The timing of hormone therapy for men with asymptomatic advanced prostate cancer

Management of prostate cancer patients with lymph node involvement: a rapidly evolving paradigm

Although widespread PSA screening has inevitably led to increased diagnosis of lower risk prostate cancer, the number of patients with nodal involvement at baseline remains high (nearly 40% of high risk patients initially staged cN0). These rates probably do not reflect the true incidence of prostate cancer with lymph node involvement among patients selected for external beam radiotherapy (EBRT), as patients selected for surgery often have more favorable prognostic features. At many institutions, radical treatment directed only at the prostate is considered standard and patients known to have regional disease are often managed palliatively with androgen deprivation therapy (ADT) for presumed systemic disease. New imaging tools such as MR lymphangiography, choline-based PET imaging or combined SPECT/CT now allow surgeons and radiation oncologists to identify and target nodal metastasis and/or lymph nodes with a high risk of occult involvement. Recent advances in the field of surgery including the advent of extended nodal dissection and sentinel node procedures have suggested that cancer-specific survival might be improved for lymph-node positive patients with a low burden of nodal involvement when managed with aggressive interventions. These new imaging tools can provide radiation oncologists with maps to guide delivery of high dose conformal radiation to a target volume while minimizing radiation toxicity to non-target normal tissue. This review highlights advances in imaging and reports how they may help to define a new paradigm to manage node-positive prostate cancer patients with a curative-intent.

Androgen deprivation therapy and cataract incidence among elderly prostate cancer patients in the United States

PURPOSE

The side-effects associated with androgen deprivation therapy (ADT) include weight gain, dyslipidemia, and insulin resistance. As cataracts have been linked to these metabolic abnormalities, an increased risk of cataract may be another adverse consequence of ADT use.

METHODS

Using data from the Surveillance, Epidemiology and End Results-Medicare database, we estimated risk of cataract associated with ADT among 65,852 prostate-cancer patients. ADT treatment was defined as at least one dose of a gonadotropin-releasing hormone agonist or orchiectomy within 6 months after prostate cancer diagnosis. The outcome measure was a first claim of cataract diagnosis identified in Medicare claim files. Cox regression was used to estimate hazard ratios (HR) for the effects of ADT treatment, controlling for confounders.

RESULTS

Gonadotropin-releasing hormone agonist use was associated with a modest increase in cataract incidence (HR 1.09, 95% confidence interval 1.06-1.12). Orchiectomy was also associated with an increased risk of cataract among men with no history of cataract prior to prostate cancer diagnosis (HR 1.26, 95% confidence interval 1.07-1.47).

CONCLUSIONS

In the first systematic investigation of the association between ADT and cataract, our results suggest an elevation in the incidence of cataract among ADT users. Further study, preferably prospective in design, is needed to provide additional evidence to support or refute these findings.

Trends and racial differences in the use of androgen deprivation therapy for metastatic prostate cancer

CONTEXT

Androgen deprivation therapy (ADT) is widely used to manage the symptoms of advanced prostate cancer and has been shown to slow the progression of the disease. Previous research investigating racial differences in the use of ADT has reported inconsistent findings.

OBJECTIVES

The purpose of this study was to assess use trends for ADT overall and by type (orchiectomy and luteinizing hormone-releasing hormone [LHRH] agonists) and the factors associated with time to receipt for metastatic prostate cancer.

METHODS

Data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims database were obtained for 5,273 men, aged 65 years and older and diagnosed with Stage IV prostate cancer during 1991-1999 from seven SEER regions. An accelerated failure time regression model with log-normal distribution was used to examine factors associated with mean time to receipt of ADT.

RESULTS

African-American men were less likely than white men to receive any ADT after diagnosis (P<0.001). Differences were noted in the time to receipt of ADT, with African-American men having a longer mean time to receipt of orchiectomy (time ratio [TR]=1.50; 95% confidence interval [CI]=1.03, 2.17) or LHRH agonist (TR=1.42; 95% CI=1.06, 1.89) than white men.

CONCLUSION

African-American men with metastatic prostate cancer were significantly less likely to receive ADT and, when treated, had a slightly longer time to receipt than white men, which has implications for patients and physicians involved in the palliative management of metastatic prostate cancer.

The Coffey Lecture: steroidogenic enzyme inhibitors and hormone dependent cancer

OBJECTIVES

To improve treatment for patients with breast and prostate cancer.

METHODS

A number of novel inhibitors of steroidogenic enzymes have been developed. Their biological effects have been evaluated in a variety of preclinical models. Aromatase (estrogen synthetase) inhibitors have now been extensively tested in clinical trials in breast cancer patients. Inhibitors of 17alpha-hydroxylase/lyase have also been studied in preclinical models and are beginning trials in prostate cancer patients.

RESULTS

The enzyme aromatase (CYP19) has proven to be an important therapeutic target. Inhibitors of aromatase (AIs) are showing greater benefit than antiestrogens in the treatment of breast cancer. Although effective in other conditions in both women and men, AIs have not been useful in benign prostatic hypertrophy or prostate cancer. However inhibitors of 17alphahydroxylase/lyase (CYP17) to block synthesis of androgens may be effective for prostate cancer. Recent clinical trials with abiraterone and preclinical studies with other novel CYP17 inhibitors, which also interact with the androgen receptor and cause its down-regulation, could provide a new approach for treating this disease. In further studies, we optimized treatment with aromatase inhibitors and antiestrogens utilizing an intratumoral aromatase xenograft model. AIs were more effective and sustained growth inhibition was longer than antiestrogens. However, inevitably tumors eventually began to grow despite continued treatment. Analysis of breast tumors from mice treated with letrozole revealed up-regulation of HER-2 and MAP Kinase signaling proteins and down-regulation of the estrogen receptor. Our studies showed that tumors adapt to AI treatment by activating alternate signaling pathways, thus enabling them to proliferate in the absence of estrogen. When mice bearing resistant tumors were treated with trastuzumab, the anti-HER-2 antibody (herceptin), HER-2 was decreased in the tumor but the estrogen receptor and aromatase were restored. Tumor growth was significantly inhibited by treatment with trastuzumab in addition to letrozole.

CONCLUSIONS

Aromatase inhibitors are proving to be an effective new class of agents for the treatment of breast cancer. Compounds inhibiting 17alphahydroxylase/lyase have potential for the treatment of prostate cancer. Our results suggest that strategies to overcome resistance to these types of agents can restore sensitivity of the tumors to hormone therapy.

Management of complications of androgen deprivation therapy in the older man

Prostate cancer is the most common malignancy in older men. With the aging of the population, the number of older men with prostate cancer will grow rapidly. Androgen deprivation therapy (ADT) is the mainstay of treatment for men with systemic disease and is increasingly utilized as primary therapy or in combination with other therapies for localized disease. Side effects of therapy are multifold and include hot flashes, osteoporosis, and adverse psychological and metabolic effects. Recent research has illustrated that ADT can negatively impact the functional, cognitive, and physical performance of older men. Patients with prostate cancer, despite recurrence of the disease, have a long life expectancy and may be subjected to the side effects of ADT for many years. This review highlights the complications of ADT and approaches to management. We also provide recommendations for assessment and management of ADT complications among the most vulnerable and frail older male patients.

A pilot study of the vulnerable elders survey-13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation

BACKGROUND

Impairments in geriatric domains adversely affect health outcomes of the elderly. The Comprehensive Geriatric Assessment (CGA) is a key component of the treatment approach for older cancer patients, but it is time consuming. In this pilot study, the authors evaluated the validity of a brief, functionally based screening tool, the Vulnerable Elders Survey-13 (VES-13), for identifying older patients with prostate cancer (PCa) with impairment in the oncology clinic setting.

METHODS

Patients with PCa aged >or=70 years who actively were receiving androgen ablation treatment and who were followed within the clinics at the University of Chicago were eligible. Patients self-completed the VES-13 and CGA instruments and repeated the VES-13 1 month later. Physical performance and cognitive assessments were administered by a research assistant.

RESULTS

Of 50 participating patients, 50% were identified as impaired by the VES-13 (score >or=3). Sixty percent of patients scored as impaired on >or=2 tests within the CGA, exhibiting deficits in multiple domains. The reliability of the VES-13 (Pearson correlation coefficient) was 0.92. The cut-off score of 3 on the VES-13 had 72.7% sensitivity and 85.7% specificity for CGA deficits and was highly predictive for identifying impairment (area under the receiver operating characteristic curve, 0.90). Patients who had mean VES-13 scores >or=3 performed significantly worse on evaluations of activities of daily living (P = .001), physical performance (P = .002), comorbidity (P = .004), and cognitive impairment (P = .003).

CONCLUSIONS

Functional and cognitive impairments are highly prevalent among older patients with PCa who receive androgen ablation in oncology clinics. The current results indicated that the brief VES-13 performed nearly as well as a conventional CGA in detecting geriatric impairment in this population.

Patterns of care for men with prostate cancer after failure of primary treatment

BACKGROUND

This study sought to determine trends in patterns of care after failure of primary prostate cancer treatment and to determine whether nonclinical factors influenced the receipt of secondary treatment.

METHODS

The authors identified individuals treated for nonmetastatic prostate cancer in the years 1991-1999 from the linked databases of Medicare and the National Cancer Institute's Surveillance, Epidemiology, and End Results registry. The outcome of interest was receipt of secondary therapy. They performed Cox proportional hazard analyses to investigate the link between demographic and clinical characteristics and the likelihood of receiving secondary treatment after either surgery or radiation.

RESULTS

Of 65,716 subjects who met our inclusion criteria, 10,200 (15%) received some form of secondary therapy. For men undergoing initial surgical or radiation therapy, tumor grade, year of diagnosis, and geographic region were associated with secondary therapy. No socioeconomic factors such as education, ethnicity, or income level were associated with secondary therapy.

CONCLUSIONS

Patterns of care after primary prostate cancer therapy continue to vary regionally. Standardized clinical algorithms and utilization of prostate-specific antigen testing appear to have influenced secondary therapy rates.

Clinical Approach to the Prostate: An Update

Prostatic disease continues to present clinicians with challenges. Although giant strides have been made in the medical and surgical management of benign prostatic hyperplasia, many fundamental questions about its pathogenesis, progression, and treatment efficacy remain unanswered. Prostate cancer also continues to be an area in which progress is needed despite major recent advancements. Numerous debates that include the value of prostate-specific antigen screening and appropriate roles for each of the numerous therapeutic modalities await resolution. For millions of patients who suffer from prostatitis, a major breakthrough is yet to come. Current treatment regimens for prostatitis remain ineffective at best. Contemporary approaches to the pathogenesis, diagnosis, and treatment of benign prostatic hyperplasia, prostate cancer, and prostatitis are discussed in this review.

Advancing prostate cancer: treatment options for the urologist

Today's urologists often face the dilemma of how to treat patients who have advancing prostate cancer. The diversity of this patient population makes treatment decisions challenging. For over 60 years the mainstay of treatment for patients who have advancing prostate cancer has been androgen deprivation therapy. Now there are new chemotherapeutic options, novel hormone manipulations, and other adjunctive therapies available. Based on a case presentation, the authors have attempted to outline for the practicing urologist, a logical progression of treatment options for advancing prostate cancer.

Actualización del tratamiento del cáncer de próstata avanzado y de sus complicaciones

Prostate adenocarcinoma is the leading cause of cancer in Spain, among men older than 65. 1,200 new cases out of every 100,000 males are diagnosed with prostate cancer on an annual basis. In the United States, this illness represents the second leading cause of death due to cancer in males. In those patients whose prostate tumors progress after surgery or radiotherapy, or have metastatic disease when diagnosed, a systemic approach in order to improve their quality of life and overall survival is mandatory. First line hormone therapies usually reach a proper control of the tumor maintaining an acceptable quality of life. However, most of these tumors becomes androgen-independent over time and behave as a more aggressive cancer type. In these patients, combination therapy protocols have recently demonstrated a benefit not only in terms of symptoms control and response rates but also in improving survival. In addition, several new molecules are currently under study. The accurate knowledge of the symptoms due to disease spreading as well as treatment's side effects is necessary to provide an appropriate palliative management that contributes to an improvement of the quality of life in advanced prostate cancer patients.

Bisphosphonate therapy in the oncology setting

Patients with metastatic cancer and bone involvement are at chronic risk of skeletal complications, including bone pain, fractures, spinal cord compression and hypercalcaemia of malignancy. Therapies targeting the primary malignancy are often unable to prevent skeletal complications, which often require orthopaedic surgery, radiation therapy and analgesics. Intravenous bisphosphonates can reduce the risk of skeletal complications and the requirement for palliative radiation therapy. Since its broad regulatory approval, zoledronic acid (ZOMETA, Novartis Pharma AG/Novartis Pharmaceuticals Corporation) 4 mg by 15-minute intravenous infusion has become widely used to treat bone metastases from all solid tumours and is becoming the standard of care for advanced breast cancer and multiple myeloma. Additionally, cancer treatment-induced bone loss is an emerging problem in clinical oncology, and bisphosphonates -- particularly intravenous bisphosphonates -- may provide benefits even before bone lesions develop. Further investigations of bisphosphonates in these and other indications are ongoing.