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Stattin P, Fleming S, Lin X, Lefresne F, Brookman-May SD, Mundle SD, Pai H, Gifkins D, Robinson D, Styrke J, Garmo H. Population-based study of disease trajectory after radical treatment for high-risk prostate cancer. BJU Int 2024; 134:96-102. [PMID: 38621388 DOI: 10.1111/bju.16362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
OBJECTIVES To investigate long-term disease trajectories among men with high-risk localized or locally advanced prostate cancer (HRLPC) treated with radical radiotherapy (RT) or radical prostatectomy (RP). MATERIAL AND METHODS Men diagnosed with HRLPC in 2006-2020, who received primary RT or RP, were identified from the Prostate Cancer data Base Sweden (PCBaSe) 5.0. Follow-up ended on 30 June 2021. Treatment trajectories and risk of death from prostate cancer (PCa) or other causes were assessed by competing risk analyses using cumulative incidence for each event. RESULTS In total, 8317 men received RT and 4923 men underwent RP. The median (interquartile range) follow-up was 6.2 (3.6-9.5) years. After RT, the 10-year risk of PCa-related death was 0.13 (95% confidence interval [CI] 0.12-0.14) and the risk of death from all causes was 0.32 (95% CI 0.31-0.34). After RP, the 10-year risk of PCa-related death was 0.09 (95% CI 0.08-0.10) and the risk of death from all causes was 0.19 (95% CI 0.18-0.21). The 10-year risks of androgen deprivation therapy (ADT) as secondary treatment were 0.42 (95% CI 0.41-0.44) and 0.21 (95% CI 0.20-0.23) after RT and RP, respectively. Among men who received ADT as secondary treatment, the risk of PCa-related death at 10 years after initiation of ADT was 0.33 (95% CI 030-0.36) after RT and 0.27 (95% CI 0.24-0.30) after RP. CONCLUSION Approximately one in 10 men with HRLPC who received primary RT or RP had died from PCa 10 years after diagnosis. Approximately one in three men who received secondary ADT, an indication of PCa progression, died from PCa 10 years after the start of ADT. Early identification and aggressive treatment of men with high risk of progression after radical treatment are warranted.
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Affiliation(s)
- Pär Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Xiwu Lin
- Janssen Global Services, Horsham, PA, USA
| | | | - Sabine D Brookman-May
- Janssen Research & Development, Spring House, PA, USA
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | | | - Helen Pai
- Janssen Research & Development, Raritan, NJ, USA
| | - Dina Gifkins
- Janssen Research & Development, Raritan, NJ, USA
| | - David Robinson
- Department of Urology, Ryhov County Hospital, Jönköping, Sweden
| | - Johan Styrke
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Hans Garmo
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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2
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Sayan M, Chen MH, Loffredo M, McMahon E, Moningi S, Orio PF, Nguyen PL, D'Amico AV. Elective Pelvic Lymph Node Radiation Therapy and the Risk of Death in Patients With Unfavorable-Risk Prostate Cancer: A Postrandomization Analysis. J Clin Oncol 2024:JCO2302394. [PMID: 38691823 DOI: 10.1200/jco.23.02394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/19/2023] [Accepted: 03/07/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE Although a contemporary randomized clinical trial has led to the use of whole-pelvic radiation therapy (WPRT), long-term data evaluating a potential reduction in mortality are lacking and are addressed in the current study. MATERIALS AND METHODS From 2005 to 2015, 350 men with localized, unfavorable-risk prostate cancer (PC) were randomly assigned to receive androgen deprivation therapy (ADT) and RT plus docetaxel versus ADT and RT. Treatment of the pelvic lymph nodes was at the discretion of the treating physician. Multivariable Cox and Fine and Grays regression analyses were performed to assess whether a significant association existed between radiation treatment volume and all-cause mortality (ACM) and PC-specific mortality (PCSM), respectively, adjusting for known PC prognostic factors and comorbidity. An interaction term between age (categorized by dichotomization at 65 years to enable clinical interpretation and applicability of the results and which approximates the median (66 years [IQR, 61-70]) and radiation treatment volume was included in the analysis. RESULTS After a median follow-up of 10.20 years (IQR, 7.96-11.41), 89 men died (25.43%); of these, 42 died of PC (47.19%). Of the 350 randomly assigned patients, 88 (25.14%) received WPRT. In men younger than 65 years, WPRT was associated with a significantly lower ACM risk (adjusted hazard ratio [AHR], 0.33 [95% CI, 0.11 to 0.97]; P = .04) and lower PCSM risk (AHR, 0.17 [95% CI, 0.02 to 1.35]; P = .09) after adjusting for covariates, whereas this was not the case for men 65 years or older. CONCLUSION WPRT has the potential to reduce mortality in younger men with unfavorable-risk PC.
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Affiliation(s)
- Mutlay Sayan
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Ming-Hui Chen
- Department of Statistics, University of Connecticut, Storrs, CT
| | - Marian Loffredo
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Elizabeth McMahon
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Shalini Moningi
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Peter F Orio
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
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3
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Onal C, Guler OC, Erbay G, Elmali A. The effect of dose-escalation radiotherapy with simultaneous-integrated-boost on the use of short-term androgen deprivation therapy in patients with intermediate risk prostate cancer. Prostate 2024. [PMID: 38528236 DOI: 10.1002/pros.24693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE To compare the biochemical failure (FFBF) and prostate cancer specific survival (PCSS) rates of patients with intermediate-risk prostate cancer (IR-PC) who were treated with 6 months of androgen deprivation therapy (ADT) with 78 Gy to the prostate, those treated with ADT and focal boost (FB) of 86 Gy to intraprostatic lesion (IPL) using the simultaneous-integrated boost (SIB) technique, and those treated with SIB alone. MATERIALS AND METHODS A retrospective analysis of 320 IR-PC patients treated between January 2012 and April 2021 was performed. Patients were divided into three groups based on their treatment arm: 78 + ADT (109 patients, 34.1%), 78/86 (102 patients, 31.8%), and 78/86 + ADT. Univariable and multivariable analyses were used to determine prognostic factors for FFBF and PCSS. RESULTS Median follow-up was 8.8 years. The 8-year FFBF and PCSS rates were 88.6% and 99.0%. Patients who received ADT had significantly higher pretreatment PSA levels and clinical tumor stage. Disease progression occurred in 45 patients (7.3%) at a median of 41.9 months after definitive radiotherapy (RT). Younger age, positive core biopsy (PCB) ≥ 50%, and the absence of ADT were all independent predictors of poor FFBF in multivariate analysis, whereas patients with PCB < 50% who were also given ADT had better PCSS. Patients treated with 78/86 Gy alone had worse FFBF than those treated with 78 Gy and ADT (Hazard ratio [HR] = 3.39 [95% CI = 1.46-7.88]; p = 0.005), as well as than those treated with 78/86 Gy and ADT (HR = 3.21 [95% CI = 1.23-6.46]; p = 0.009). However, FB to IPL has no effect on PCSS in multivariable analysis. There was no significant difference between treatment groups in terms of acute and late Grade ≥2 genitourinary or gastrointestinal toxicity. CONCLUSIONS Our findings demonstrated that patients who received 78/86 alone did worse than patients who received ADT with either 78 or 78/86 Gy. However, because IR-PC patients are so diverse, additional prospective trials are needed to validate our findings.
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Affiliation(s)
- Cem Onal
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Turkey
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Ozan Cem Guler
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Turkey
| | - Gurcan Erbay
- Department of Radiology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Turkey
| | - Aysenur Elmali
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Ankara, Turkey
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4
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Bonde TM, Garmo H, Stattin P, Nilsson P, Gunnlaugsson A, Swanberg D, Robinson D. Risk of prostate cancer death after radical radiotherapy with neoadjuvant and adjuvant therapy with bicalutamide or gonadotropin-releasing hormone agonists. Acta Oncol 2023; 62:1815-1821. [PMID: 37850633 DOI: 10.1080/0284186x.2023.2269600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/06/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Oncological outcome after radical radiotherapy (RRT) combined with neoadjuvant and adjuvant androgen suppression therapy (AST) may differ according to type of AST. The aim of this nationwide register-based study was to investigate risk of prostate cancer (Pca) death after different neoadjuvant and adjuvant ASTs; (i) bicalutamide, (ii) gonadotropin-releasing hormone agonists (GnRH) or (iii) combined bicalutamide and GnRH (CAB), together with RRT. MATERIALS AND METHODS Data for 6882 men diagnosed with high-risk Pca between 2007 and 2020 and treated with primary RRT was retrieved from Prostate Cancer data Base Sweden (PCBaSe) 5.0. Time to Pca death according to type of neoadjuvant and adjuvant AST was assessed by use of Kaplan-Meier plots and Cox proportional hazard models adjusted for putative confounders. RESULTS Data were stratified by RRT type since the effect of AST in risk of Pca death differed according to type of RRT. Compared with the reference RRT combined with neoadjuvant CAB/adjuvant GnRH, risk of Pca death for men treated with CAB/bicalutamide and conventionally fractionated external beam radiotherapy (CF-EBRT) was hazard ratio (HR) 0.73 (95% CI: 0.50-1.04), hypofractionated EBRT (HF-EBRT), HR 1.35 (95% CI: 0.65-2.81) and EBRT with high dose rate brachytherapy (EBRT-HDRBT), HR 0.85 (95% CI: 0.37-1.95). Risk of Pca death for men treated with bicalutamide/bicalutamide and: (i) CF-EBRT was HR 2.35 (95% CI: 1.42-3.90), (ii) HF-EBRT, HR 0.70 (95% CI: 0.26-1.85), (iii) HF-EBRT, HR 4.07 (95% CI: 1.88-8.77) vs the reference. CONCLUSION In this observational study, risk of Pca death between men receiving different combinations of AST varied according to RRT type. No difference was found in risk of Pca death for men treated with bicalutamide or GnRH as adjuvant therapy to RRT following neoadjuvant CAB. Risk of Pca death was increased for men with monotherapy neo-/adjuvant bicalutamide in combination with CF-EBRT or EBRT-HDRBT.
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Affiliation(s)
- Tiago M Bonde
- Department of Urology, Ryhov Hospital, Jönköping, Sweden
| | - Hans Garmo
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Nilsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund University, Sweden
| | - Adalsteinn Gunnlaugsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund University, Sweden
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5
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Gómez-Aparicio MA, López-Campos F, Lozano AJ, Maldonado X, Caballero B, Zafra J, Suarez V, Moreno E, Arcangeli S, Scorsetti M, Couñago F. Novel Approaches in the Systemic Management of High-Risk Prostate Cancer. Clin Genitourin Cancer 2023; 21:e485-e494. [PMID: 37453915 DOI: 10.1016/j.clgc.2023.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/18/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023]
Abstract
Locally advanced prostate cancer comprises approximately 20% of new prostate cancer diagnoses. For these patients, international guidelines recommend treatment with radiotherapy (RT) to the prostate in combination with long-term (2-3 years) androgen deprivation therapy (ADT), or radical prostatectomy in combination with extended pelvic lymph node dissection (PLND) as another treatment option for selected patients as part of multimodal therapy. Improvements in overall survival with docetaxel or an androgen receptor signaling inhibitor have been achieved in patients with metastatic castration sensitive or castration resistant prostate cancer. However, the role of systemic therapy combinations for high risk and/or unfavorable prostate cancer is unclear. In this context, the aim of this review is to assess the current evidence for systemic treatment combinations as part of primary definitive therapy in patients with high-risk localized prostate cancer.
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Affiliation(s)
| | - Fernando López-Campos
- Department of Radiation Oncology, Hospital Universitario Ramon y Cajal, Madrid, Spain.
| | - Antonio José Lozano
- Department of Radiation Oncology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Xavier Maldonado
- Department of Radiation Oncology, Hospital Vall d´Hebron, Barcelona, Spain
| | - Begoña Caballero
- Department of Radiation Oncology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Juan Zafra
- Department of Radiation Oncology, Hospital Virgen de la Victoria, Malaga, Spain
| | - Vladamir Suarez
- Department of Radiation Oncology, GenesisCare Malaga, Malaga, Spain
| | - Elena Moreno
- Department of Radiation Oncology, GenesisCare Madrid, Madrid, Spain
| | - Stefano Arcangeli
- Department of Radiation Oncology, University of Milan, Bicocca, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Felipe Couñago
- Department of Radiation Oncology, GenesisCare Madrid, Madrid, Spain; Department of Radiation Oncology, GenesisCare Madrid Clinical Director, Hospital San Francisco de Asís and Hospital Vithas La Milagrosa, National Chair of Research and Clinical Trials, GenesisCare, Madrid, Spain
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6
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Roy S, Kishan AU, Morgan SC, Martinka L, Spratt DE, Sun Y, Malone J, Grimes S, Citrin DE, Malone S. Association of PSA kinetics after testosterone recovery with subsequent recurrence: secondary analysis of a phase III randomized controlled trial. World J Urol 2023; 41:3905-3911. [PMID: 37792009 DOI: 10.1007/s00345-023-04635-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023] Open
Abstract
PURPOSE After cessation of androgen deprivation therapy (ADT), testosterone gradually recovers to supracastrate levels (> 50 ng/dL). After this, rises in prostate-specific antigen (PSA) are often seen. However, it remains unknown whether early PSA kinetics after testosterone recovery are associated with subsequent biochemical recurrence (BCR). METHODS We performed a secondary analysis of a phase III randomized controlled trial in which newly diagnosed localized prostate cancer patients were randomly allocated to ADT for 6 months starting 4 months prior to or simultaneously with prostate RT. We calculated the PSA doubling time (PSADT) based on PSA values up to 18 months after supracastrate testosterone recovery. Competing risk regression was used to evaluate the association of PSADT with relative incidence of BCR, considering deaths as competing events. RESULTS Overall, 313 patients were eligible. Median PSADT was 8 months. Cumulative incidence of BCR at 10 years from supracastrate testosterone recovery was 19% and 11% in patients with PSADT < 8 months and ≥ 8 months (p = 0.03). Compared to patients with PSADT of < 4 months, patients with higher PSADT (sHR for PSADT 4 to < 8 months: 0.36 [95% CI 0.16-0.82]; 8 to < 12 months: 0.26 [0.08-0.91]; ≥ 12 months: 0.20 [0.07-0.56]) had lower risk of relative incidence of BCR. CONCLUSIONS Early PSA kinetics, within 18 months of recovery of testosterone to a supracastrate level, can predict for subsequent BCR. Taking account of early changes in PSA after testosterone recovery may allow for recognition of potential failures earlier in the disease course and thereby permit superior personalization of treatment.
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Affiliation(s)
- Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, 500 S Paulina St, Atrium Bldg, A-013, Chicago, IL, 60605, USA.
| | - Amar U Kishan
- Department of Radiation Oncology, UCLA, Los Angeles, CA, USA
| | - Scott C Morgan
- Division of Radiation Oncology, Department of Radiology, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Levi Martinka
- Rush Medical College, Rush University Medical Center, Chicago, IL, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, UH-Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Yilun Sun
- Department of Biostatistics, Case Western Reserve University, Cleveland, OH, USA
| | - Julia Malone
- Division of Radiation Oncology, Department of Radiology, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Scott Grimes
- Division of Radiation Oncology, Department of Radiology, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Deborah E Citrin
- Radiation Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Shawn Malone
- Division of Radiation Oncology, Department of Radiology, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
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7
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Allen SG, Zhang C, Malone S, Roy S, Dess RT, Jackson WC, Mehra R, Speers C, Chinnaiyan AM, Sun Y, Spratt DE. Impact of sequencing of androgen receptor-signaling inhibition and radiotherapy in prostate cancer: importance of homologous recombination disruption. World J Urol 2023; 41:3877-3887. [PMID: 37851053 DOI: 10.1007/s00345-023-04649-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/18/2023] [Indexed: 10/19/2023] Open
Abstract
PURPOSE The synergy of combining androgen receptor-signaling inhibition (ARSI) to radiotherapy (RT) in prostate cancer has been largely attributed to non-homologous end joining (NHEJ) inhibition. However, this mechanism is unlikely to explain recently observed trial results that demonstrated the sequencing of ARSI and RT significantly impacts clinical outcomes, with adjuvant ARSI following RT yielding superior outcomes to neoadjuvant/concurrent therapy. We hypothesized this is driven by differential effects on AR-signaling and alternative DNA repair pathway engagement based on ARSI/RT sequencing. METHODS We explored the effects of ARSI sequencing with RT (neoadjuvant vs concurrent vs adjuvant) in multiple prostate cancer cell lines using androgen-deprived media and validation with the anti-androgen enzalutamide. The effects of ARSI sequencing were measured with clonogenic assays, AR-target gene transcription and translation quantification, cell cycle analysis, DNA damage and repair assays, and xenograft animal validation studies. RESULTS Adjuvant ARSI after RT was significantly more effective at killing colony forming cells and decreasing the transcription and translation of downstream AR-target genes across all prostate cancer models evaluated. These results were reproduced in xenograft studies. The differential effects of ARSI sequencing were not fully explained by NHEJ inhibition alone, but by the additional disruption of homologous recombination specifically with adjuvant sequencing of ARSI. CONCLUSION We demonstrate that altered sequencing of ARSI and RT mediates differential anti-AR-signaling and anti-cancer effects, with the greatest benefit from adjuvant ARSI following RT. These results, combined with our prior clinical findings, support the superiority of an adjuvant-based sequencing approach when using ARSI with RT.
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Affiliation(s)
- Steven G Allen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Chao Zhang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Shawn Malone
- Department of Radiation Oncology, The Ottawa Hospital Cancer Center, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Soumyajit Roy
- Department of Radiation Oncology, The Ottawa Hospital Cancer Center, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Rohit Mehra
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Corey Speers
- Department of Radiation Oncology, UH Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Arul M Chinnaiyan
- Rogel Cancer Center and Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Yilun Sun
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, UH Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA.
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8
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Roy S, Romero T, Michalski JM, Feng FY, Efstathiou JA, Lawton CA, Bolla M, Maingon P, de Reijke T, Joseph D, Ong WL, Sydes MR, Dearnaley DP, Tree AC, Carrier N, Nabid A, Souhami L, Incrocci L, Heemsbergen WD, Pos FJ, Zapatero A, Guerrero A, Alvarez A, San-Segundo CG, Maldonado X, Reiter RE, Rettig MB, Nickols NG, Steinberg ML, Valle LF, Ma TM, Farrell MJ, Neilsen BK, Juarez JE, Deng J, Vangala S, Avril N, Jia AY, Zaorsky NG, Sun Y, Spratt D, Kishan AU. Biochemical Recurrence Surrogacy for Clinical Outcomes After Radiotherapy for Adenocarcinoma of the Prostate. J Clin Oncol 2023; 41:5005-5014. [PMID: 37639648 PMCID: PMC10642893 DOI: 10.1200/jco.23.00617] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/30/2023] [Accepted: 07/12/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE The surrogacy of biochemical recurrence (BCR) for overall survival (OS) in localized prostate cancer remains controversial. Herein, we evaluate the surrogacy of BCR using different surrogacy analytic methods. MATERIALS AND METHODS Individual patient data from 11 trials evaluating radiotherapy dose escalation, androgen deprivation therapy (ADT) use, and ADT prolongation were obtained. Surrogate candidacy was assessed using the Prentice criteria (including landmark analyses) and the two-stage meta-analytic approach (estimating Kendall's tau and the R2). Biochemical recurrence-free survival (BCRFS, time from random assignment to BCR or any death) and time to BCR (TTBCR, time from random assignment to BCR or cancer-specific deaths censoring for noncancer-related deaths) were assessed. RESULTS Overall, 10,741 patients were included. Dose escalation, addition of short-term ADT, and prolongation of ADT duration significantly improved BCR (hazard ratio [HR], 0.71 [95% CI, 0.63 to 0.79]; HR, 0.53 [95% CI, 0.48 to 0.59]; and HR, 0.54 [95% CI, 0.48 to 0.61], respectively). Adding short-term ADT (HR, 0.91 [95% CI, 0.84 to 0.99]) and prolonging ADT (HR, 0.86 [95% CI, 0.78 to 0.94]) significantly improved OS, whereas dose escalation did not (HR, 0.98 [95% CI, 0.87 to 1.11]). BCR at 48 months was associated with inferior OS in all three groups (HR, 2.46 [95% CI, 2.08 to 2.92]; HR, 1.51 [95% CI, 1.35 to 1.70]; and HR, 2.31 [95% CI, 2.04 to 2.61], respectively). However, after adjusting for BCR at 48 months, there was no significant treatment effect on OS (HR, 1.10 [95% CI, 0.96 to 1.27]; HR, 0.96 [95% CI, 0.87 to 1.06] and 1.00 [95% CI, 0.90 to 1.12], respectively). The patient-level correlation (Kendall's tau) for BCRFS and OS ranged between 0.59 and 0.69, and that for TTBCR and OS ranged between 0.23 and 0.41. The R2 values for trial-level correlation of the treatment effect on BCRFS and TTBCR with that on OS were 0.563 and 0.160, respectively. CONCLUSION BCRFS and TTBCR are prognostic but failed to satisfy all surrogacy criteria. Strength of correlation was greater when noncancer-related deaths were considered events.
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Affiliation(s)
- Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL
| | - Tahmineh Romero
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University, St Louis, MO
| | - Felix Y. Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Colleen A.F. Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Michel Bolla
- Radiotherapy Department, University Hospital, Grenoble, France
| | - Philippe Maingon
- Department of Oncology, Hematology, and Supportive Care, Sorbonne University, Paris, France
| | - Theo de Reijke
- Department of Urology, Prostate Cancer Network in the Netherlands, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, WA, Australia
| | - Wee Loon Ong
- Alfred Health Radiation Oncology, Monash University, Melbourne, VIC, Australia
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - David P. Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Department of Urology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C. Tree
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Nathalie Carrier
- Clinical Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, QC, Canada
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wilma D. Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Floris J. Pos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | | | - Ana Alvarez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Robert E. Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA
| | - Matthew B. Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, CA
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Luca F. Valle
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - T. Martin Ma
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Matthew J. Farrell
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Beth K. Neilsen
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jesus E. Juarez
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jie Deng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Sitaram Vangala
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Norbert Avril
- Department of Radiology, Division of Nuclear Medicine, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Angela Y. Jia
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Yilun Sun
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Daniel Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
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9
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Gallagher L, Xiao J, Hsueh J, Shah S, Danner M, Zwart A, Ayoob M, Yung T, Simpson T, Fallick M, Kumar D, Leger P, Dawson NA, Suy S, Collins SP. Early biochemical outcomes following neoadjuvant/adjuvant relugolix with stereotactic body radiation therapy for intermediate to high risk prostate cancer. Front Oncol 2023; 13:1289249. [PMID: 37916156 PMCID: PMC10616590 DOI: 10.3389/fonc.2023.1289249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Injectable GnRH receptor agonists have been shown to improve cancer control when combined with radiotherapy. Prostate SBRT offers an abbreviated treatment course with comparable efficacy to conventionally fractionated radiotherapy. Relugolix is a new oral GnRH receptor antagonist which achieves rapid, sustained testosterone suppression. This prospective study sought to evaluate early testosterone suppression and PSA response following relugolix and SBRT for intermediate to high prostate cancer. Methods Relugolix was initiated at least 2 months prior to SBRT. Interventions to improve adherence were not utilized. PSA and total testosterone levels were obtained prior to and 1-4 months post SBRT. Profound castration was defined as serum testosterone ≤ 20 ng/dL. Early PSA nadir was defined as the lowest PSA value within 4 months of completion of SBRT. Per prior trials, we examined the percentage of patients who achieved PSA level of ≤ 0.5 ng/mL and ≤ 0.2 ng/mL during the first 4 months post SBRT. Results Between July 2021 and January 2023, 52 men were treated at Georgetown with relugolix (4-6 months) and SBRT (36.25-40 Gy in 5 fractions) per an institutional protocol (IRB 12-1775). Median age was 71 years. 26.9% of patients were African American and 28.8% were obese (BMI ≥30 kg/m2). The median pretreatment PSA was 9.1 ng/ml. 67% of patients were ≥ Grade Group 3. 44 patients were intermediate- and 8 were high-risk. Patients initiated relugolix at a median of 3.6 months prior to SBRT with a median duration of 6.2 total months. 92.3% of patients achieved profound castration during relugolix treatment. Poor drug adherence was observed in 2 patients. A third patient chose to discontinue relugolix due to side effects. By post-SBRT month 4, 87.2% and 74.4% of patients achieved PSA levels ≤ 0.5 ng/ml and ≤ 0.2 ng/ml, respectively. Discussion Relugolix combined with SBRT allows for high rates of profound castration with low early PSA nadirs. We observed a 96% testosterone suppresion rate without the utilization of scheduled cues/reminders. This finding supports the notion that patients with localized prostate cancer can consistently and successfully follow an oral ADT protocol without daily reminders. Given relugolix's potential benefits over injectable GnRH receptor agonists, its usage may be preferred in specific patient populations (fear of needles, prior cardiovascular events). Future studies should focus on boundaries to adherence in specific underserved populations.
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Affiliation(s)
- Lindsey Gallagher
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Jerry Xiao
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Jessica Hsueh
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sarthak Shah
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Alan Zwart
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Tiffany Simpson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Mark Fallick
- Medical Science Department, Myovant Sciences, Inc, United States
| | - Deepak Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Paul Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Nancy A. Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P. Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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10
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Tanaka N. The oncologic and safety outcomes of low-dose-rate brachytherapy for the treatment of prostate cancer. Prostate Int 2023; 11:127-133. [PMID: 37745911 PMCID: PMC10513906 DOI: 10.1016/j.prnil.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023] Open
Abstract
Around 40 years have passed since a modern low-dose-rate (LDR) brachytherapy for prostate cancer was introduced. LDR brachytherapy has become one of the definitive treatment options besides radical prostatectomy (RP) and external beam radiation therapy (EBRT). LDR brachytherapy has several advantages over EBRT such as a higher prescribed dose to the prostate gland while avoiding unnecessary irradiation of organs at risk, a precipitous dose gradient, a brief treatment time, and a short hospital stay. Previous reports revealed that the long-term oncologic outcomes of LDR brachytherapy are superior to those of EBRT. The oncologic outcomes of low- to intermediate-risk patients are equivalent to those of RP using the recurrence definition of surgery of prostate specific antigen (PSA) >0.2 ng/mL, while the oncologic outcomes of LDR brachytherapy as tri-modality (combined EBRT and androgen deprivation therapy) for high-risk patients is superior to that of RP using the recurrence definition of surgery. In respect of toxicity, urinary disorders such as urgency and frequency are often observed after the acute phase of treatment, but these events usually resolve, while the quality of life of urinary continence is well preserved for a long time. Erectile function decreases yearly, but is relatively preserved compared to RP. In conclusion, the most noteworthy strength of LDR brachytherapy for low- to intermediate-risk patients is the "brief treatment time" that provides long recurrence-free survival, while that for high-risk patients who received LDR brachytherapy (tri-modality) is "excellent disease control."
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Affiliation(s)
- Nobumichi Tanaka
- Department of Prostate Brachytherapy, Nara Medical University, Japan
- Department of Urology, Nara Medical University, Japan
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11
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Rivero Belenchón I, Congregado Ruiz CB, Saez C, Osman García I, Medina López RA. Parp Inhibitors and Radiotherapy: A New Combination for Prostate Cancer (Systematic Review). Int J Mol Sci 2023; 24:12978. [PMID: 37629155 PMCID: PMC10455664 DOI: 10.3390/ijms241612978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
PARPi, in combination with ionizing radiation, has demonstrated the ability to enhance cellular radiosensitivity in different tumors. The rationale is that the exposure to radiation leads to both physical and biochemical damage to DNA, prompting cells to initiate three primary mechanisms for DNA repair. Two double-stranded DNA breaks (DSB) repair pathways: (1) non-homologous end-joining (NHEJ) and (2) homologous recombination (HR); and (3) a single-stranded DNA break (SSB) repair pathway (base excision repair, BER). In this scenario, PARPi can serve as radiosensitizers by leveraging the BER pathway. This mechanism heightens the likelihood of replication forks collapsing, consequently leading to the formation of persistent DSBs. Together, the combination of PARPi and radiotherapy is a potent oncological strategy. This combination has proven its efficacy in different tumors. However, in prostate cancer, there are only preclinical studies to support it and, recently, an ongoing clinical trial. The objective of this paper is to perform a review of the current evidence regarding the use of PARPi and radiotherapy (RT) in PCa and to give future insight on this topic.
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Affiliation(s)
- Inés Rivero Belenchón
- Urology and Nephrology Department, University Hospital Virgen del Rocío, 41013 Seville, Spain; (I.O.G.); (R.A.M.L.)
- Biomedical Institute of Seville (IBIS), 41013 Seville, Spain;
| | - Carmen Belen Congregado Ruiz
- Urology and Nephrology Department, University Hospital Virgen del Rocío, 41013 Seville, Spain; (I.O.G.); (R.A.M.L.)
- Biomedical Institute of Seville (IBIS), 41013 Seville, Spain;
| | - Carmen Saez
- Biomedical Institute of Seville (IBIS), 41013 Seville, Spain;
| | - Ignacio Osman García
- Urology and Nephrology Department, University Hospital Virgen del Rocío, 41013 Seville, Spain; (I.O.G.); (R.A.M.L.)
- Biomedical Institute of Seville (IBIS), 41013 Seville, Spain;
| | - Rafael Antonio Medina López
- Urology and Nephrology Department, University Hospital Virgen del Rocío, 41013 Seville, Spain; (I.O.G.); (R.A.M.L.)
- Biomedical Institute of Seville (IBIS), 41013 Seville, Spain;
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12
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Achard V, Peyrottes A, Sargos P. How To Manage T3b Prostate Cancer in the Contemporary Era: Is Radiotherapy the Standard of Care? EUR UROL SUPPL 2023; 53:60-62. [PMID: 37287636 PMCID: PMC10241847 DOI: 10.1016/j.euros.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/09/2023] Open
Affiliation(s)
- Vérane Achard
- Department of Radiation Oncology, HFR Fribourg, Villars-sur-Glâne, Switzerland
| | - Arthur Peyrottes
- Department of Urology, Hôpital européen Georges-Pompidou, AP-HP, Paris, France
| | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonie, Bordeaux, France
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13
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Cartes R, Karim MU, Tisseverasinghe S, Tolba M, Bahoric B, Anidjar M, McPherson V, Probst S, Rompré-Brodeur A, Niazi T. Neoadjuvant versus Concurrent Androgen Deprivation Therapy in Localized Prostate Cancer Treated with Radiotherapy: A Systematic Review of the Literature. Cancers (Basel) 2023; 15:3363. [PMID: 37444473 DOI: 10.3390/cancers15133363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND There is an ongoing debate on the optimal sequencing of androgen deprivation therapy (ADT) and radiotherapy (RT) in patients with localized prostate cancer (PCa). Recent data favors concurrent ADT and RT over the neoadjuvant approach. METHODS We conducted a systematic review in PubMed, EMBASE, and Cochrane Databases assessing the combination and optimal sequencing of ADT and RT for Intermediate-Risk (IR) and High-Risk (HR) PCa. FINDINGS Twenty randomized control trials, one abstract, one individual patient data meta-analysis, and two retrospective studies were selected. HR PCa patients had improved survival outcomes with RT and ADT, particularly when a long-course Neoadjuvant-Concurrent-Adjuvant ADT was used. This benefit was seen in IR PCa when adding short-course ADT, although less consistently. The best available evidence indicates that concurrent over neoadjuvant sequencing is associated with better metastases-free survival at 15 years. Although most patients had IR PCa, HR participants may have been undertreated with short-course ADT and the absence of pelvic RT. Conversely, retrospective data suggests a survival benefit when using the neoadjuvant approach in HR PCa patients. INTERPRETATION The available literature supports concurrent ADT and RT initiation for IR PCa. Neoadjuvant-concurrent-adjuvant sequencing should remain the standard approach for HR PCa and is an option for IR PCa.
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Affiliation(s)
- Rodrigo Cartes
- Department of Radiation Oncology, McGill University, Montreal, QC H3A 0G4, Canada
| | - Muneeb Uddin Karim
- Department of Radiation Oncology, McGill University, Montreal, QC H3A 0G4, Canada
| | | | - Marwan Tolba
- Department of Radiation Oncology, Dalhousie University, and Nova Scotia Health Authority, Sydney, NS B1P 1P3, Canada
| | - Boris Bahoric
- Department of Radiation Oncology, McGill University, Montreal, QC H3A 0G4, Canada
| | - Maurice Anidjar
- Department of Urology, McGill University, Montreal, QC H3A 0G4, Canada
| | - Victor McPherson
- Department of Urology, McGill University, Montreal, QC H3A 0G4, Canada
| | - Stephan Probst
- Department of Nuclear Medicine, McGill University, Montreal, QC H3A 0G4, Canada
| | | | - Tamim Niazi
- Department of Radiation Oncology, McGill University, Montreal, QC H3A 0G4, Canada
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14
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Krauss DJ, Karrison T, Martinez AA, Morton G, Yan D, Bruner DW, Movsas B, Elshaikh M, Citrin D, Hershatter B, Michalski JM, Efstathiou JA, Currey A, Kavadi VS, Cury FL, Lock M, Raben A, Seaward SA, El-Gayed A, Rodgers JP, Sandler HM. Dose-Escalated Radiotherapy Alone or in Combination With Short-Term Androgen Deprivation for Intermediate-Risk Prostate Cancer: Results of a Phase III Multi-Institutional Trial. J Clin Oncol 2023; 41:3203-3216. [PMID: 37104748 PMCID: PMC10489479 DOI: 10.1200/jco.22.02390] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/18/2023] [Accepted: 02/28/2023] [Indexed: 04/29/2023] Open
Abstract
PURPOSE It remains unknown whether or not short-term androgen deprivation (STAD) improves survival among men with intermediate-risk prostate cancer (IRPC) treated with dose-escalated radiotherapy (RT). METHODS The NRG Oncology/Radiation Therapy Oncology Group 0815 study randomly assigned 1,492 patients with stage T2b-T2c, Gleason score 7, or prostate-specific antigen (PSA) value >10 and ≤20 ng/mL to dose-escalated RT alone (arm 1) or with STAD (arm 2). STAD was 6 months of luteinizing hormone-releasing hormone agonist/antagonist therapy plus antiandrogen. RT modalities were external-beam RT alone to 79.2 Gy or external beam (45 Gy) with brachytherapy boost. The primary end point was overall survival (OS). Secondary end points included prostate cancer-specific mortality (PCSM), non-PCSM, distant metastases (DMs), PSA failure, and rates of salvage therapy. RESULTS Median follow-up was 6.3 years. Two hundred nineteen deaths occurred, 119 in arm 1 and 100 in arm 2. Five-year OS estimates were 90% versus 91%, respectively (hazard ratio [HR], 0.85; 95% CI, 0.65 to 1.11]; P = .22). STAD resulted in reduced PSA failure (HR, 0.52; P <.001), DM (HR, 0.25; P <.001), PCSM (HR, 0.10; P = .007), and salvage therapy use (HR, 0.62; P = .025). Other-cause deaths were not significantly different (P = .56). Acute grade ≥3 adverse events (AEs) occurred in 2% of patients in arm 1 and in 12% for arm 2 (P <.001). Cumulative incidence of late grade ≥3 AEs was 14% in arm 1 and 15% in arm 2 (P = .29). CONCLUSION STAD did not improve OS rates for men with IRPC treated with dose-escalated RT. Improvements in metastases rates, prostate cancer deaths, and PSA failures should be weighed against the risk of adverse events and the impact of STAD on quality of life.
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Affiliation(s)
| | - Theodore Karrison
- NRG Oncology Statistics and Data Management Center, University of Chicago, Chicago, IL
| | | | - Gerard Morton
- Toronto-Sunnybrook Regional Cancer Center, Toronto, ON, Canada
| | - Di Yan
- Corewell Health Beaumont University Hospital, Royal Oak, MI
| | | | | | | | | | | | | | | | - Adam Currey
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI
| | | | - Fabio L. Cury
- McGill University Health Center, Montreal, QC, Canada
| | - Michael Lock
- London Regional Cancer Program, London, ON, Canada
| | - Adam Raben
- Delaware/Christiana Care NCI Community Oncology Research Program, Newark, DE
- Milwaukee Veterans Administration Medical Center, Milwaukee, WI
| | | | | | - Joseph P. Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
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15
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Farzat M, Weib P, Sukhanov I, Rosenbauer J, Tanislav C, Wagenlehner FM. Effect of Neoadjuvant Hormonal Therapy on the Postoperative Course for Patients Undergoing Robot-Assisted Radical Prostatectomy. J Clin Med 2023; 12:jcm12093053. [PMID: 37176494 PMCID: PMC10179004 DOI: 10.3390/jcm12093053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVES Neoadjuvant hormonal therapy (NHT) preceding robot-assisted radical prostatectomy (RARP) may be beneficial in high-risk cases to facilitate surgical resection. Yet, its improvement in local tumor control is not obvious. Its benefit regarding overall cancer survival is also not evident, and it may worsen sexual and hormonal functions. This study explores the effect of NHT on the perioperative course after RARP. METHODS In this study, 500 patients from a tertiary referral center who underwent RARP by a specialized surgeon were retrospectively included. Patients were divided into two groups: the NHT (n = 55, 11%) group, which included patients who received NHT (median: 1 month prior to RARP), and the standard non-NHT (NNHT) group (n = 445, 89%). Demographic and perioperative data were analyzed. Postoperative results, complications, and readmission rates were compared between the groups. RESULTS NHT patients were heterogeneous from the rest regarding cancer parameters such as PSA (25 vs. 7.8 ng/mL) and tumor risk stratification, and they were more comorbid (p = 0.006 for the ASA score). They also received fewer nerve-sparing procedures (14.5% vs. 80.4%), while the operation time was similar. Positive surgical margins (PSM) (21.8% vs. 5.4%) and positive lymph nodes (PLN) (56.4% vs. 12.7%) were significantly higher in the NHT group compared to the non-NHT (NNHT) group. Hospital stay was equal, whereas catheter days were 3 days longer in the NHT group. NHT patients also suffered more minor vesicourethral-anastomosis-related complications. Major complications (p = 0.825) and readmissions (p = 0.070) did not differ between groups. CONCLUSION Patients receiving NHT before RARP did not experience more major complications or readmissions within 90 days after surgery. Patients with unfavorable, high-risk tumors may benefit from NHT since it facilitates surgical resection. Randomized controlled trials are necessary to measure the advantages and disadvantages of NHT.
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Affiliation(s)
- Mahmoud Farzat
- Department of Urology and Robotic Urology, Diakonie Klinikum Siegen, Academic Teaching Hospital of the University of Bonn, 57074 Siegen, Germany
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, 35392 Giessen, Germany
| | - Peter Weib
- Department of Urology and Robotic Urology, Diakonie Klinikum Siegen, Academic Teaching Hospital of the University of Bonn, 57074 Siegen, Germany
| | - Iurii Sukhanov
- Department of Urology and Robotic Urology, Diakonie Klinikum Siegen, Academic Teaching Hospital of the University of Bonn, 57074 Siegen, Germany
| | - Josef Rosenbauer
- Department of Geriatric and Neurology, Diakonie Klinkum Siegen, Academic Teaching Hospital of the University of Bonn, 57074 Siegen, Germany
| | - Christian Tanislav
- Department of Geriatric and Neurology, Diakonie Klinkum Siegen, Academic Teaching Hospital of the University of Bonn, 57074 Siegen, Germany
| | - Florian M Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, 35392 Giessen, Germany
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16
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Kord E, Ferenczi B, DiNatale RG, Daily A, Koenig H, Frankel J, Jung N, Flores JP, Porter C. Are high-risk prostate cancer patients being treated equally? The impact of PSA. Urol Oncol 2023; 41:204.e17-204.e25. [PMID: 36918337 DOI: 10.1016/j.urolonc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/27/2022] [Accepted: 01/09/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Patients with high-risk (HR) prostate cancer (PCa) represent a heterogeneous group, however, current treatment guidelines do not consider their specific features. The objective of this study was to evaluate treatment trends and outcomes in HR patients defined by PSA alone and otherwise low-risk features. METHODS Using the National Cancer Database, we identified patients diagnosed with HR PCa between 2010 and 2016. A study group of patients defined by PSA >20 ng/ml alone and otherwise low-risk features, was compared to a group of HR patients defined by Gleason score or stage. We compared treatment rates over time, the use of concomitant androgen deprivation therapy (ADT), and overall survival (OS). Examination of treatment trends was done using a Z-test analysis. A Kaplan-Meier survival analysis was used to determine 5-year OS with the Log-rank test for comparison. Statistical analyses were completed using R Version 3.5.2. RESULTS We identified 5,652 patients in the study group and 71,922 in the comparison group. Only 6.8% of the study group had disease ≥cT2, compared to 43.7% in the comparison group. In the study group, 12.5% (709), underwent active surveillance (AS), 36.4% (2,055) radiation therapy (EBRT) and 51.1% (2,888) radical prostatectomy (RP), while the rate of AS, EBRT, and RP in the comparison group were 0.3% (191), 43.0% (30,928), and 56.7% (40,803), respectively. Over the study period, adoption of AS increased from 6.2% in 2010 to 25.0% in 2016 in the study group (P< 0.001), but not in the comparison group. In patients undergoing EBRT, ADT treatment increased from 2010 to 2016 in both groups, though by 2016 only 45.3% of patients in the study group and 86.3% in the comparison group received ADT. The 5-year OS was 93.7% (95% CI 92.8-94.6) in the study group and 89.7% (95% CI 89.2-90.1) in the comparison group (P< 0.001). CONCLUSIONS Men with HR PCa defined by PSA with otherwise low risk features present at an earlier stage and receive less aggressive therapy than other HR patients. Despite increased rates of AS and decreased use of ADT, these patients appear to have improved survival when compared to other HR patients. These findings suggest that not all HR patients will benefit from aggressive definitive treatment.
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Affiliation(s)
- Eyal Kord
- Virginia Mason Franciscan Health, Section of Urology, Seattle WA
| | - Basil Ferenczi
- Virginia Mason Franciscan Health, Section of Urology, Seattle WA
| | - Renzo G DiNatale
- Virginia Mason Franciscan Health, Section of Urology, Seattle WA
| | - Adam Daily
- Virginia Mason Franciscan Health, Section of Urology, Seattle WA
| | - Hannah Koenig
- Virginia Mason Franciscan Health, Section of Urology, Seattle WA
| | - Jason Frankel
- Virginia Mason Franciscan Health, Section of Urology, Seattle WA
| | - Nathan Jung
- Virginia Mason Franciscan Health, Section of Urology, Seattle WA
| | - John Paul Flores
- Virginia Mason Franciscan Health, Section of Urology, Seattle WA
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17
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Ma TM, Sun Y, Malone S, Roach M, Dearnaley D, Pisansky TM, Feng FY, Sandler HM, Efstathiou JA, Syndikus I, Hall EC, Tree AC, Sydes MR, Cruickshank C, Roy S, Bolla M, Maingon P, De Reijke T, Nabid A, Carrier N, Souhami L, Zapatero A, Guerrero A, Alvarez A, Gonzalez San-Segundo C, Maldonado X, Romero T, Steinberg ML, Valle LF, Rettig MB, Nickols NG, Shoag JE, Reiter RE, Zaorsky NG, Jia AY, Garcia JA, Spratt DE, Kishan AU. Sequencing of Androgen-Deprivation Therapy of Short Duration With Radiotherapy for Nonmetastatic Prostate Cancer (SANDSTORM): A Pooled Analysis of 12 Randomized Trials. J Clin Oncol 2023; 41:881-892. [PMID: 36269935 PMCID: PMC9902004 DOI: 10.1200/jco.22.00970] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/24/2022] [Accepted: 08/17/2022] [Indexed: 02/01/2023] Open
Abstract
PURPOSE The sequencing of androgen-deprivation therapy (ADT) with radiotherapy (RT) may affect outcomes for prostate cancer in an RT-field size-dependent manner. Herein, we investigate the impact of ADT sequencing for men receiving ADT with prostate-only RT (PORT) or whole-pelvis RT (WPRT). MATERIALS AND METHODS Individual patient data from 12 randomized trials that included patients receiving neoadjuvant/concurrent or concurrent/adjuvant short-term ADT (4-6 months) with RT for localized disease were obtained from the Meta-Analysis of Randomized trials in Cancer of the Prostate consortium. Inverse probability of treatment weighting (IPTW) was performed with propensity scores derived from age, initial prostate-specific antigen, Gleason score, T stage, RT dose, and mid-trial enrollment year. Metastasis-free survival (primary end point) and overall survival (OS) were assessed by IPTW-adjusted Cox regression models, analyzed independently for men receiving PORT versus WPRT. IPTW-adjusted Fine and Gray competing risk models were built to evaluate distant metastasis (DM) and prostate cancer-specific mortality. RESULTS Overall, 7,409 patients were included (6,325 neoadjuvant/concurrent and 1,084 concurrent/adjuvant) with a median follow-up of 10.2 years (interquartile range, 7.2-14.9 years). A significant interaction between ADT sequencing and RT field size was observed for all end points (P interaction < .02 for all) except OS. With PORT (n = 4,355), compared with neoadjuvant/concurrent ADT, concurrent/adjuvant ADT was associated with improved metastasis-free survival (10-year benefit 8.0%, hazard ratio [HR], 0.65; 95% CI, 0.54 to 0.79; P < .0001), DM (subdistribution HR, 0.52; 95% CI, 0.33 to 0.82; P = .0046), prostate cancer-specific mortality (subdistribution HR, 0.30; 95% CI, 0.16 to 0.54; P < .0001), and OS (HR, 0.69; 95% CI, 0.57 to 0.83; P = .0001). However, in patients receiving WPRT (n = 3,049), no significant difference in any end point was observed in regard to ADT sequencing except for worse DM (HR, 1.57; 95% CI, 1.20 to 2.05; P = .0009) with concurrent/adjuvant ADT. CONCLUSION ADT sequencing exhibits a significant impact on clinical outcomes with a significant interaction with field size. Concurrent/adjuvant ADT should be the standard of care where short-term ADT is indicated in combination with PORT.
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Affiliation(s)
- Ting Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Yilun Sun
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Shawn Malone
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mack Roach
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - David Dearnaley
- Academic Urology Unit, Royal Marsden Hospital, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
| | | | - Felix Y. Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | | | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Isabel Syndikus
- Clatterbridge Cancer Centre, Bebington, Wirral, United Kingdom
| | - Emma C. Hall
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, United Kingdom
| | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | | | - Claire Cruickshank
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, United Kingdom
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL
| | - Michel Bolla
- Radiotherapy Department Grenoble, Grenoble Alpes University, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Philippe Maingon
- Sorbonne University, APHP Sorbonne University, La Pitié Salpêtrière, Paris, France
| | - Theo De Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitaler Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Nathalie Carrier
- Department of Radiation Oncology, Centre Hospitaler Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Luis Souhami
- Division of Radiation Oncology, McGill University Health Center, Montreal, Canada
| | - Almudena Zapatero
- Department of Radiation Oncology, University Hospital La Princesa, Health Research Institute, Madrid, Spain
| | | | - Ana Alvarez
- Department of Radiation Oncology, University Hospital Gregorio Maranon, Complutense University, Madrid, Spain
| | - Carmen Gonzalez San-Segundo
- Department of Radiation Oncology, University Hospital Gregorio Maranon, Complutense University, Madrid, Spain
| | | | - Tahmineh Romero
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, CA
| | | | - Luca F. Valle
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Matthew B. Rettig
- Department of Urology, University of California, Los Angeles, CA
- Department of Medicine, University of California Los Angeles, Los Angeles, CA
| | | | - Jonathan E. Shoag
- Department of Urology, University Hospitals Seidman Cancer Center, Cleveland Medical Center, Cleveland, OH
| | - Robert E. Reiter
- Department of Urology, University of California, Los Angeles, CA
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland Medical Center, Cleveland, OH
| | - Angela Y. Jia
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland Medical Center, Cleveland, OH
| | - Jorge A. Garcia
- Department of Hematology Oncology, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Daniel E. Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland Medical Center, Cleveland, OH
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA
- Department of Urology, University of California, Los Angeles, CA
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18
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Neoadjuvent androgen deprivation for seminal vesicle reduction: The optimal portion of seminal vesicle included in the high-dose CTV in localized prostate cancer radiotherapy. RADIATION MEDICINE AND PROTECTION 2023. [DOI: 10.1016/j.radmp.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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19
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Cardiovascular toxicities of androgen deprivation therapy in Asian men with localized prostate cancer after curative radiotherapy: a registry-based observational study. CARDIO-ONCOLOGY 2022; 8:4. [PMID: 35287756 PMCID: PMC8919574 DOI: 10.1186/s40959-022-00131-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/28/2022] [Indexed: 11/20/2022]
Abstract
Background Androgen deprivation therapy (ADT) and radiotherapy (RT) are the mainstay treatment for localized prostate cancer and recurrence after surgery. Cardiovascular (CV) toxicity of ADT is increasingly recognized, and the risk relates to pre-existing risk factors and ADT modalities. Despite ethnic differences in the prevalence of CV risk factors and variations of CV mortality, data on ADT-related cardiotoxicities in the Asian population remain inconclusive. Our registry-based study investigated ADT-related major adverse cardiovascular events (MACE) after primary or salvage RT. Methods Our study combined two prospectively established registry databases from National Cancer Center Singapore and National Heart Center Singapore. The primary endpoint is time to first MACE after treatment. MACE is defined as myocardial infarction, stroke, unstable angina, or cardiovascular death. Two types of propensity score adjustments, including ADT propensity score as a covariate in the multivariable regression model and propensity score weighting, were applied to balance baseline features and CV risk factors between RT alone and RT + ADT groups. Results From 2000 to 2019, 1940 patients received either RT alone (n = 494) or RT + ADT (n = 1446) were included. After a median follow-up of 10 years (RT) and 7.2 years (RT+ ADT), the cumulative incidence of MACE at 1, 3 and 9 years was 1.2, 5 and 16.2% in RT group, and 1.1, 5.2 and 17.6% in RT + ADT group, respectively. There were no differences in the incidence of MACE between 2 groups (HR 1.01, 95% CI 0.78–1.30, p = 0.969). Pre-treatment CV risk factors were common (80%), and CV disease (15.9%) was the second leading cause of death after prostate cancer (21.1%). On univariate analysis, older age, Indians and Malays, pre-existing CV risk factors, and history of MACE were associated with higher MACE risk. After propensity score adjustments, there remained no significant differences in MACE risk between RT + ADT and RT group on multivariable analysis. Conclusions In our registry-based study, ADT is not associated with increased risk of major cardiovascular events among Southeast Asian men with prostate cancer after curative radiotherapy. Supplementary Information The online version contains supplementary material available at 10.1186/s40959-022-00131-4.
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20
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Zhang H, Zhou Y, Xing Z, Sah RK, Hu J, Hu H. Androgen Metabolism and Response in Prostate Cancer Anti-Androgen Therapy Resistance. Int J Mol Sci 2022; 23:ijms232113521. [PMID: 36362304 PMCID: PMC9655897 DOI: 10.3390/ijms232113521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
All aspects of prostate cancer evolution are closely related to androgen levels and the status of the androgen receptor (AR). Almost all treatments target androgen metabolism pathways and AR, from castration-sensitive prostate cancer (CSPC) to castration-resistant prostate cancer (CRPC). Alterations in androgen metabolism and its response are one of the main reasons for prostate cancer drug resistance. In this review, we will introduce androgen metabolism, including how the androgen was synthesized, consumed, and responded to in healthy people and prostate cancer patients, and discuss how these alterations in androgen metabolism contribute to the resistance to anti-androgen therapy.
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Affiliation(s)
- Haozhe Zhang
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen 518055, China
| | - Yi Zhou
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen 518055, China
| | - Zengzhen Xing
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen 518055, China
| | - Rajiv Kumar Sah
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen 518055, China
| | - Junqi Hu
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen 518055, China
| | - Hailiang Hu
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen 518055, China
- Key University Laboratory of Metabolism and Health of Guangdong, Southern University of Science and Technology, Shenzhen 518055, China
- Correspondence: ; Tel.: +86-0755-88018249
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21
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Ma TM, Chu FI, Sandler H, Feng FY, Efstathiou JA, Jones CU, Roach M, Rosenthal SA, Pisansky T, Michalski JM, Bolla M, de Reijke TM, Maingon P, Neven A, Denham J, Steigler A, Joseph D, Nabid A, Souhami L, Carrier N, Incrocci L, Heemsbergen W, Pos FJ, Sydes MR, Dearnaley DP, Tree AC, Syndikus I, Hall E, Cruickshank C, Malone S, Roy S, Sun Y, Zaorsky NG, Nickols NG, Reiter RE, Rettig MB, Steinberg ML, Reddy VK, Xiang M, Romero T, Spratt DE, Kishan AU. Local Failure Events in Prostate Cancer Treated with Radiotherapy: A Pooled Analysis of 18 Randomized Trials from the Meta-analysis of Randomized Trials in Cancer of the Prostate Consortium (LEVIATHAN). Eur Urol 2022; 82:487-498. [PMID: 35934601 DOI: 10.1016/j.eururo.2022.07.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/03/2022] [Accepted: 07/14/2022] [Indexed: 02/07/2023]
Abstract
CONTEXT The prognostic importance of local failure after definitive radiotherapy (RT) in National Comprehensive Cancer Network intermediate- and high-risk prostate cancer (PCa) patients remains unclear. OBJECTIVE To evaluate the prognostic impact of local failure and the kinetics of distant metastasis following RT. EVIDENCE ACQUISITION A pooled analysis was performed on individual patient data of 12 533 PCa (6288 high-risk and 6245 intermediate-risk) patients enrolled in 18 randomized trials (conducted between 1985 and 2015) within the Meta-analysis of Randomized Trials in Cancer of the Prostate Consortium. Multivariable Cox proportional hazard (PH) models were developed to evaluate the relationship between overall survival (OS), PCa-specific survival (PCSS), distant metastasis-free survival (DMFS), and local failure as a time-dependent covariate. Markov PH models were developed to evaluate the impact of specific transition states. EVIDENCE SYNTHESIS The median follow-up was 11 yr. There were 795 (13%) local failure events and 1288 (21%) distant metastases for high-risk patients and 449 (7.2%) and 451 (7.2%) for intermediate-risk patients, respectively. For both groups, 81% of distant metastases developed from a clinically relapse-free state (cRF state). Local failure was significantly associated with OS (hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.06-1.30), PCSS (HR 2.02, 95% CI 1.75-2.33), and DMFS (HR 1.94, 95% CI 1.75-2.15, p < 0.01 for all) in high-risk patients. Local failure was also significantly associated with DMFS (HR 1.57, 95% CI 1.36-1.81) but not with OS in intermediate-risk patients. Patients without local failure had a significantly lower HR of transitioning to a PCa-specific death state than those who had local failure (HR 0.32, 95% CI 0.21-0.50, p < 0.001). At later time points, more distant metastases emerged after a local failure event for both groups. CONCLUSIONS Local failure is an independent prognosticator of OS, PCSS, and DMFS in high-risk and of DMFS in intermediate-risk PCa. Distant metastasis predominantly developed from the cRF state, underscoring the importance of addressing occult microscopic disease. However a "second wave" of distant metastases occurs subsequent to local failure events, and optimization of local control may reduce the risk of distant metastasis. PATIENT SUMMARY Among men receiving definitive radiation therapy for high- and intermediate-risk prostate cancer, about 10% experience local recurrence, and they are at significantly increased risks of further disease progression. About 80% of patients who develop distant metastasis do not have a detectable local recurrence preceding it.
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Affiliation(s)
- Ting Martin Ma
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Fang-I Chu
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars Sinai, Los Angeles, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Mack Roach
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Seth A Rosenthal
- Department of Radiation Oncology, Sutter Medical Group, Roseville, CA, USA
| | - Thomas Pisansky
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Michel Bolla
- Department of Radiation Therapy, CHU Grenoble, Grenoble, France
| | - Theo M de Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Philippe Maingon
- Department of Radiation Oncology, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France
| | - Anouk Neven
- Luxembourg Institute of Health, Competence Center for Methodology and Statistics, Strassen, Luxembourg
| | - James Denham
- School of Medicine and Public Health, Faculty of Health and Medicine University of Newcastle, Newcastle, NSW, Australia
| | - Allison Steigler
- School of Medicine and Public Health, Faculty of Health and Medicine University of Newcastle, Newcastle, NSW, Australia
| | - David Joseph
- Department of Surgery, University of Western Australia
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitaler Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Nathalie Carrier
- Centre de recherche clinique, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wilma Heemsbergen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, University College London, London, UK
| | - David P Dearnaley
- Academic Urology Unit, Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | - Alison C Tree
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Emma Hall
- The Institute of Cancer Research, London, UK
| | | | - Shawn Malone
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Yilun Sun
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nicholas G Nickols
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Matthew B Rettig
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA; Division of Hematology/Oncology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael L Steinberg
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Vishruth K Reddy
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael Xiang
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Tahmineh Romero
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Amar U Kishan
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA.
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22
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King L, Bernaitis N, Christie D, Chess-Williams R, Sellers D, McDermott C, Dare W, Anoopkumar-Dukie S. Drivers of Radioresistance in Prostate Cancer. J Clin Med 2022; 11:jcm11195637. [PMID: 36233505 PMCID: PMC9573022 DOI: 10.3390/jcm11195637] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Prostate cancer (PCa) is the second most commonly diagnosed cancer worldwide. Radiotherapy remains one of the first-line treatments in localised disease and may be used as monotherapy or in combination with other treatments such as androgen deprivation therapy or radical prostatectomy. Despite advancements in delivery methods and techniques, radiotherapy has been unable to totally overcome radioresistance resulting in treatment failure or recurrence of previously treated PCa. Various factors have been linked to the development of tumour radioresistance including abnormal tumour vasculature, oxygen depletion, glucose and energy deprivation, changes in gene expression and proteome alterations. Understanding the biological mechanisms behind radioresistance is essential in the development of therapies that are able to produce both initial and sustained response to radiotherapy. This review will investigate the different biological mechanisms utilised by PCa tumours to drive radioresistance.
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Affiliation(s)
- Liam King
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD 4215, Australia or
- Ramsay Pharmacy Group, Melbourne, VIC 3004, Australia
| | - Nijole Bernaitis
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD 4215, Australia or
| | - David Christie
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD 4215, Australia or
- GenesisCare, Gold Coast, QLD 4224, Australia
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, QLD 4229, Australia
| | - Russ Chess-Williams
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, QLD 4229, Australia
| | - Donna Sellers
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, QLD 4229, Australia
| | - Catherine McDermott
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, QLD 4229, Australia
| | - Wendy Dare
- Ramsay Pharmacy Group, Melbourne, VIC 3004, Australia
| | - Shailendra Anoopkumar-Dukie
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD 4215, Australia or
- Correspondence: ; Tel.: +61-(0)-7-5552-7725
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23
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Valeriani M, Di Staso M, Facondo G, Vullo G, De Sanctis V, Gravina GL, di Genesio Pagliuca M, Osti MF, Bonfili P. Hypofractionated Radiotherapy in Intermediate-Risk Prostate Cancer Patients: Long-Term Results. J Clin Med 2022; 11:jcm11164783. [PMID: 36013023 PMCID: PMC9410091 DOI: 10.3390/jcm11164783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/09/2022] [Accepted: 08/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background: To evaluate outcomes in terms of survival and toxicity in a series of intermediate-risk prostate cancer (PCa) patients treated with hypofractionated radiotherapy (HyRT) + hormonal therapy (HT) with or without image guidance (IGRT) and to investigate the impact of different variables. Methods: This is a multi-centric study. From January 2005 to December 2019, we treated 313 intermediate-risk PCa patients (T2b−T2c, Gleason score 7, or pre-treatment PSA 10 to 20 ng/mL) with HyRT. Patients received 54.75 Gy in 15 fractions in 5 weeks plus 9 months of neo-adjuvant, concomitant, and adjuvant HT with or without IGRT. Results: Median follow-up was 91.6 months (range 5.1−167.8 months). Median OS was not reached, and the 8- and 10-year OS was 81.9% and 72.4%, respectively. Median CSS was not reached, and the 8- and 10-year CSS was 97.9% and 94.5%, respectively. PSA at first follow-up <0.8 ng/mL was significantly related to better oncological outcomes (CSS, bRFS, LRFS, cPFS, and MFS) in both univariate and multivariate analysis. After Propensity Score matching, grade 2−3 acute and cumulative late GU (p = 0.153 and p = 0.581, respectively) and GI (p = 0.196 and p = 0.925, respectively) toxicity were not statistically different in patients treated with or without IGRT. Conclusions: HyRT is effective and safe regardless of the use of IGRT. PSA at first follow-up is an easily accessible prognostic factor that may help the clinicians to identify patients who require a treatment intensification.
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Affiliation(s)
- Maurizio Valeriani
- Department of Medicine and Surgery and Translational Medicine, Sapienza University of Rome, Radiotherapy Oncology, St Andrea Hospital, 00189 Rome, Italy
- Correspondence:
| | - Mario Di Staso
- Radiotherapy Oncology Unit, University of L’Aquila, St Salvatore Hospital, 67100 L’Aquila, Italy
| | - Giuseppe Facondo
- Department of Medicine and Surgery and Translational Medicine, Sapienza University of Rome, Radiotherapy Oncology, St Andrea Hospital, 00189 Rome, Italy
| | - Gianluca Vullo
- Department of Medicine and Surgery and Translational Medicine, Sapienza University of Rome, Radiotherapy Oncology, St Andrea Hospital, 00189 Rome, Italy
| | - Vitaliana De Sanctis
- Department of Medicine and Surgery and Translational Medicine, Sapienza University of Rome, Radiotherapy Oncology, St Andrea Hospital, 00189 Rome, Italy
| | - Giovanni Luca Gravina
- Radiotherapy Oncology Unit, University of L’Aquila, St Salvatore Hospital, 67100 L’Aquila, Italy
| | | | - Mattia Falchetto Osti
- Department of Medicine and Surgery and Translational Medicine, Sapienza University of Rome, Radiotherapy Oncology, St Andrea Hospital, 00189 Rome, Italy
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24
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Gongora M, Stranne J, Johansson E, Bottai M, Thellenberg Karlsson C, Brasso K, Hansen S, Jakobsen H, Jäderling F, Lindberg H, Lilleby W, Meidahl Petersen P, Mirtti T, Olsson M, Rannikko A, Røder MA, Henrik Vincent P, Akre O. Characteristics of Patients in SPCG-15—A Randomized Trial Comparing Radical Prostatectomy with Primary Radiotherapy plus Androgen Deprivation Therapy in Men with Locally Advanced Prostate Cancer. EUR UROL SUPPL 2022; 41:63-73. [PMID: 35813256 PMCID: PMC9257646 DOI: 10.1016/j.euros.2022.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/28/2022] Open
Abstract
Background There is no high-grade evidence for surgery as primary treatment for locally advanced prostate cancer. The SPCG-15 study is the first randomized trial comparing surgical treatment with radiotherapy. Objective To describe the baseline characteristics of the first 600 randomized men in the SPCG-15 study. The study will compare mortality and functional outcomes. Design, setting, and participants This study is a Scandinavian prospective, open, multicenter phase III randomized clinical trial aiming to randomize 1200 men. Intervention Radical prostatectomy with or without consecutive radiotherapy (experimental) and radiotherapy with neoadjuvant androgen deprivation therapy (standard of care). Outcome measurements and statistical analysis Cause-specific survival, metastasis-free survival, overall survival, and patient-reported bowel function, sexual health, and lower urinary tract symptoms were measured. Results and limitations The distribution of characteristics was similar in the two study arms. The median age was 67 yr (range 45–75 yr). Among the operated men, 36% had pT3a stage of disease and 39% had pT3b stage. International Society of Urological Pathology grades 2, 3, 4, and 5 were prevalent in 21%, 35%, 7%, and 27%, respectively. Half of the men (51%) in the surgery arm had no positive lymph nodes. The main limitation is the pragmatic design comparing the best available practice at each study site leading to heterogeneity of treatment regimens within the study arms. Conclusions We have proved that randomization between surgery and radiotherapy for locally advanced prostate cancer is feasible. The characteristics of the study population demonstrate a high prevalence of advanced disease, well-balanced comparison groups, and a demography mirroring the Scandinavian population of men with prostate cancer at large. Patient summary This study, which has recruited >600 men, compares radiotherapy with surgery for prostate cancer, and an analysis at the time of randomization indicates that the study will be informative and generalizable to most men with locally advanced but not metastasized prostate cancer.
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Affiliation(s)
- Magdalena Gongora
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
- Corresponding author. Department of Molecular Molecule and Surgery, Karolinska Institutet, Solna, GKS D1:05, 171 76 Stockholm, Sweden. Tel. +46733018726.
| | - Johan Stranne
- Department of Urology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Johansson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Klaus Brasso
- Department of Urology, Center for Cancer and Organ Diseases, Copenhagen Prostate Cancer Center, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Steinbjørn Hansen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Henrik Jakobsen
- Department of Urology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik Jäderling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Capio S:t Görans Hospital, Stockholm, Sweden
| | - Henriette Lindberg
- Department of Oncology, Copenhagen University Hospital − Herlev and Gentofte, Herlev, Denmark
| | | | | | - Tuomas Mirtti
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- iCAN-Digital Precision Cancer Medicine Flagship, Helsinki, Finland
| | - Mats Olsson
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Antti Rannikko
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, Faculty of Medicine and Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Martin Andreas Røder
- Department of Urology, Center for Cancer and Organ Diseases, Copenhagen Prostate Cancer Center, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Per Henrik Vincent
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Akre
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
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25
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Baude J, Caubet M, Defer B, Teyssier CR, Lagneau E, Créhange G, Lescut N. Combining androgen deprivation and radiation therapy in the treatment of localised prostate cancer: summary of level 1 evidence and current gaps in knowledge. Clin Transl Radiat Oncol 2022; 37:1-11. [PMID: 36039172 PMCID: PMC9418036 DOI: 10.1016/j.ctro.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jérémy Baude
- Department of Radiation Oncology, Centre Georges François Leclerc, 1 rue du professeur Marion, 21000 Dijon, France
- Corresponding author.
| | - Matthieu Caubet
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
| | - Blanche Defer
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
| | - Charles Régis Teyssier
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
| | - Edouard Lagneau
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
| | - Gilles Créhange
- Department of Radiation Oncology, Institut Curie, 26 rue d’Ulm, 75005 Paris, France
| | - Nicolas Lescut
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
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26
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Kishan AU, Wang X, Sun Y, Romero T, Michalski JM, Ma TM, Feng FY, Sandler HM, Bolla M, Maingon P, De Reijke T, Neven A, Steigler A, Denham JW, Joseph D, Nabid A, Carrier N, Souhami L, Sydes MR, Dearnaley DP, Syndikus I, Tree AC, Incrocci L, Heemsbergen WD, Pos FJ, Zapatero A, Efstathiou JA, Guerrero A, Alvarez A, San-Segundo CG, Maldonado X, Xiang M, Rettig MB, Reiter RE, Zaorsky NG, Ong WL, Dess RT, Steinberg ML, Nickols NG, Roy S, Garcia JA, Spratt DE. High-dose Radiotherapy or Androgen Deprivation Therapy (HEAT) as Treatment Intensification for Localized Prostate Cancer: An Individual Patient-data Network Meta-analysis from the MARCAP Consortium. Eur Urol 2022; 82:106-114. [PMID: 35469702 DOI: 10.1016/j.eururo.2022.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The relative benefits of radiotherapy (RT) dose escalation and the addition of short-term or long-term androgen deprivation therapy (STADT or LTADT) in the treatment of prostate cancer are unknown. OBJECTIVE To perform a network meta-analysis (NMA) of relevant randomized trials to compare the relative benefits of RT dose escalation ± STADT or LTADT. DESIGN, SETTING, AND PARTICIPANTS An NMA of individual patient data from 13 multicenter randomized trials was carried out for a total of 11862 patients. Patients received one of the six permutations of low-dose RT (64 to <74 Gy) ± STADT or LTADT, high-dose RT (≥74 Gy), or high-dose RT ± STADT or LTADT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES Metastasis-free survival (MFS) was the primary endpoint. Frequentist and Bayesian NMAs were performed to rank the various treatment strategies by MFS and biochemical recurrence-free survival (BCRFS). RESULTS AND LIMITATIONS Median follow-up was 8.8 yr (interquartile range 5.7-11.5). The greatest relative improvement in outcomes was seen for addition of LTADT, irrespective of RT dose, followed by addition of STADT, irrespective of RT dose. RT dose escalation did not improve MFS either in the absence of ADT (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.80-1.18) or with STADT (HR 0.99, 95% CI 0.8-1.23) or LTADT (HR 0.94, 95% CI 0.65-1.37). According to P-score ranking and rankogram analysis, high-dose RT + LTADT was the optimal treatment strategy for both BCRFS and longer-term outcomes. CONCLUSIONS Conventionally escalated RT up to 79.2 Gy, alone or in the presence of ADT, does not improve MFS, while addition of STADT or LTADT to RT alone, regardless of RT dose, consistently improves MFS. RT dose escalation does provide a high probability of improving BCRFS and, provided it can be delivered without compromising quality of life, may represent the optimal treatment strategy when used in conjunction with ADT. PATIENT SUMMARY Using a higher radiotherapy dose when treating prostate cancer does not reduce the chance of developing metastases or death, but it does reduce the chance of having a rise in prostate-specific antigen (PSA) signifying recurrence of cancer. Androgen deprivation therapy improves all outcomes. A safe increase in radiotherapy dose in conjunction with androgen deprivation therapy may be the optimal treatment.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California Los Angeles, Los Angeles, CA, USA.
| | - Xiaoyan Wang
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Yilun Sun
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA; Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michel Bolla
- Radiotherapy Department, University Hospital, Grenoble, France
| | - Philippe Maingon
- Department of Oncology, Hematology, and Supportive Care, Sorbonne University, Paris, France
| | - Theo De Reijke
- Department of Urology, Prostate Cancer Network in the Netherlands, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anouk Neven
- Statistics Department, European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium; Competence Center for Methodology and Statistics, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Allison Steigler
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, WA, Australia
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Nathalie Carrier
- Clinical Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, QC, Canada
| | - Matt R Sydes
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | | | | | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wilma D Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ana Alvarez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Michael Xiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Matthew B Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Wee Loon Ong
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University, Chicago, IL, USA
| | - Jorge A Garcia
- Division of Oncology, Seidman Cancer Center, Cleveland, OH, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Janssen J, Staal FHE, Brouwer CL, Langendijk JA, de Jong IJ, van Moorselaar RJA, Schuit E, Verzijlbergen JF, Smeenk RJ, Aluwini S. Androgen Deprivation therapy for Oligo-recurrent Prostate cancer in addition to radioTherapy (ADOPT): study protocol for a randomised phase III trial. BMC Cancer 2022; 22:482. [PMID: 35501744 PMCID: PMC9063099 DOI: 10.1186/s12885-022-09523-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background More than 60% of oligo-recurrent prostate cancer (PCa) patients treated with metastasis-directed radiotherapy (MDRT) develop biochemical recurrence within 2 years. This recurrence rate emphasises the need for improved treatment and patient selection. In line with the treatment of primary PCa, the efficacy of MDRT may be enhanced when combined with androgen-deprivation therapy (ADT). Furthermore, the availability of PSMA PET/CT offers an excellent tool for optimal patient selection for MDRT. This phase III randomised controlled trial will investigate the role of the addition of ADT to MDRT in oligo-recurrent PCa patients selected with PSMA PET/CT to enhance oncological outcome. Methods Two hundred and eighty patients will be randomised in a 1:1 ratio to the standard treatment arm (MDRT alone) or the experimental arm (MDRT + 6 months ADT). Patients with biochemical recurrence after primary treatment of PCa presenting with ≤ 4 metastases will be included. The primary endpoint is the 2.5-year metastases progression-free survival (MPFS). Secondary endpoints are acute and late toxicity, quality of life, biochemical progression-free survival, overall survival, and the sensitivity of the PSMA PET/CT for detecting oligometastases at low PSA-levels. So far, between March 2020 and December 2021, one hundred patients have been included. Discussion This phase III randomised controlled trial will assess the possible benefit of the addition of 6 months ADT to MDRT on metastases progression-free survival, toxicity, QoL and survival in PCa patients with 1–4 recurrent oligometastatic lesions. Trial registration ClinicalTrials.gov, NCT04302454. Registered 10 March 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09523-2.
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Affiliation(s)
- J Janssen
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands.
| | - F H E Staal
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands
| | - C L Brouwer
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands
| | - J A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands
| | - I J de Jong
- Department of Urology, University Medical Center Groningen, Groningen, the Netherlands
| | - R J A van Moorselaar
- Department of Urology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - E Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J F Verzijlbergen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - R J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - S Aluwini
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands
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28
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The Clinical Cell-Cycle Risk (CCR) Score Is Associated With Metastasis After Radiation Therapy and Provides Guidance on When to Forgo Combined Androgen Deprivation Therapy With Dose-Escalated Radiation. Int J Radiat Oncol Biol Phys 2022; 113:66-76. [PMID: 34610388 DOI: 10.1016/j.ijrobp.2021.09.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 09/20/2021] [Accepted: 09/25/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE The clinical cell-cycle risk (CCR) score, which combines the University of California, San Francisco's Cancer of the Prostate Risk Assessment (CAPRA) and the cell cycle progression (CCP) molecular score, has been validated to be prognostic of disease progression for men with prostate cancer. This study evaluated the ability of the CCR score to prognosticate the risk of metastasis in men receiving dose-escalated radiation therapy (RT) with or without androgen deprivation therapy (ADT). METHODS AND MATERIALS This retrospective, multi-institutional cohort study included men with localized National Comprehensive Cancer Network (NCCN) intermediate-, high-, and very high-risk prostate cancer (N = 741). Patients were treated with dose-escalated RT with or without ADT. The primary outcome was time to metastasis. RESULTS The CCR score prognosticated metastasis with a hazard ratio (HR) per unit score of 2.22 (95% confidence interval [CI], 1.71-2.89; P < .001). The CCR score better prognosticated metastasis than NCCN risk group (CCR, P < .001; NCCN, P = .46), CAPRA score (CCR, P = .002; CAPRA, P = .59), or CCP score (CCR, P < .001; CCP, P = .59) alone. In bivariable analyses, CCR score remained highly prognostic when accounting for ADT versus no ADT (HR, 2.18; 95% CI, 1.61-2.96; P < .001), ADT duration as a continuous variable (HR, 2.11; 95% CI, 1.59-2.79; P < .001), or ADT given at or below the recommended duration for each NCCN risk group (HR, 2.19; 95% CI, 1.69-2.86; P < .001). Men with CCR scores below or above the multimodality threshold (CCR score, 2.112) had a 10-year risk of metastasis of 3.7% and 21.24%, respectively. Men with below-threshold scores receiving RT alone had a 10-year risk of metastasis of 3.7%, and for men receiving RT plus ADT, the 10-year risk of metastasis was also 3.7%. CONCLUSIONS The CCR score accurately and precisely prognosticates metastasis and adds clinically actionable information relative to guideline-recommended therapies based on NCCN risk in men undergoing dose-escalated RT with or without ADT. For men with scores below the multimodality threshold, adding ADT may not significantly reduce their 10-year risk of metastasis.
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29
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Forster RB, Engeland A, Kvåle R, Hjellvik V, Bjørge T. Association between medical androgen deprivation therapy and long-term cardiovascular disease and all-cause mortality in non-metastatic prostate cancer. Int J Cancer 2022; 151:1109-1119. [PMID: 35489025 PMCID: PMC9544783 DOI: 10.1002/ijc.34058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/08/2022] [Accepted: 04/19/2022] [Indexed: 11/10/2022]
Abstract
Studies have suggested that prostate cancer (PCa) patients receiving androgen deprivation therapy (ADT) are at increased risk of developing or exacerbating cardiovascular disease (CVD). We aimed to explore the association between ADT for PCa and subsequent CVD and all‐cause mortality in this nationwide, longitudinal study. We also evaluated the role of cardiovascular risk and ADT duration to determine effect modification. Norwegian registry data were used to identify patients with PCa from 2008‐18 and who received primary ADT in the first year after diagnosis. The associations between ADT and composite cardiovascular events, and the individual components of myocardial infarction, stroke and heart failure, in addition to atrial fibrillation and all‐cause mortality, were explored using time‐varying Cox regression models. We included 30 923 PCa patients, of whom 8449 (27%) received primary ADT. Mean follow‐up was 2.9 and 3.8 years for CVD events and mortality, respectively. We found an association between ADT and composite CVD (adjusted HR 1.13: 95% CI 1.05‐1.21), myocardial infarction (1.18: 1.05‐1.32), stroke (1.21: 1.06‐1.38), heart failure (1.23: 1.13‐1.35) and all‐cause mortality (1.49: 1.39‐1.61). These associations persisted in those with low and moderate CVD risk and ADT longer than 7 months. A relationship between ADT and composite CVD and all‐cause mortality was observed, especially in those with moderate CVD risk and longer treatment duration. Future studies with more detailed cancer data are needed to verify the clinical relevance of these results, especially when considering all‐cause mortality within the context of treatment guidelines and benefits of ADT.
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Affiliation(s)
- R B Forster
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
| | - A Engeland
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - R Kvåle
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway.,Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - V Hjellvik
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - T Bjørge
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Cancer Registry of Norway, Oslo, Norway
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30
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Kissel M, Créhange G, Graff P. Stereotactic Radiation Therapy versus Brachytherapy: Relative Strengths of Two Highly Efficient Options for the Treatment of Localized Prostate Cancer. Cancers (Basel) 2022; 14:2226. [PMID: 35565355 PMCID: PMC9105931 DOI: 10.3390/cancers14092226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) has become a valid option for the treatment of low- and intermediate-risk prostate cancer. In randomized trials, it was found not inferior to conventionally fractionated external beam radiation therapy (EBRT). It also compares favorably to brachytherapy (BT) even if level 1 evidence is lacking. However, BT remains a strong competitor, especially for young patients, as series with 10-15 years of median follow-up have proven its efficacy over time. SBRT will thus have to confirm its effectiveness over the long-term as well. SBRT has the advantage over BT of less acute urinary toxicity and, more hypothetically, less sexual impairment. Data are limited regarding SBRT for high-risk disease while BT, as a boost after EBRT, has demonstrated superiority against EBRT alone in randomized trials. However, patients should be informed of significant urinary toxicity. SBRT is under investigation in strategies of treatment intensification such as combination of EBRT plus SBRT boost or focal dose escalation to the tumor site within the prostate. Our goal was to examine respective levels of evidence of SBRT and BT for the treatment of localized prostate cancer in terms of oncologic outcomes, toxicity and quality of life, and to discuss strategies of treatment intensification.
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Affiliation(s)
| | | | - Pierre Graff
- Department of Radiation Oncology, Institut Curie, 26 Rue d’Ulm, 75005 Paris, France; (M.K.); (G.C.)
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31
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Saxby H, Boussios S, Mikropoulos C. Androgen Receptor Gene Pathway Upregulation and Radiation Resistance in Oligometastatic Prostate Cancer. Int J Mol Sci 2022; 23:ijms23094786. [PMID: 35563176 PMCID: PMC9105839 DOI: 10.3390/ijms23094786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/09/2022] [Accepted: 04/24/2022] [Indexed: 12/20/2022] Open
Abstract
Stereotactic ablative body radiotherapy (SABR) is currently used as a salvage intervention for men with oligometastatic prostate cancer (PC), and increasingly so since the results of the Stereotactic Ablative Body Radiotherapy for the Comprehensive Treatment of Oligometastatic Cancers (SABR-COMET) trial reported a significant improvement in overall survival with SABR. The addition of androgen deprivation therapy (ADT) to localised prostate radiotherapy improves survival as it sensitises PC to radiotherapy-induced cell death. The importance of the androgen receptor (AR) gene pathway in the development of resistance to radiotherapy is well established. In this review paper, we will examine the data to determine how we can overcome the upregulation of the AR pathway and suggest a strategy for improving outcomes in men with oligometastatic hormone-sensitive PC.
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Affiliation(s)
- Helen Saxby
- Torbay & South Devon NHS Healthcare Foundation Trust, Lowes Bridge, Torquay TQ2 7AA, UK;
| | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham Kent ME7 5NY, UK
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London SE1 9RT, UK
- AELIA Organization, 9th Km Thessaloniki–Thermi, 57001 Thessaloniki, Greece
- Correspondence: , or
| | - Christos Mikropoulos
- St Lukes Cancer Centre, Royal Surrey County Hospital, Egerton Rd, Guildford GU2 7XX, UK;
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32
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Bahl A, Rajappa S, Rawal S, Bakshi G, Murthy V, Patil K. A review of clinical evidence to assess differences in efficacy and safety of luteinizing hormone-releasing hormone (LHRH) agonist (goserelin) and LHRH antagonist (degarelix). Indian J Cancer 2022; 59:S160-S174. [PMID: 35343199 DOI: 10.4103/ijc.ijc_1415_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Luteinizing hormone-releasing hormone agonist (LHRH-A), goserelin, and antagonist, degarelix, are both indicated for the treatment of advanced prostate cancer (PCa); however, large comparative trials evaluating their efficacy and safety are lacking. In this review, we assessed the available evidence for both the drugs. Although degarelix achieves an early rapid decline in testosterone (T) and prostate-specific antigen (PSA) levels, median T and PSA levels, in addition to prostate volume and International Prostate Symptom Scores, become comparable with goserelin over the remaining treatment period. Degarelix causes no initial flare, therefore it is recommended in patients with spinal metastases or ureteric obstruction. Goserelin achieves lower PSA, improved time to progression, and better survival outcomes when administered adjunctively to radiotherapy compared with radiotherapy alone, with significant results even over long-term follow-up. The evidence supporting adjuvant degarelix use is limited. Goserelin has better injection site safety, single-step delivery, and an efficient administration schedule compared with degarelix, which has significantly higher injection site reactions and less efficient administration mechanism. There is conflicting evidence about the risk of cardiovascular disease (CVD), and caution is required when using LHRH-A in patients with preexisting CVD. There is considerable long-term evidence for goserelin in patients with advanced PCa, with degarelix being a more recent option. The available comparative evidence of goserelin versus degarelix has several inherent limitations related to study design, sample size, conduct, and statistical analyses, and hence warrants robust prospective trials and long-term follow-up.
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Affiliation(s)
- Ankur Bahl
- Senior Consultant, Medical Oncology and Hematology, Max Cancer Centre, New Delhi, India
| | - Senthil Rajappa
- Consultant Medical Oncologist, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, India
| | - Sudhir Rawal
- Medical Director, Chief Genito Uro-Oncology, RCGI, Delhi, India
| | - Ganesh Bakshi
- Department of Uro oncology, P D Hinduja National Hospital, Mahim, Mumbai, India
| | - Vedang Murthy
- Professor & Radiation Oncologist, Tata Memorial Center, Mumbai, India
| | - Ketaki Patil
- Medical Affairs, AstraZeneca Pharma India Ltd, Manyatha Tech Park, Rachenahalli, Bangalore, India
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Sasamura K, Soyano T, Kozuka T, Yuasa T, Yamamoto S, Yonese J, Oguchi M, Yoshimura R, Yoshioka Y. Outcomes of intensity-modulated radiation therapy for intermediate- or high-risk prostate cancer: a single-institutional study. Jpn J Clin Oncol 2022; 52:170-178. [PMID: 34689189 DOI: 10.1093/jjco/hyab167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/07/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND There are few reports from Japan about the outcomes of intensity-modulated radiation therapy for localized prostate cancer. This study was aimed at assessing the efficacy and toxicity of intensity-modulated radiation therapy in patients with intermediate- or high-risk prostate cancer. METHODS We conducted a review of the data, retrieved from our institutional database, of patients who had received intensity-modulated radiation therapy for localized prostate cancer at a radiation dose of 78 Gy in 39 fractions. Data of 201 patients with intermediate-risk prostate cancer and 311 patients with high-risk prostate cancer were analyzed. RESULTS The median follow-up period after the completion of intensity-modulated radiation therapy was 100 months (range, 24-154). The rates of cause-specific survival, overall survival, metastasis-free survival and biochemical recurrence-free survival in the intermediate-risk patients were 99, 95, 95 and 94% at 5 years and 99, 91, 90 and 86% at 8 years, respectively; the corresponding rates in the high-risk patients were 100, 97, 91 and 84% at 5 years and 96, 92, 84 and 76% at 8 years, respectively. The crude incidence of late grade 2-3 genitourinary toxicity was 28.1%, and that of late grade 3 genitourinary toxicity was 2.0%. The crude incidence of late grade 2 gastrointestinal toxicity was 5.1%, and there were no cases of late grade 3 gastrointestinal toxicity. CONCLUSIONS Our data demonstrated that intensity-modulated radiation therapy is effective for patients with localized intermediate-risk or high-risk prostate cancer while having minimal toxicity.
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Affiliation(s)
- Kazuma Sasamura
- Radiation Oncology Department, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Soyano
- Department of Radiology, Japan Self-Defense Forces Central Hospital, Tokyo, Japan
| | - Takuyo Kozuka
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | - Takeshi Yuasa
- Department of Urology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinya Yamamoto
- Department of Urology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junji Yonese
- Department of Urology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masahiko Oguchi
- Radiation Oncology Department, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryoichi Yoshimura
- Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuo Yoshioka
- Radiation Oncology Department, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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34
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Agrawal V, Ma X, Hu JC, Barbieri CE, Nagar H. Trends in Androgen Deprivation Use in Men with Intermediate Risk Prostate Cancer Who Underwent Radiotherapy. Adv Radiat Oncol 2022; 7:100904. [PMID: 35814856 PMCID: PMC9260097 DOI: 10.1016/j.adro.2022.100904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/10/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose Until 2018, National Cancer Comprehensive Network guidelines recommended androgen deprivation therapy (ADT) for all men with intermediate-risk prostate cancer who had undergone radiation therapy. Intermediate risk was stratified as favorable and unfavorable in 2018, and ADT recommendation was limited to men with unfavorable intermediate-risk prostate cancer. Data suggesting this stratification and treatment deintensification were first published in December 2013. This study characterizes US national trends for demographic, clinical, and socioeconomic factors associated with ADT use in men with intermediate-risk prostate cancer who have undergone definitive radiation therapy. Methods and Materials This retrospective cohort study examined 108,185 men in the National Cancer Database who were diagnosed with intermediate-risk prostate cancer from 2004 to 2016. Temporal trends in demographic, clinical, and socioeconomic factors among men with intermediate-risk prostate cancer and associations with the use of ADT were characterized. Results In total, 108,185 men diagnosed with intermediate-risk prostate cancer underwent radiation therapy from 2004 to 2016. Of these men, 41.09% received ADT. Among the 60,705 men with favorable intermediate-risk prostate cancer, 32.06% received ADT. Among the 47,480 men with unfavorable intermediate-risk prostate cancer, 52.64% received ADT. On multivariate analysis, use of ADT was associated with age and year of diagnosis; being a race other than White; having government-based insurance; having a higher prostate-specific antigen level, tumor stage, and Gleason score; receiving treatment at a nonacademic center; and receiving external beam radiation therapy alone. Conclusions The findings highlight that ADT use is variable in men undergoing definitive radiation therapy for intermediate-risk prostate cancer, with the data suggesting that several clinical and socioeconomic disparities influence its use. The findings suggest that a significant proportion of men with favorable intermediate-risk prostate cancer receive ADT and remain candidates for treatment de-escalation, whereas a significant proportion of men with unfavorable intermediate-risk prostate cancer may be undertreated when ADT is omitted.
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Affiliation(s)
- Vishesh Agrawal
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Xiaoyue Ma
- Division of Biostatistics and Epidemiology, Department of Health Care Policy and Research, Weill Cornell Medicine, New York, New York
| | - Jim C. Hu
- Department of Urology, Weill Cornell Medicine, New York, New York
| | | | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
- Corresponding author: Himanshu Nagar, MD
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Kishan AU, Sun Y, Hartman H, Pisansky TM, Bolla M, Neven A, Steigler A, Denham JW, Feng FY, Zapatero A, Armstrong JG, Nabid A, Carrier N, Souhami L, Dunne MT, Efstathiou JA, Sandler HM, Guerrero A, Joseph D, Maingon P, de Reijke TM, Maldonado X, Ma TM, Romero T, Wang X, Rettig MB, Reiter RE, Zaorsky NG, Steinberg ML, Nickols NG, Jia AY, Garcia JA, Spratt DE. Androgen deprivation therapy use and duration with definitive radiotherapy for localised prostate cancer: an individual patient data meta-analysis. Lancet Oncol 2022; 23:304-316. [DOI: 10.1016/s1470-2045(21)00705-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 12/22/2022]
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36
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Tharmalingam H, Tsang Y, Alonzi R, Beasley W, Taylor N, McWilliam A, Padhani A, Choudhury A, Hoskin P. Changes in Magnetic Resonance Imaging Radiomic Features in Response to Androgen Deprivation Therapy in Patients with Intermediate- and High-risk Prostate Cancer. Clin Oncol (R Coll Radiol) 2022; 34:e246-e253. [DOI: 10.1016/j.clon.2021.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/26/2021] [Accepted: 12/22/2021] [Indexed: 11/03/2022]
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An Expert Review on the Combination of Relugolix with Definitive Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2021; 113:278-289. [PMID: 34923058 DOI: 10.1016/j.ijrobp.2021.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 11/20/2022]
Abstract
Androgen deprivation therapy (ADT) is an integral component in the management of prostate cancer across multiple disease states. Traditionally, luteinizing hormone-releasing hormone (LHRH) agonists constituted the backbone of ADT. However, gonadotropin-releasing hormone receptor hormone (GnRH) antagonists are also available, which offer faster testosterone suppression and reduced likelihood of ADT-related adverse effects compared to LHRH agonists, including the potential for fewer ADT-associated major cardiac events. Until recently, all forms of LHRH agonists and GnRH antagonist formulations are of parenteral administration. However, recently relugolix gained FDA approval as the first oral GnRH antagonist. Relugolix achieves faster and more complete testosterone suppression compared to an LHRH agonist. This translates to more rapid prostate-specific antigen response compared to LHRH agonists. After discontinuation of relugolix, testosterone recovers faster than after GnRH agonists or injectable GnRH antagonist therapy. Overall, these factors provide opportunities for more precisely defined ADT duration when combined with radiation therapy. The rapid onset and offset testosterone suppression with relugolix, however, may require physicians to rethink the mechanism and goals of ADT when prescribing. As an oral formulation, relugolix enables patients to avoid pain and injection site reactions, limit extra office visits for injections, and achieve a shorter duration of experiencing the side effects of castrate testosterone levels. This convenience and tolerability may enhance physicians' willingness to prescribe ADT and patients' feeling of control over their ADT course, but the potential advantages are accompanied by the risks of patients choosing to discontinue therapy to escape side effects of ADT. This article focuses on different aspects of what is known and unknown regarding the optimal use of ADT and radiation therapy, and how relugolix, due to its properties, fit into our current treatment paradigms for localized prostate cancer.
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George DJ, Dearnaley DP. Relugolix, an oral gonadotropin-releasing hormone antagonist for the treatment of prostate cancer. Future Oncol 2021; 17:4431-4446. [PMID: 34409852 DOI: 10.2217/fon-2021-0575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Androgen deprivation therapy using gonadotropin-releasing hormone (GnRH) analogues is standard treatment for intermediate and advanced prostate cancer. GnRH agonist therapy results in an initial testosterone flare, and increased metabolic and cardiovascular risks. The GnRH antagonist relugolix is able to reduce serum testosterone levels in men with prostate cancer without inducing testosterone flare. In the HERO Phase III trial, relugolix was superior to leuprolide acetate at rapidly reducing testosterone and continuously suppressing testosterone, with faster post-treatment recovery of testosterone levels. Relugolix was associated with a 54% lower incidence of major adverse cardiovascular events than leuprolide acetate. As the first oral GnRH antagonist approved for the treatment of advanced prostate cancer, relugolix offers a new treatment option.
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Affiliation(s)
- Daniel J George
- Department of Medicine & Surgery, Duke Cancer Institute, Duke University, Durham, NC 27710, USA
| | - David P Dearnaley
- The Institute of Cancer Research & Royal Marsden NHS Foundation Trust, London, UK
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Sánchez C, Mercado A, Contreras HR, Carvajal V F, Salgado A, Huidobro C, Castellón EA. Membrane translocation and activation of GnRH receptor sensitize prostate cancer cells to radiation. Int J Radiat Biol 2021; 97:1555-1562. [PMID: 34519609 DOI: 10.1080/09553002.2021.1980628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND GnRH analogs are widely used as neoadjuvant agents for radiotherapy in prostate cancer (PCa) patients, with well-documented effects in reducing tumor bulk and increasing progression-free survival. GnRH analogs act locally in the prostate by triggering apoptosis of PCa cells via activation of the GnRH receptor (GnRHR). During PCa progression, the distribution of GnRHR within the cell is altered, with reduced expression in the cell membrane and remaining sequestered in the endoplasmic reticulum. Pharmacoperone IN3 is able to relocalize GnRHR to the cell membrane. The aim of this study was to evaluate the effect of radiation on PCa cells pretreated with leuprolide, alone or in combination with IN3, as radiosensitizers. MATERIAL AND METHODS PC3 and human PCa primary cell cultures were treated with IN3 for 24 h, followed by different doses of leuprolide for 48 h and, finally, single doses of radiation (3, 6, and 9 Gy). After radiation, cell survival, apoptosis, cell cycle distribution, and colony growth were evaluated. RESULTS Radiation reduced cell survival and increased apoptosis in a dose-dependent manner. This effect was also directly related to leuprolide concentration. Pretreatment with IN3 enhanced apoptosis and decreased cell survival, also observing a higher proportion of cells arrested in G2. CONCLUSION Neoadjuvant leuprolide increases radiation-mediated apoptosis of PCa cells. This effect was enhanced by pretreatment with pharmacoperone IN3. Clinical use of IN3 as a radiosensitizer combined with androgen deprivation therapy to improve survival of patients with PCa remains to be evaluated.
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Affiliation(s)
| | - Alejandro Mercado
- Clínica Las Condes, Santiago, Chile.,Departamento de Oncología Básica y Clínica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Héctor R Contreras
- Departamento de Oncología Básica y Clínica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Felipe Carvajal V
- Departamento de Oncología Básica y Clínica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | | | | | - Enrique A Castellón
- Departamento de Oncología Básica y Clínica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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D'Rummo KA, Chen RC, Shen X. Narrative review of management strategies and outcomes in node-positive prostate cancer. Transl Androl Urol 2021; 10:3176-3187. [PMID: 34430420 PMCID: PMC8350237 DOI: 10.21037/tau-20-1031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/27/2020] [Indexed: 11/06/2022] Open
Abstract
Pelvic nodal involvement is present in 13% of new prostate cancer diagnoses each year and is associated with a poor prognosis compared to localized disease. Grouped as stage IV along with distant metastatic disease, node-positive nonmetastatic patients historically received systemic therapy alone as primary treatment. This treatment paradigm has shifted as data have demonstrated that these patients may benefit from aggressive locoregional therapy and are potentially curable. There is currently a lack of randomized evidence to define the optimal management for node-positive patients. While a few trials have included node-positive patients, the majority of data are derived from large multi-institutional series or population-based series. This narrative review summarizes the current literature supporting curative-intent management strategies for patients diagnosed with nonmetastatic clinically node-positive prostate cancer (cN1M0), as well as patients found to have pathologic nodal disease at the time of surgery (pN1M0). Treatment of both scenarios requires multimodality considerations including surgery, radiation therapy (RT) and systemic therapy to minimize the risks of both locoregional and distant recurrence. Future considerations include developments in enhanced imaging and systemic therapy. Inclusion of node-positive patients on prospective, randomized trials such as NRG GU 008 is needed to enhance our understanding of optimal management strategies.
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Affiliation(s)
- Kevin A D'Rummo
- Department of Radiation Oncology, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Ronald C Chen
- Department of Radiation Oncology, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Xinglei Shen
- Department of Radiation Oncology, The University of Kansas Medical Center, Kansas City, KS, USA
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41
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Marvaso G, Corrao G, Zaffaroni M, Pepa M, Augugliaro M, Volpe S, Musi G, Luzzago S, Mistretta FA, Verri E, Cossu Rocca M, Ferro M, Petralia G, Nolè F, De Cobelli O, Orecchia R, Jereczek-Fossa BA. Therapeutic Sequences in the Treatment of High-Risk Prostate Cancer: Paving the Way Towards Multimodal Tailored Approaches. Front Oncol 2021; 11:732766. [PMID: 34422672 PMCID: PMC8371196 DOI: 10.3389/fonc.2021.732766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/13/2021] [Indexed: 12/21/2022] Open
Abstract
Various definitions are currently in use to describe high-risk prostate cancer. This variety in definitions is important for patient counseling, since predicted outcomes depend on which classification is applied to identify patient’s prostate cancer risk category. Historically, strategies for the treatment of localized high-risk prostate cancer comprise local approaches such as surgery and radiotherapy, as well as systemic approaches such as hormonal therapy. Nevertheless, since high-risk prostate cancer patients remain the group with higher-risk of treatment failure and mortality rates, nowadays, novel treatment strategies, comprising hypofractionated-radiotherapy, second-generation antiandrogens, and hadrontherapy, are being explored in order to improve their long-term oncological outcomes. This narrative review aims to report the current management of high-risk prostate cancer and to explore the future perspectives in this clinical setting.
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Affiliation(s)
- Giulia Marvaso
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Giulia Corrao
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Matteo Pepa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Matteo Augugliaro
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Stefania Volpe
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Gennaro Musi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.,Department of Urology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Stefano Luzzago
- Department of Urology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Elena Verri
- Department of Medical Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Maria Cossu Rocca
- Department of Medical Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Matteo Ferro
- Department of Urology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Petralia
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.,Precision Imaging and Research Unit, Department of Medical Imaging and Radiation Sciences, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Franco Nolè
- Medical Oncology Division of Urogenital & Head & Neck Tumors, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Ottavio De Cobelli
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.,Department of Urology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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42
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Suppressed PLIN3 frequently occurs in prostate cancer, promoting docetaxel resistance via intensified autophagy, an event reversed by chloroquine. Med Oncol 2021; 38:116. [PMID: 34410522 PMCID: PMC8374126 DOI: 10.1007/s12032-021-01566-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022]
Abstract
Lipid metabolism reprogramming is one of the adaptive events that drive tumor development and survival, and may account for resistance to chemotherapeutic drugs. Perilipins are structural proteins associated with lipophagy and lipid droplet integrity, and their overexpression is associated with tumor aggressiveness. Here, we sought to explore the role of lipid droplet-related protein perilipin-3 (PLIN3) in prostate cancer (PCa) chemotherapy. We investigated the role of PLIN3 suppression in docetaxel cytotoxic activity in PCa cell lines. Additional effects of PLIN3 depletion on autophagy-related proteins and gene expression patterns, apoptotic potential, proliferation rate, and ATP levels were examined. Depletion of PLIN3 resulted in docetaxel resistance, accompanied by enhanced autophagic flux. We further assessed the synergistic effect of autophagy suppression with chloroquine on docetaxel cytotoxicity. Inhibition of autophagy with chloroquine reversed chemoresistance of stably transfected shPLIN3 PCa cell lines, with no effect on the parental ones. The shPLIN3 cell lines also exhibited reduced Caspase-9 related apoptosis initiation. Moreover, we assessed PLIN3 expression in a series of PCa tissue specimens, were complete or partial loss of PLIN3 expression was frequently noted in 70% of the evaluated specimens. Following PLIN3 silencing, PCa cells were characterized by impaired lipophagy and acquired an enhanced autophagic response upon docetaxel-induced cytotoxic stress. Such an adaptation leads to resistance to docetaxel, which could be reversed by the autophagy blocker chloroquine. Given the frequent loss of PLIN3 expression in PCa specimens, we suggest that combination of docetaxel with chloroquine may improve the efficacy of docetaxel treatment in PLIN3-deficient cancer patients.
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43
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Bolla M, Neven A, Maingon P, Carrie C, Boladeras A, Andreopoulos D, Engelen A, Sundar S, van der Steen-Banasik EM, Armstrong J, Peignaux-Casasnovas K, Boustani J, Herrera FG, Pieters BR, Slot A, Bahl A, Scrase CD, Azria D, Jansa J, O'Sullivan JM, Van Den Bergh ACM, Collette L. Short Androgen Suppression and Radiation Dose Escalation in Prostate Cancer: 12-Year Results of EORTC Trial 22991 in Patients With Localized Intermediate-Risk Disease. J Clin Oncol 2021; 39:3022-3033. [PMID: 34310202 DOI: 10.1200/jco.21.00855] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The European Organisation for Research and Treatment of Cancer (EORTC) trial 22991 (NCT00021450) showed that 6 months of concomitant and adjuvant androgen suppression (AS) improves event- (EFS, Phoenix) and clinical disease-free survival (DFS) of intermediate- and high-risk localized prostatic carcinoma, treated by external-beam radiotherapy (EBRT) at 70-78 Gy. We report the long-term results in intermediate-risk patients treated with 74 or 78 Gy EBRT, as per current guidelines. PATIENT AND METHODS Of 819 patients randomly assigned between EBRT or EBRT plus AS started on day 1 of EBRT, 481 entered with intermediate risk (International Union Against Cancer TNM 1997 cT1b-c or T2a with prostate-specific antigen (PSA) ≥ 10 ng/mL or Gleason ≤ 7 and PSA ≤ 20 ng/mL, N0M0) and had EBRT planned at 74 (342 patients, 71.1%) or 78 Gy (139 patients, 28.9%). We report the trial primary end point EFS, DFS, distant metastasis-free survival (DMFS), and overall survival (OS) by intention-to-treat stratified by EBRT dose at two-sided α = 5%. RESULTS At a median follow-up of 12.2 years, 92 of 245 patients and 132 of 236 had EFS events in the EBRT plus AS and EBRT arm, respectively, mostly PSA relapse (48.7%) or death (45.1%). EBRT plus AS improved EFS and DFS (hazard ratio [HR] = 0.53; CI, 0.41 to 0.70; P < .001 and HR = 0.67; CI, 0.49 to 0.90; P = .008). At 10 years, DMFS was 79.3% (CI, 73.4 to 84.0) with EBRT plus AS and 72.7% (CI, 66.2 to 78.2) with EBRT (HR = 0.74; CI, 0.53 to 1.02; P = .065). With 140 deaths (EBRT plus AS: 64; EBRT: 76), 10-year OS was 80.0% (CI, 74.1 to 84.7) with EBRT plus AS and 74.3% (CI, 67.8 to 79.7) with EBRT, but not statistically significantly different (HR = 0.74; CI, 0.53 to 1.04; P = .082). CONCLUSION Six months of concomitant and adjuvant AS statistically significantly improves EFS and DFS in intermediate-risk prostatic carcinoma, treated by irradiation at 74 or 78 Gy. The effects on OS and DMFS did not reach statistical significance.
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Affiliation(s)
- Michel Bolla
- Radiotherapy Department Grenoble, Grenoble Alpes University, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Anouk Neven
- European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Philippe Maingon
- Sorbonne University, APHP Sorbonne University, La Pitié Salpêtrière, Paris, France
| | | | - Ana Boladeras
- Radiation Oncology Department, Catalan Institute of Oncology-University Hospital Germans Trias I Pujol, Badalona, Barcelona, Catalonia, Spain
| | | | | | - Santhanam Sundar
- Nottingham University Hospitals NHS Trust-City Hospital, Consultant Medical Oncologist, Nottingham, United Kingdom
| | | | - John Armstrong
- Radiation Oncology Department, All Ireland Cooperative Oncology Research Group, St Luke's Hospital, Dublin, Ireland
| | | | - Jihane Boustani
- Radiotherapy Department, University Hospital of Besancon-Jean Minjoz Hospital, Besancon, France
| | - Fernanda G Herrera
- Radiation Oncology and Immuno-Oncology Service, University Hospital of Lausanne, Lausanne, Switzerland
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, the Netherlands
| | - Annerie Slot
- Radiotherapeutisch Instituut Friesland, Leeuwarden, the Netherlands
| | - Amit Bahl
- University Hospitals Bristol National Health Service Foundation Trust-Bristol Haematology and Oncology Centre, Bristol Avon, United Kingdom
| | | | - David Azria
- Institut du Cancer de Montpellier, Université de Montpellier, INSERM U1194, Montpellier, France
| | - Jan Jansa
- Klinika Onkologie a Radioterapie-Fakultni nemocnice Hradec Kralove, Hradec Kralove, Czech Republic
| | - Joe M O'Sullivan
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, Ireland
| | - Alphonsus C M Van Den Bergh
- Radiotherapy Department, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Laurence Collette
- European Organization for Research and Treatment of Cancer, Brussels, Belgium
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Roy S, Grimes S, Morgan SC, Eapen L, Malone J, Craig J, Spratt DE, Malone S. Patient-Reported Outcomes From a Phase 3 Randomized Controlled Trial Exploring Optimal Sequencing of Short-Term Androgen Deprivation Therapy With Prostate Radiation Therapy in Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2021; 110:1101-1113. [PMID: 33524545 DOI: 10.1016/j.ijrobp.2021.01.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE Two phase 3 randomized controlled trials (OTT-0101, RTOG-9413) and a meta-analysis have shown an impact of sequencing of androgen deprivation therapy (ADT) and radiation therapy on oncologic outcomes in prostate cancer (PCa). However, the impact of sequencing strategy on health-related quality of life (HR-QoL) is unclear. Here, we present the patient-reported HR-QoL outcomes from the OTT-0101 study. METHODS AND MATERIALS In this trial, patients with PCa with Gleason score ≤7, clinical stage T1b to T3a, and prostate-specific antigen level <30 ng/mL were randomly assigned to neoadjuvant and concurrent ADT for 6 months, starting 4 months before or concurrent with prostate radiation therapy, or concurrent and adjuvant ADT for 6 months, starting simultaneously with prostate radiation therapy. HR-QoL was assessed using European Organisation for Research and Treatment of Cancer QoL questionnaires. Time until definitive deterioration was defined as time from random allocation to the first deterioration of at least 10 points with no further improvement of ≥10 points or if the patient experienced progression, died, or dropped out after deterioration, resulting in missing data. Stratified log-rank tests were applied for between-group comparisons of time-to-event estimates. RESULTS Overall, 393 patients (194 and 199 in the 2 arms, respectively) were evaluable, except 214 (101 and 113 in the 2 arms, respectively) for sexual function. Five-year rates of freedom from definitive deterioration of urinary symptoms, bowel symptoms, and sexual activity were 33.5%, 33.1%, and 38.5% in the neoadjuvant group and 34.1%, 35.4%, and 36.7% in the adjuvant group, respectively, with no significant between-group differences. The adjuvant approach was associated with a reduced risk of definitive deterioration of sexual function (hazard ratio, 0.68; 95% confidence interval, 0.49-0.94; P = .02). With respect to clinical relevance, the mean change in score for sexual function showed only a small to moderate difference favoring the adjuvant group at and beyond 3 years. CONCLUSIONS In this study, no differences were found in the bowel or urinary symptoms between the adjuvant and neoadjuvant approach. Considering a significant likelihood of type I and type II errors and because of a lack of a persistent and clinically meaningful between-group difference in mean score changes over time, our findings do not confer a clear and conclusive picture of the impact of sequencing strategy on sexual function.
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Affiliation(s)
- Soumyajit Roy
- New York Medical College, New York, New York; Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada; Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Scott Grimes
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada; Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Scott Carlyle Morgan
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada; Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Libni Eapen
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada; Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Julia Malone
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada; Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Julia Craig
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada; Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Eidelberg Spratt
- Department of Radiation Oncology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Shawn Malone
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada; Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada.
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45
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Dorff TB, O'Neil B, Hoffman KE, Lin DW, Loughlin KR, Dall'Era M. 25-year perspective on prostate cancer: Conquering frontiers and understanding tumor biology. Urol Oncol 2021; 39:521-527. [PMID: 34266741 DOI: 10.1016/j.urolonc.2021.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 10/20/2022]
Abstract
Major changes in the field of prostate cancer over the last 25 years include the implementation of prostate specific antigen screening and the recognition that BRCA confers hereditary risk of prostate cancer. Quality of life and survivorship have driven risk stratification for localized prostate cancer, facilitated by molecular signatures and leading to increased acceptance of active surveillance as a mainstream treatment option. Advances in technology have improved efficacy and reduced toxicity in both radical prostatectomy and radiation therapy for localized prostate cancer. Improved understanding of the androgen receptor has yielded substantially more effective therapies. Future growth areas include personalized treatment based on genomic and genetic information, theranostics radiopharmaceuticals, and more aggressive treatment of metastatic disease to include focal therapy. Multidisciplinary management between specialized urologists, radiation oncologists, and medical oncologists remains central to maximizing patient outcomes.
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Affiliation(s)
- Tanya B Dorff
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center. Duarte, CA.
| | - Brock O'Neil
- Department of Urology, University of Utah Huntsman Comprehensive Cancer Center. Salt Lake City, UT
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center. Houston, TX
| | - Daniel W Lin
- Department of Urology, University of Washington, Seattle Cancer Care Alliance. Seattle, WA
| | - Kevin R Loughlin
- Vascular biology research laboratory, Boston Children's Hospital. Boston, MA
| | - Marc Dall'Era
- Department of Urology, University of California Davis Comprehensive Cancer Center. Davis, CA
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46
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Peixoto GA, Korkes F, Pazeto CL, De Castro MG, Lima TFN, Wroclawski ML, Christofe NM, Tobias-Machado M, Santiago LHS, Glina S. The influence of testosterone suppression on HER2 immunoexpression in prostatic neoplastic tissue. Mol Clin Oncol 2021; 15:185. [PMID: 34277004 PMCID: PMC8278412 DOI: 10.3892/mco.2021.2347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/17/2021] [Indexed: 12/04/2022] Open
Abstract
During initial risk assessments, the metastatic potential of prostate cancer (PCa) may not be fully considered. The tumor's multicentric origin, which is associated with genetic mutations, may explain existing treatment limitations. Investigating human epidermal growth factor receptor 2 (HER2) expression in patients with different stages of PCa may therefore increase understanding of the mechanisms associated with the development of castration resistance. The present study examined the association between HER2 expression and the histologic features of PCa subjected to radical prostatectomy (RP) and evaluated the role of testosterone suppression in HER2 expression. In group 1, specimens from individuals who underwent RP without prior neoadjuvant androgen deprivation therapy (ADT) were included (n=42). In group 2 (PCa with ADT), specimens from individuals who underwent RP and received neoadjuvant cyproterone acetate during distinct periods (200 mg daily for 1-24 months) were included (n=150; cohort derived from a previous study). Immunohistochemical expression of HER2 was associated with prognostic factors such as perineural invasion, extra-prostatic disease, T stage, serum prostate-specific antigen (PSA), angiolymphatic invasion and surgical margins. Univariate regression analysis indicated that perineural invasion, PSA, International Society of Urological Pathology, angiolymphatic invasion, margin, T stage and neoadjuvant ADT was associated with HER2 expression. Ordinal regression analysis indicated a significant effect of neoadjuvant ADT alone on HER2 expression (P<0.001). In addition, regression analysis indicated a significant effect of neoadjuvant ADT alone on HER2 expression (odd ratio=0.01; 95% CI, 0.00, 0.02; P<0.001). HER2 was expressed in PCa samples but was not associated with known prognostic factors. The use of short-acting ADT and the consequent blockage of testosterone effect may suppress the expression of HER2 in PCa cells.
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Affiliation(s)
- Guilherme Andrade Peixoto
- Department of Urology, Centro Universitário FMABC, Santo André, São Paulo 09060-870, Brazil.,Department of Urology, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Fernando Korkes
- Department of Urology, Centro Universitário FMABC, Santo André, São Paulo 09060-870, Brazil.,Department of Urology, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Cristiano Linck Pazeto
- Department of Urology, Centro Universitário FMABC, Santo André, São Paulo 09060-870, Brazil.,Department of Urology, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | | | | | - Marcelo Langer Wroclawski
- Department of Urology, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil.,Department of Urology, Beneficência Portuguesa de São Paulo, São Paulo 01323-001, Brazil
| | - Nicolle Martin Christofe
- Department of Urology, Centro Universitário FMABC, Santo André, São Paulo 09060-870, Brazil.,Department of Urology, Faculty of Ciências Médicas da Santa Casa de São Paulo, São Paulo 01238-010, Brazil
| | - Marcos Tobias-Machado
- Department of Urology, Centro Universitário FMABC, Santo André, São Paulo 09060-870, Brazil
| | | | - Sidney Glina
- Department of Urology, Centro Universitário FMABC, Santo André, São Paulo 09060-870, Brazil.,Department of Urology, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
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47
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Wang V, Geybels MS, Jordahl KM, Gerke T, Hamid A, Penney KL, Markt SC, Freedman M, Pomerantz M, Lee GSM, Rana H, Börnigen D, Rebbeck TR, Huttenhower C, Eeles RA, Stanford JL, Consortium P, Berndt SI, Claessens F, Sørensen KD, Park JY, Vega A, Usmani N, Mucci L, Sweeney CJ. A polymorphism in the promoter of FRAS1 is a candidate SNP associated with metastatic prostate cancer. Prostate 2021; 81:683-693. [PMID: 33956343 PMCID: PMC8491321 DOI: 10.1002/pros.24148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/19/2021] [Accepted: 04/22/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Inflammation and one of its mediators, NF-kappa B (NFκB), have been implicated in prostate cancer carcinogenesis. We assessed whether germline polymorphisms associated with NFκB are associated with the risk of developing lethal disease (metastases or death from prostate cancer). METHODS Using a Bayesian approach leveraging NFκB biology with integration of publicly available datasets we used a previously defined genome-wide functional association network specific to NFκB and lethal prostate cancer. A dense-module-searching method identified modules enriched with significant genes from a genome-wide association study (GWAS) study in a discovery data set, Physicians' Health Study and Health Professionals Follow-up Study (PHS/HPFS). The top 48 candidate single nucleotide polymorphisms (SNPs) from the dense-module-searching method were then assessed in an independent prostate cancer cohort and the one SNP reproducibly associated with lethality was tested in a third cohort. Logistic regression models evaluated the association between each SNP and lethal prostate cancer. The candidate SNP was assessed for association with lethal prostate cancer in 6 of 28 studies in the prostate cancer association group to investigate cancer associated alterations in the genome (PRACTICAL) Consortium where there was some medical record review for death ascertainment which also had SNP data from the ONCOARRAY platform. All men self-identified as Caucasian. RESULTS The rs1910301 SNP which was reproducibly associated with lethal disease was nominally associated with lethal disease (odds ratio [OR] = 1.40; p = .02) in the discovery cohort and the minor allele was also associated with lethal disease in two independent cohorts (OR = 1.35; p = .04 and OR = 1.35; p = .07). Fixed effects meta-analysis of all three cohorts found an association: OR = 1.37 (95% confidence interval [CI]: 1.15-1.62, p = .0003). This SNP is in the promoter region of FRAS1, a gene involved in epidermal-basement membrane adhesion and is present at a higher frequency in men with African ancestry. No association was found in the subset of studies from the PRACTICAL consortium studies which had a total of 106 deaths out total of 3263 patients and a median follow-up of 4.4 years. CONCLUSIONS Through its connection with the NFκB pathway, a candidate SNP with a higher frequency in men of African ancestry without cancer was found to be associated with lethal prostate cancer across three well-annotated independent cohorts of Caucasian men.
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Affiliation(s)
- Victoria Wang
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Milan S Geybels
- Division of Public Health Sciences, Fred Hutchison Cancer Research Center, Seattle, Washington, USA
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Kristina M Jordahl
- Division of Public Health Sciences, Fred Hutchison Cancer Research Center, Seattle, Washington, USA
| | - Travis Gerke
- Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anis Hamid
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Kathryn L Penney
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah C Markt
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Matthew Freedman
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mark Pomerantz
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Gwo-Shu M Lee
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Huma Rana
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniela Börnigen
- University Medical Center Hamburg-Eppendorf, Bioinformatics Core, Hamburg, Germany
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
- The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Timothy R Rebbeck
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Curtis Huttenhower
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
- The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Ros A Eeles
- Oncogenetics, Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Janet L Stanford
- Division of Public Health Sciences, Fred Hutchison Cancer Research Center, Seattle, Washington, USA
| | - Practical Consortium
- Prostate Cancer Association Group to Investigate Cancer Associated Alterations in the Genome
| | - Sonja I Berndt
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Frank Claessens
- Molecular Endocrinology Laboratory, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Karina D Sørensen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Jong Y Park
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Ana Vega
- Fundación Pública Galega Medicina Xenómica, Santiago de Compostela, Spain
| | - Nawaid Usmani
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Lorelei Mucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Christopher J Sweeney
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
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48
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Joyce DD, Wallis CJD, Luckenbaugh AN, Huelster HL, Zhao Z, Hoffman KE, Huang LC, Koyama T, Conwill R, Goodman M, Hamilton AS, Wu XC, Paddock LE, Stroup A, Cooperberg MR, Hashibe M, Neil BBO, Kaplan SH, Greenfield S, Penson DF, Barocas DA. Sexual function outcomes of radiation and androgen deprivation therapy for localized prostate cancer in men with good baseline function. Prostate Cancer Prostatic Dis 2021; 25:238-247. [PMID: 34108648 DOI: 10.1038/s41391-021-00405-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/23/2021] [Accepted: 05/27/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Sexual dysfunction, including erectile dysfunction and loss of libido, are common among men undergoing treatment for localized prostate cancer. Both local treatments and systemic androgen deprivation therapy may contribute to these outcomes and are differentially indicated based on disease characteristics. We sought to compare sexual function through 5 years after radiation treatment with and without androgen deprivation therapy in men with good baseline sexual function to better understand long-term effects in this understudied subset of patients. METHODS We retrospectively reviewed a prospectively assembled population-based cohort of men who underwent radiation with and without androgen deprivation therapy for intermediate or high-risk localized prostate cancer. Sexual function was assessed longitudinally over 5 years. Men with erections sufficient for intercourse at baseline were selected for inclusion. RESULTS Out of 167 patients included, 73 underwent radiation alone and 94 received androgen deprivation therapy plus radiation (51 with intermediate and 43 with high-risk disease). Androgen deprivation therapy use was associated with worse sexual function through 1 year regardless of disease risk. This difference was no longer statistically significant at 3 years in the intermediate-risk group. Compared to radiation alone, androgen deprivation therapy in high-risk disease was associated with worse sexual function at 3 years (effect: -20.3 points, CI [-31.8, -8.8], p < 0.001) but not at 5 years (effect: -3.4, CI [-17.2, 10.5], p = 0.63). CONCLUSIONS Androgen deprivation therapy plus radiation is associated with worse sexual function through 3-years follow-up in men with high-risk prostate cancer compared to radiation alone. The addition of androgen deprivation therapy in the treatment of intermediate-risk disease does not appear to result in worse sexual function at 3 or 5-year follow-up compared to radiation alone.
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Affiliation(s)
- Daniel D Joyce
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | | | - Amy N Luckenbaugh
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Heather L Huelster
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ralph Conwill
- Office of Patient and Community Education, Patient Advocacy Program, Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Goodman
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Ann S Hamilton
- Department of Preventative Medicine, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | - Xiao-Cheng Wu
- Department of Epidemiology, Louisiana State University New Orleans School of Public Health, New Orleans, LA, USA
| | - Lisa E Paddock
- Department of Epidemiology, Cancer Institute of New Jersey, Rutgers Health, New Brunswick, NJ, USA
| | - Antoinette Stroup
- Department of Epidemiology, Cancer Institute of New Jersey, Rutgers Health, New Brunswick, NJ, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
| | - Mia Hashibe
- Department of Family and Preventative Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Brock B O' Neil
- Department of Urology, University of Utah Health, Salt Lake City, UT, USA
| | - Sherrie H Kaplan
- Department of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Sheldon Greenfield
- Department of Medicine, University of California, Irvine, Irvine, CA, USA
| | - David F Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel A Barocas
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
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49
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Genomic Strategies to Personalize Use of Androgen Deprivation Therapy With Radiotherapy. ACTA ACUST UNITED AC 2021; 26:13-20. [PMID: 31977380 DOI: 10.1097/ppo.0000000000000419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The use of combination RT and androgen deprivation therapy in many prostate cancer curative-intent treatment scenarios is supported by level 1 evidence. However, in our current clinical paradigm, we have no ability to determine a priori which patients truly benefit from combination therapy and therefore apply the combination RT and androgen deprivation therapy intensification strategy to all patients, which results in overtreatment or undertreatment of the majority of our patients. Genomics has the ability to more deeply and objectively characterize the disease, in turn refining our prognostication capabilities and enabling the individualization of treatments. We review the commercially available prostate cancer genomic tests, focusing on those able to predict patient outcomes following radiotherapy or guide radiotherapy treatment decisions.
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50
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Jan I, Parikh RR. Feeding the Controversy: When Pelvic Irradiation Improves Outcomes in High-Risk and Very High-Risk Prostate Cancer. J Clin Oncol 2021; 39:1196-1202. [PMID: 33683923 DOI: 10.1200/jco.20.03636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.
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Affiliation(s)
- Imraan Jan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
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