "Any" clinical failure was defined as any distant, nodal, or local failure, or the use of salvage therapy. "True" clinical failure was defined as any distant, nodal, or local failure. PSA doubling time was calculated by using the log PSA values from patients with a PSA failure as defined by the American Society of Therapeutic Radiology Oncology consensus statement. One hundred thirty-seven men were at intermediate risk for PSA failure (as determined by T2b, Gleason score of 7, or PSA 10.1-0 ng/mL) and 484 men were at high risk for failure (T2c-4; Gleason 8-10; or PSA >20 ng/mL). Pretreatment PSA value, Gleason score, tumor stage, timing and duration of hormone therapy, radiation therapy dose, and PSA doubling time were analyzed for any associations with time to clinical failure by using Cox regression analysis. Estimates of survival were calculated by using the Kaplan-Meier method. Pairwise comparisons were made by using the log-rank test.

RESULTS

Sixty-two men experienced any clinical failure, and 22 men experienced true clinical failure. Multivariate analysis revealed that pretreatment PSA (p = 0.013), Gleason score (p = 0.0019), and a PSA doubling time (PSADT) < or =8 months (p < 0.001) were independently associated with time to any clinical failure. Tumor stage, hormone therapy timing, hormone therapy duration, and radiation therapy dose were not statistically significant on multivariate or univariate analysis. Only hormone therapy duration (p = 0.008) and PSADT < or =8 months (<0.001) were significantly associated with time to true clinical failure. The estimated 5-year rate of any clinical failure was 9.4% for men with a PSADT >8 months and 60.4% for men with a PSA doubling time < or =8 months (p < 0.001). The estimated 5-year rate of true clinical failure was 6.5% for men with a PSADT >8 months and 68.5% for men with a PSADT < or =8 months (p < 0.001). Lower radiation dose was the only significant predictor of PSADT < or =8 months on multivariate regression analysis. The estimated 6-year overall survival rate after PSA failure was 79.1% for men with a PSADT >8 months and 29.7% for men with a PSADT < or =8 months. The median overall survival time for patients with a PSADT >8 months was not reached in this study. The median overall survival time for patients with a PSADT < or =8 months was 61.8 months (p = 0.015).

CONCLUSION

In men with prostate cancer that has been treated with combined hormone and radiation therapy, a posttreatment PSADT of < or =8 months is associated with worse clinical outcomes and may be an early surrogate marker for decreased survival. These patients should be considered for more aggressive salvage therapy protocols.

DEFINING RECURRENCE AFTER RADIATION FOR PROSTATE CANCER

PURPOSE

We reviewed prostate specific antigen (PSA) definitions of recurrence after external beam radiation for prostatic cancer and related them to the definitions used for other treatment modalities.

MATERIALS AND METHODS

The literature on defining recurrence after external beam radiation, brachytherapy and prostatectomy for prostate cancer was reviewed through a MEDLINE search to ensure completeness and the inclusion of all pertinent information.

RESULTS

Although the definition, which is the current standard for estimating recurrence after external beam radiation, has proved to be a reasonable measure, alternative options that are more sensitive and specific have now been defined. Similar statistical testing and comparison must also be done for other treatment modalities since the choice of failure definitions has not been evaluated nearly as thoroughly for these therapies. As much as possible, outcome reporting should be done according to the same method to ensure fairness when comparisons are made. However, inherent differences between treatment modalities and their effect on PSA production must also be considered.

CONCLUSIONS

With the latest available information from patients with long-term followup PSA definitions of tumor recurrence after external beam radiation for prostatic cancer must again be reviewed in a consensus conference format. The application of a universal PSA definition of tumor recurrence across multiple treatment modalities should also be explored.

Intensity-modulated radiotherapy for adenocarcinoma of the prostate: A point of view

Adenocarcinoma of the prostate (CaP) is treated by surgery or irradiation, or both, with the type of treatment determined largely by local resources and referral patterns. Although the techniques employed by surgeons and radiation oncologists have improved and the morbidities associated with each have declined, for neither are they negligible. Epidemiologic data suggest that between 81% and 85% of men with CaP die of other causes, and a recent survey of untreated men arrived at a similar figure of 83%. Clinical reports, based upon postoperative tumor volume and grade, show that at least 5% of prostatectomies are unnecessary but the extent to which the other 95% benefit from this procedure is unclear. Some sense of these benefits is provided by a randomized, prospective clinical trial that compared prostatectomy with watchful waiting, and found only a 6% gain in overall survival after 8 years. These data call into question the promotion of highly complex and expensive radiation therapy equipment for the treatment of CaP when the prospects for increased life expectancies are at best small and unlikely to be distinguishable from results achieved by surgery, conventional external beam, or radioactive-seed implants.

Racial differences in prostate cancer treatment outcomes: a systematic review

Although differences in prostate cancer incidence and mortality between black and white men are widely accepted, the existence of racial differences in treatment outcomes remains controversial. We conducted a systematic review of racial differences in prostate cancer treatment outcomes. Systematic review of literature from 1992-2002 was conducted. Database searches were performed using the terms: "prostate cancer" (keyword) or "prostate neoplasm" (subject heading) + "blacks" (subject heading) or "blacks" (keyword) + "African-Americans" (subject heading or "African-Americans" (keyword). Two hundred fifty-eight relevant articles were identified; 29 fit the inclusion criteria. All but 3 were retrospective. Seven (24%) studies were conducted at Veterans Affairs medical centers. Treatment included radical prostatectomy (15 studies), hormonal therapy (5 studies), and radiotherapy (12 studies). Three studies included more than 1 treatment. Twenty-three (79%) studies, observed no significant difference in treatment outcomes between races. The remainder found worse outcomes among black men, including worse 5-year survival (HR range, 2.35-96.74) and higher rates of PSA failure (OR range, 1.15-1.69). Most studies investigating racial differences in prostate cancer treatment outcomes over the past 10 years found no difference between races after controlling for tumor and patient characteristics. Efforts to narrow the gap between black and white prostate cancer mortality should focus on ensuring that all patients receive optimal treatment and that all patients become informed about the use of screening for early cancer detection. Research should focus on interventions to reduce advanced presentation of the disease and disease-related mortality among black men.

Phase II trial of GM-CSF + thalidomide in patients with androgen-independent metastatic prostate cancer

BACKGROUND

Androgen-independent metastatic prostate cancer is a major therapeutic dilemma. Granulocyte-macrophage colony stimulating factor (GM-CSF) and thalidomide have some biologic activity as single agents in this disease subset. We performed a Phase II trial of this combination to assess its toxicity and potential utility as an immunomodulatory approach to management of advanced prostate cancer.

METHODS

Twenty-two patients were treated with GM-CSF 250 microg administered SC on Monday, Wednesday and Friday of each week. Thalidomide was escalated to reach the study dose of 200 mg/day. Patients were assessed every 4 weeks with therapy continuing to a maximum of 6 months.

RESULTS

All 22 patients had a decrement in PSA at 2 weeks postinitiation of therapy. Five patients had a > or =50% decline (56, 64,66,66, and 94%, respectively) from baseline verified at 4 weeks post best response. This corresponds to an observed response rate of 23% (95% confidence interval 8-45%). Therapy was well tolerated with the majority of patients experiencing only one event.

CONCLUSIONS

The combination of GM-CSF + thalidomide is relatively well tolerated and has the potential to produce antitumor activity in a population of patients with metastatic, androgen independent prostate cancer. This nonchemotherapy combination should be explored in a subset of patients with less advanced disease.

PSA failure and the risk of death in prostate cancer patients treated with radiotherapy

PURPOSE

To determine the relationship between prostate-specific antigen (PSA) failure and cause-specific and overall survival in prostate cancer patients treated with radical radiotherapy.

METHODS AND MATERIALS

Patients with and without PSA failure were compared with respect to overall survival and cause-specific survival in a cohort of 1786 patients. The relationship between PSA failure and survival was further investigated among six subgroups defined by three tumor risk groups (high, intermediate, and low risk based on T stage, Gleason score, and presenting PSA) and two age groups (<75 years and >/=75 years).

RESULTS

The 5-year overall survival among patients who had PSA failure was 79.5% vs. 87.5% among patients who had not failed (p = 0.0003). The corresponding 5-year cause-specific survival was 84.4% vs. 99.0% (p <0.0001). When the six subgroups are considered separately, PSA failure was associated with a worse cause-specific survival in the groups with intermediate- and high-risk disease. PSA failure was only associated with a worse overall survival in one subgroup: patients younger than 75 with high-risk disease. Deaths from nonprostate causes made the survival curves of patients with and without PSA failure in the other subgroups almost identical.

CONCLUSION

PSA failure in prostate cancer patients treated with radiotherapy was associated with a poorer overall survival, which is seen mainly in younger patients with high-risk disease.

Intervention after PSA failure: examination of intervention time and subsequent outcomes from a prospective patient database

PURPOSE

To investigate timing of intervention for solitary biochemical relapse following external beam radiation therapy (EBRT) for localized prostate cancer, and to assess the impact on survival.

METHODS AND MATERIALS

Of 1499 men treated with EBRT from 1994 to 2000, 544 men had prostate-specific antigen (PSA) relapse by the Vancouver Criteria. Patients with near-simultaneous clinical relapse (n = 79) were excluded, leaving 465 for analysis. Pretreatment prognostic factors, the time that biochemical relapse was realized (trigger PSA time), and postrelapse doubling time (PSAdt) were examined for effect on the timing of intervention and cause-specific survival (CSS).

RESULTS

Median actuarial time from trigger-PSA time to intervention was 30 months. The only factor associated with early intervention on multivariate analysis (MVA) was faster PSAdt (p < 0.0001). Not significant were initial PSA, Gleason score, T stage, or adjuvant androgen ablation use or duration. Seventy-five percent of interventions occurred with PSAdt faster than 12 months. The 5-year CSS was 89%. Faster PSAdt (p = 0.0007), higher Gleason score (p = 0.018), and earlier intervention (p = 0.0006) were significantly associated with increased prostate cancer death on MVA. The 5-year CSS is 19% where the PSAdt was <3 months, 84% where 3-6 months, 93% where 6-12 months, and 98% where >12 months (p < 0.0001).

CONCLUSIONS

Men with a biochemical relapse post-EBRT with PSAdt >1 year had excellent 5-year CSS (98%). Rapid PSAdt is associated with increased mortality on MVA. The association of earlier intervention with increased mortality may be due to the selection of those with occult metastasis for early intervention.

Both pretreatment prostate-specific antigen level and posttreatment biochemical failure are independent predictors of overall survival after radiotherapy for prostate cancer

PURPOSE

To assess the impact of pretreatment prognostic factors plus subsequent biochemical failure on overall survival after radiotherapy for prostate cancer.

METHODS AND MATERIALS

We analyzed the prostate-specific antigen (PSA) and survival records of 1571 men with clinically localized prostate cancer treated with external beam radiotherapy monotherapy at the former Queensland Radium Institute between 1990 and 1997. The pretreatment PSA level, biopsy Gleason score, clinical stage, patient age, and the development of biochemical failure were assessed in relationship to overall survival and cause-specific survival, using fixed, as well as time-dependent, statistics.

RESULTS

The median follow-up was 88.1 months (95 months for those still alive). The actuarial overall survival, cause-specific survival, and biochemical failure-free survival rate at 10 years was 61.1%, 80.9%, and 25.9% respectively. Cause-specific survival was independently influenced by the pretreatment PSA level, Gleason score, clinical stage, and the development of biochemical failure (relative risk, 19.1). Using the overall survival endpoint, multivariate analysis showed age, pretreatment PSA level, Gleason score, and biochemical failure (relative risk 1.27) to be statistically significant variables.

CONCLUSION

In addition to previously identified factors, the pretreatment PSA level and occurrence of biochemical failure after radiotherapy for prostate cancer are associated with an increased overall mortality risk. Both pretreatment PSA level and posttreatment biochemical failure are independent predictors of overall survival after radiotherapy for prostate cancer.