Changes in incidence, survival and mortality of prostate cancer in Europe and the United States in the PSA era: additional diagnoses and avoided deaths

Aggressive Prostate Cancer in Patients Treated with Active Surveillance

Active surveillance has emerged as a promising approach for managing low-risk and favorable intermediate-risk prostate cancer (PC), with the aim of minimizing overtreatment and maintaining the quality of life. However, concerns remain about identifying "aggressive prostate cancer" within the active surveillance cohort, which refers to cancers with a higher potential for progression. Previous studies are predictors of aggressive PC during active surveillance. To address this, a personalized risk-based follow-up approach that integrates clinical data, biomarkers, and genetic factors using risk calculators was proposed. This approach enables an efficient risk assessment and the early detection of disease progression, minimizes unnecessary interventions, and improves patient management and outcomes. As active surveillance indications expand, the importance of identifying aggressive PC through a personalized risk-based follow-up is expected to increase.

Active Surveillance for Prostate Cancer: Past, Current, and Future Trends

In response to the rising incidence of indolent, low-risk prostate cancer (PCa) due to increased prostate-specific antigen (PSA) screening in the 1990s, active surveillance (AS) emerged as a treatment modality to combat overtreatment by delaying or avoiding unnecessary definitive treatment and its associated morbidity. AS consists of regular monitoring of PSA levels, digital rectal exams, medical imaging, and prostate biopsies, so that definitive treatment is only offered when deemed necessary. This paper provides a narrative review of the evolution of AS since its inception and an overview of its current landscape and challenges. Although AS was initially only performed in a study setting, numerous studies have provided evidence for the safety and efficacy of AS which has led guidelines to recommend it as a treatment option for patients with low-risk PCa. For intermediate-risk disease, AS appears to be a viable option for those with favourable clinical characteristics. Over the years, the inclusion criteria, follow-up schedule and triggers for definitive treatment have evolved based on the results of various large AS cohorts. Given the burdensome nature of repeat biopsies, risk-based dynamic monitoring may further reduce overtreatment by avoiding repeat biopsies in selected patients.

Prediction of prostate cancer recurrence after radiation therapy using multiparametric magnetic resonance imaging and spectroscopy: assessment of prognostic factors on pretreatment imaging

BACKGROUND

To assess whether data from pre-therapeutic multiparametric magnetic resonance imaging (mpMRI) combined with three-dimensional magnetic resonance spectroscopy (3D MRS) provide prognostic factors of biochemical relapse in patients with localized prostate cancer treated by external radiotherapy or brachytherapy.

METHODS

In our single institution observational retrospective study we included a cohort of 230 patients treated by external radiotherapy or brachytherapy who had an initial mpMRI with 3D MRS from January 2008 to December 2015 for newly diagnosed localized prostatic cancer, proven histologically. Three trained radiologists recorded tumor characteristics, MRI T-stage and metabolic abnormalities from 3D MRS data. Univariate and multivariate Cox analyzes explored the relationship between clinical and imaging variables to highlight prognostic factors for recurrence, using biochemical relapse as the primary endpoint.

RESULTS

mpMRI data analysis allowed to reclassify 21.7% of the patients in a MRI National Comprehensive Cancer Network (NCCN) group higher than their initial clinical T-stage, but also to detect a lesion in 78% of the patients considered as clinically T1c. After a median of follow-up of 8.7 years (IQR, 6.6-10.1) following cancer diagnosis, 36 (16%) patients developed a biochemical relapse. The multivariate Cox analysis demonstrated the existence of 3 independent factors for prediction of biochemical recurrence: extracapsular extension (ECE) (HR =3.33; 95% CI: 1.93-5.73; P<0.01), choline/citrate ratio in healthy tissue in the transition zone (TZ) (HR =2.96; 95% CI: 1.06-8.28; P=0.04) and the NCCN Magnetic Resonance Imaging classification (intermediate versus low-risk, HR =3.06; 95% CI: 1.13-8.30; P<0.01).

CONCLUSIONS

Combination of mpMRI and 3DMRS could aid in the prognostic stratification of localized prostate cancer treated by radiotherapy or brachytherapy, by combining accurate evaluation of tumor extension, and quantification of prostate metabolism.

A Novel Risk Score (P-score) Based on a Three-Gene Signature, for Estimating the Risk of Prostate Cancer-Specific Mortality

Purpose

To develop and validate a risk score (P-score) algorithm which includes previously described three-gene signature and clinicopathological parameters to predict the risk of death from prostate cancer (PCa) in a retrospective cohort.

Patients and Methods

A total of 591 PCa patients diagnosed between 2003 and 2008 in Stockholm, Sweden, with a median clinical follow-up time of 7.6 years (1–11 years) were included in this study. Expression of a three-gene signature (IGFBP3, F3, VGLL3) was measured in formalin-fixed paraffin-embedded material from diagnostic core needle biopsies (CNB) of these patients. A point-based scoring system based on a Fine-Gray competing risk model was used to establish the P-score based on the three-gene signature combined with PSA value, Gleason score and tumor stage at diagnosis. The endpoint was PCa-specific mortality, while other causes of death were treated as a competing risk. Out of the 591 patients, 315 patients (estimation cohort) were selected to develop the P-score. The P-score was subsequently validated in an independent validation cohort of 276 patients.

Results

The P-score was established ranging from the integers 0 to 15. Each one-unit increase was associated with a hazard ratio of 1.39 (95% confidence interval: 1.27–1.51, p < 0.001). The P-score was validated and performed better in predicting PCa-specific mortality than both D’Amico (0.76 vs 0.70) and NCCN (0.76 vs 0.71) by using the concordance index for competing risk. Similar improvement patterns are shown by time-dependent area under the curve. As demonstrated by cumulative incidence function, both P-score and gene signature stratified PCa patients into significantly different risk groups.

Conclusion

We developed the P-score, a risk stratification system for newly diagnosed PCa patients by integrating a three-gene signature measured in CNB tissue. The P-score could provide valuable decision support to distinguish PCa patients with favorable and unfavorable outcomes and hence improve treatment decisions.

Diagnostic and prognostic potential of the proteomic profiling of serum-derived extracellular vesicles in prostate cancer

Extracellular vesicles (EVs) and their cargo represent an intriguing source of cancer biomarkers for developing robust and sensitive molecular tests by liquid biopsy. Prostate cancer (PCa) is still one of the most frequent and deadly tumor in men and analysis of EVs from biological fluids of PCa patients has proven the feasibility and the unprecedented potential of such an approach. Here, we exploited an antibody-based proteomic technology, i.e. the Reverse-Phase Protein microArrays (RPPA), to measure key antigens and activated signaling in EVs isolated from sera of PCa patients. Notably, we found tumor-specific protein profiles associated with clinical settings as well as candidate markers for EV-based tumor diagnosis. Among others, PD-L1, ERG, Integrin-β5, Survivin, TGF-β, phosphorylated-TSC2 as well as partners of the MAP-kinase and mTOR pathways emerged as differentially expressed endpoints in tumor-derived EVs. In addition, the retrospective analysis of EVs from a 15-year follow-up cohort generated a protein signature with prognostic significance. Our results confirm that serum-derived EV cargo may be exploited to improve the current diagnostic procedures while providing potential prognostic and predictive information. The approach proposed here has been already applied to tumor entities other than PCa, thus proving its value in translational medicine and paving the way to innovative, clinically meaningful tools.

Influence of the diagnostic protocol and age on the prostate cancer incidence rate in Castilla y León according to the national registry 2010

OBJECTIVE

Cross-sectional descriptive observational study of incidence and association, to determine whether the higher incidence of prostate cancer in Castilla y León (with respect to the national rate) could be due to modifiable factors.

LOCATION

University Hospital Río Hortega.

PARTICIPANTS

New prostate cancer diagnoses.

MAIN MEASUREMENTS

Incidence rate (IR). Age, family history, symptoms, comorbidity, rectal examination, ultrasound volume (cc), PSA (ng/mL), cylinders, volume cylinder ratio, Gleason, TNM and D'Amico groups.

RESULTS

Castilla y León showed the highest prostate cancer IR in Spain (141.1 per 100,000 inhabitants per year), with a peak of early incidence (65-74 years) and significant differences in < 64 and 65-74 years. Age at diagnosis was the lowest (Castilla y León, 66.9 ±7.1 vs. Spain, 69.1 ± 8.2 years; P < .001). No differences: family history, symptoms, comorbidity and PSA. The number of cylinders was 10.7 ± 1.8. In multivariate analysis (AUC = 0.801; P < .001), they were more frequent in Castilla y León: grade i rectal examination, non-palpable rectal examination, Gleason < 6, stage T2c and the volume cylinder ratio < 6 (only in < 64 years: OR 5.2; 95% CI 1.2-22-22.3; P = .027). In Spanish regions, volume cylinder ratio showed inverse correlation with IR in < 74 years, while age showed positive correlation in all age groups.

CONCLUSIONS

The higher prostate cancer IR in Castilla y León in 2010 was not associated to an older population. However, the biopsy technique influenced IR, as more cylinders were obtained in younger subjects, without conditioning overdiagnosis.

Perineal recurrence of prostate cancer along a brachytherapy needle track: A case report

Metastatic recurrence in an atypical site, such as the perineum, can occur after prostatectomy, cryotherapy, or brachytherapy, but is uncommon. To our knowledge, this is only the third case of perineal recurrence of prostatic cancer along a low dose rate brachytherapy needle track. A 64-year-old man was referred to an urologist with an increased PSA of 6.9ng/mL in December 2008. There were no urinary symptoms. Prostatic biopsies revealed a Gleason 6 adenocarcinoma (3+3), and he was treated with low dose rate brachytherapy in May 2009. Sixty-seven seeds of iodine 125 were loaded under ultrasound control, and the PSA subsequently fell to a nadir of 1.19ng/mL in November 2015. Eight years (May 2017) after the initial treatment, the PSA rose to 5.2ng/mL. Pelvic MRI and choline PET revealed a nodule in the region of the left internal obturator muscle. Nodule biopsies confirmed prostatic origin. This perineal recurrence is thus most likely related to seeding of tumour cells along the track of a brachytherapy needle. To our knowledge, this is only the fourth case of perineal recurrence of prostatic cancer along a low-dose rate brachytherapy needle track. Perineal recurrence of prostatic cancer along a LDR brachytherapy needle track can occur. Improved imaging techniques may help to identify this type of recurrence earlier and optimise treatment.

Influence of the diagnostic protocol and age on the prostate cancer incidence rate in Castilla y León according to the national registry 2010

OBJECTIVE

Cross-sectional descriptive observational study of incidence and association, to determine whether the higher incidence of prostate cancer in Castilla y León (with respect to the national rate) could be due to modifiable factors.

LOCATION

University Hospital Río Hortega.

PARTICIPANTS

New prostate cancer diagnoses.

MAIN MEASUREMENTS

Incidence rate (IR). Age, family history, symptoms, comorbidity, rectal examination, ultrasound volume (cc), PSA (ng/mL), cylinders, volume cylinder ratio, Gleason, TNM and D'Amico groups.

RESULTS

Castilla y León showed the highest prostate cancer IR in Spain (141.1 per 100,000 inhabitants per year), with a peak of early incidence (65-74 years) and significant differences in<64 and 65-74 years. Age at diagnosis was the lowest (Castilla y León, 66.9±7.1 vs. Spain, 69.1±8.2 years; P<.001). No differences: family history, symptoms, comorbidity and PSA. The number of cylinders was 10.7±1.8. In multivariate analysis (AUC=0.801; P<.001), they were more frequent in Castilla y León: grade i rectal examination, non-palpable rectal examination, Gleason<6, stage T2c and the volume cylinder ratio<6 (only in<64 years: OR 5.2; 95% CI 1.2-22.3; P=.027). In Spanish regions, volume cylinder ratio showed inverse correlation with IR in<74 years, while age showed positive correlation in all age groups.

CONCLUSIONS

The higher prostate cancer IR in Castilla y León in 2010 was not associated to an older population. However, the biopsy technique influenced IR, as more cylinders were obtained in younger subjects, without conditioning overdiagnosis.

Recent Advances and Current Role of Transperineal Prostate Biopsy

"Approximately 1 million prostate biopsies are performed each year in the United States. This procedure has traditionally been performed using a transrectal approach, which is associated with a significant risk of infectious complications including sepsis. In recent years, transperineal prostate biopsy has been increasingly adopted due to its lower associated infectious risk. In this review, we explore the benefits of the transperineal approach for performing prostate biopsy and detail technical advancements that have allowed for this procedure to now be routinely performed in the outpatient settings under local anesthesia."

Salvage Focal Cryotherapy Offers Similar Short-term Oncologic Control and Improved Urinary Function Compared With Salvage Whole Gland Cryotherapy for Radiation-resistant or Recurrent Prostate Cancer

BACKGROUND

We compared the short-term oncologic and functional outcomes of salvage focal cryotherapy (SFC) with those of salvage total cryotherapy (STC) for radiotherapy (RT)-persistent/recurrent prostate cancer.

MATERIALS AND METHODS

We queried the Cryo On-Line Database registry for men who had undergone SFC and STC of the prostate for RT-persistent or recurrent disease. Propensity score weighting was used to match age at treatment, presalvage therapy prostate-specific antigen level, Gleason sum, and presalvage cryotherapy androgen deprivation therapy status. The primary outcome was progression-free survival.

RESULTS

A total of 385 men with biopsy-proven persistent or recurrent prostate cancer after primary RT were included in the present study. The median follow-up, age, prostate-specific antigen, and Gleason sum before salvage cryotherapy was 24.4 months (first and third quartile, 9.8 and 60.3), 70 years (first and third quartile, 66 and 74 years), 4 ng/dL (first and third quartile, 2.7 and 5.6 ng/dL), and 7 (first and third quartile, 6 and 8), respectively. After propensity score weighting, the difference in progression-free survival was not statistically significant between the patients who had undergone STC and those who had undergone SFC (79.8% vs. 76.98%; P = .11 on weighted log-rank test). SFC was associated with a lower probability of post-treatment transient urinary retention (5.6% vs. 22.4%; P < .001). No significant differences were found in the incidence of rectal fistula (1.4% vs. 3.8; P = .30), new-onset urinary incontinence within 12 months (9.3% vs. 15.1%; P = .19), or new-onset erectile dysfunction within 12 months (52.6% vs. 59.6%; P = .47) between the SFC and STC groups, respectively.

CONCLUSIONS

STC resulted in similar 2-year oncologic outcomes compared with SFC in the RT-persistent/recurrent disease population. However, the patients who had undergone SFC had a lower urinary retention rate compared with those who had undergone STC.

Role of novel hormonal therapies in the management of non-metastatic castration-resistant prostate cancer: a literature-based meta-analysis of randomized trials

BACKGROUND

Novel hormonal therapies have been recently investigated in non-metastatic castration-resistant prostate cancer (CRPC). We performed a meta-analysis to assess the efficacy and safety of novel hormonal therapies in non-metastatic CRPC.

MATERIALS AND METHODS

The primary outcome was metastasis-free survival (MFS). The secondary endpoints were overall survival (OS), time to PSA progression and safety. We planned a subgroup analysis according to the PSA doubling time (> 6 vs < 6 months), Eastern Cooperative Oncology Group (ECOG) performance status (1 vs 0) and concomitant use of bone-targeting agent (yes vs no).

RESULTS

Pooled analysis of novel hormonal therapies revealed significantly increased MFS compared with placebo (hazard ratio (HR): HR = 0.32, 95% CI 0.25-0.41; p < 0.00001). The subgroup analysis showed a statistically significant MFS advantage in favour of men with the lower ECOG performance status. Other secondary endpoints favoured the novel hormonal therapies. The relative risk (RR) of grade ≥ 3 adverse events and ≥ 3 hypertension was 1.31 and 1.39, respectively.

CONCLUSIONS

This study confirmed the efficacy and safety of the novel hormonal therapies in non-metastatic CRPC.

Prostate cancer incidence and mortality in the Baltic states, Belarus, the Russian Federation and Ukraine

BACKGROUND

Prostate cancer incidence varies internationally largely attributable to differences in prostate-specific antigen (PSA) use. The aim of this study was to provide the most recent detailed international epidemiological comparison of prostate cancer incidence and mortality in six north-eastern European countries (Belarus, Estonia, Latvia, Lithuania, the Russian Federation and Ukraine).

METHODS

The number of incident prostate cancer cases was obtained from the countries national cancer registries. Prostate cancer mortality and corresponding population data were extracted from the WHO Mortality Database. Age-specific and age-standardised incidence and mortality rates were calculated (European Standard). The joinpoint regression model was used to provide an average annual percentage change and to detect points in time where significant changes in trends occurred. The observation period was between 13 (Ukraine) and 48 (Estonia) years regarding incidence and around 30 years regarding mortality.

RESULTS

The comparison of prostate cancer incidence in six European countries showed almost sixfold differences in the age-adjusted rates in most recent years with highest incidence rates in Lithuania and Estonia. Through the observation period, overall a continuous rise was seen in incidence in all countries and a continuous rise in mortality, with a stabilisation in Estonia and a decrease in Lithuania in recent years. Data limitations included a descriptive design using ecological data.

CONCLUSIONS

A widespread use of PSA testing seems to be responsible for the changes in the epidemiology of the disease in north-eastern European countries. Substantial variation in the incidence of prostate cancer in the Baltic states suggests the possibility that PSA performance and utilisation spread have had a major influence on observed incidence trends, with a lack of effect on prostate cancer mortality.

An expanded biomarker panel for the detection of prostate cancer from urine DNA

Background

Prostate cancer diagnosis using the PSA test remains controversial because of overdiagnosis and overtreatment of potentially indolent cancers. There remains a need to increase the diagnostic lead time and to target treatment to patients with significant disease. One possible approach to overcome the limitations of PSA is to screen men for the molecular signature of early PCA, monitor the rate of disease progression and target treatment to patients who are likely to benefit from it. Such an approach requires a large panel of markers that define a molecular clock for PCA. We recently developed a panel of 19 markers for the non-invasive detection of PCA from urine DNA. It raised the possibility that additional methylation markers could be successfully analyzed from urine DNA, a prerequisite for increasing the diagnostic lead time and enabling disease monitoring.

Methods

We developed semi-quantitative polymerase chain reaction assays for 13 additional markers and determined their methylation status in 150 urine DNAs from 94 patients with elevated PSA. Eighty five samples were obtained following DRE and 65 samples were from first void. We combined the data of the 13 new markers with the previously reported 19 markers and calculated the sensitivity, specificity, negative and positive predictive values at every threshold from one to 32 positive markers.

Results

Using 10of32 positive markers as the threshold to recommend a biopsy yields a sensitivity of 81% (95% CI 0.68–0.93) and 93% (95% CI 0.84–1.02) and a specificity of 76% (95% CI 0.63–0.88) and 77% (95% CI 0.63–0.91) from DRE and FV DNA, respectively. The PPV was 71% and 77% and the NPV was 85% and 93% from DRE and FV, respectively.

Conclusions

This study shows that large marker panels can be analyzed from urine DNA without loss of sensitivity or specificity. Using 32 markers improved the stratification of patients undergoing screening for PCA particularly for patients below the 10of32 threshold. The results show the utility of larger biomarker panels for PCA diagnosis and suggest that the development of the panels needed to monitor disease progression could be successfully accomplished.

Electronic supplementary material

The online version of this article (10.1186/s40164-019-0137-x) contains supplementary material, which is available to authorized users.

Stereotactic prostate focal reirradiation therapy for local recurrence: preliminary results of Hartmann Oncology Radiotherapy Group

Objective

Our objective was to report our experience and to evaluate the feasibility and toxicity of focal salvage stereotactic body radiation therapy (SBRT) in patients with post-radiation local recurrence of prostate cancer.

Methods

We retrospectively reviewed medical records of patients treated with Cyberknife ^® between October 2014 and April 2017 at our institution for a focal reirradiation delivered to the prostate/prostatic bed for local recurrence after radical or adjuvant radiotherapy. All patients underwent prostate biopsies at recurrence at the time of fiducial markers placement, had choline PET/CT and pelvic MRI. The treatment consisted in 36 Gy in six fractions delivered every other day. Post reirradiation toxicities were assessed according to the CTCAE v4 (Common Terminology Criteria for Adverse Events).

Results

42 patients were treated with followed with a median follow-up of 21 months (range 3 - 31). 34 patients had biopsy proven recurrence. The initial treatment was radical prostatectomy and radiation therapy for 9 patients and radiation therapy alone for 33 patients. 23 patients from the group of prostate reirradiation had placement of rectal spacers. No Grade 4 or 5 toxicity were observed. 27 acute urinary events were recorded: 18 patients experienced Grade 1, 9 patients experienced Grade 2 toxicity and 1 patient experienced Grade 3 urinary toxicity, namely cystitis and/or dysuria. No Grade 2 or more digestive toxicity was observed. Rectal doses were significantly lower with rectal spacers.

Conclusion

Salvage focal Cyberknife ^® seems feasible and show promising results.

Advances in knowledge

SBRT for local prostate cancer recurrence after initial radiotherapy is well tolerated with short follow-up.

Key factors associated with social distress after prostate cancer: Results from the United Kingdom Life after Prostate Cancer diagnosis study

BACKGROUND

More men are living following a prostate cancer (PCa) diagnosis. They may need support to maximize the quality of their survival. Physical and psychological impacts of PCa are widely documented. Less is known about social impacts. We aimed to identify key factors associated with social distress following PCa.

METHODS

The Life After Prostate Cancer Diagnosis study is a UK national cross-sectional survey of men 18-42 months post diagnosis of PCa. Men (n = 58 930) were invited to participate by their diagnosing cancer centre including 82% of English NHS Trusts (n = 111) and 100% of all Health Boards in Northern Ireland (n = 5), Scotland (n = 14) and Wales (n = 6). Social distress was measured using the Social Difficulties Inventory (SDI-21), 16 item Social Distress scale with men assigned to 'socially distressed'/'not socially distressed' groups, according to published guidelines. Clinical and sociodemographic variables were collected from self-report and cancer registries.

RESULTS

Response rate 60.8% (n = 35 823) of whom 97% (n = 29 351) completed the Social Distress scale (mean age = 71.2; SD = 7.88). The proportion of 'socially distressed' men was 9.4%. Multivariable logistic regression analysis revealed unemployment versus employment (odds ratio (OR): 11.58 [95% CI 9.16-14.63]) and ≥3 co-morbidities versus none (OR: 5.37 [95% CI 4.61-6.27]) as key associations. Others were Androgen Deprivation Therapy, External Beam Radiotherapy in combination with another treatment, age, prior mental health problems and living in a socio-economically deprived area.

CONCLUSION

Most men following PCa are socially resilient. A simple checklist could help clinicians identify men at risk of social distress.

Liquid Biopsy Potential Biomarkers in Prostate Cancer

Prostate cancer (PCa) is the second most common cancer in men worldwide with an incidence of 14.8% and a mortality of 6.6%. Shortcomings in comprehensive medical check-ups in low- and middle-income countries lead to delayed detection of PCa and are causative of high numbers of advanced PCa cases at first diagnosis. The performance of available biomarkers is still insufficient and limited applicability, including logistical and financial burdens, impedes comprehensive implementation into health care systems. There is broad agreement on the need of new biomarkers to improve (i) early detection of PCa, (ii) risk stratification, (iii) prognosis, and (iv) treatment monitoring. This review focuses on liquid biopsy tests distinguishing high-grade significant (Gleason score (GS) ≥ 7) from low-grade indolent PCa. Available biomarkers still lack performance in risk stratification of biopsy naïve patients. However, biomarkers with highly negative predictive values may help to reduce unnecessary biopsies. Risk calculators using integrative scoring systems clearly improve decision-making for invasive prostate biopsy. Emerging biomarkers have the potential to substitute PSA and improve the overall performance of risk calculators. Until then, PSA should be used and may be replaced whenever enough evidence has accumulated for better performance of a new biomarker.

Toll-Like Receptor 4 (TLR4)/Cyclooxygenase-2 (COX-2) Regulates Prostate Cancer Cell Proliferation, Migration, and Invasion by NF-κB Activation

Background

Toll-like receptor 4 (TLR4)-mediated signaling has been implicated in invasion, metastasis, and survival of various cancers. Activation of TLR4 can promote cyclooxygenase-2 (COX-2) and nuclear factor-κB (NF-κB). However, little is known about the effects of TLR4/COX-2 in prostate cancer (PCa).

Material/Methods

In our study, TLR4 and COX-2 expressions were detected by quantitative real-time reverse transcription PCR (qRT-PCR) in PCa tissues (n=34). Cell proliferation was measured by Cell Counting Kit-8 (CCK-8) and carboxyfluorescein succinimidyl ester (CFSE) assays. The migration and invasion abilities were detected by wound healing and Transwell assays. qRT-PCR and western blot assays were performed to detect TLR4, COX-2, matrix metalloproteinase (MMP)-2, MMP-9, tissue inhibitor of matrix metalloproteinases (TIMP)-1, epithelial-cadherin (E-cadherin), vimentin, NF-κB (p65), and p-p65 expressions.

Results

The results revealed that TLR4 and COX-2 were upregulated in PCa tissues; Silencing of TLR4 or COX-2 inhibited PCa cell proliferation, migration, and invasion, and TLR4 siRNAs combined with COX-2 siRNAs synergistically suppressed PCa cell proliferation, migration, and invasion. Silencing of TLR4 or COX-2 also downregulated MMP-2, MMP-9, and E-cadherin expressions, and upregulated TIMP-1 and vimentin expressions. In addition, silencing of TLR4 or COX-2 inhibited p65 phosphorylation and had a synergistic effect.

Conclusions

We demonstrated that TLR4/COX-2 inhibits PCa cell proliferation, migration, and invasion by regulating NF-κB.

Survival of solid cancer patients in France, 1989-2013: a population-based study

This study provides updates of net survival (NS) estimates at 5, 10, and 15 years as well as survival trends for 35 solid cancers in France using data from 19 population-based cancer registries. The study considered all cases of solid cancer diagnosed between 1989 and 2010 in patients older than 15 years of age who were actively followed up until 30 June 2013. NS was estimated using the Pohar-Perme method. The age-standardized NS used the international cancer survival standard weights. The 5-year age-standardized NSs ranged from 4% (pleural mesothelioma) to 93% (prostate) in men and from 10% (pancreas) to 97% (thyroid) in women. The 10-year age-standardized NSs ranged from 2% (pleural mesothelioma) in both sexes to 95% (testis) in men and 91% (thyroid) in women. The most frequent cancers (namely, breast and prostate cancers) had the highest NSs: 87 and 93% at 5 years and 78 and 84% at 10 years, respectively. Several cancers (especially lung, pancreas, and liver cancer) had very poor prognoses (5-year NSs under 20%). Fifteen-year NSs remained high for testis cancer. In most cancers, 5- and 10-year age-standardized NSs increased between 1989 and 2010. Advanced age was associated with a poor prognosis and little improvement in survival. The increases in cancer survival are probably related to earlier diagnosis and therapeutic advances over the last decade. However, poor prognoses are still found in some alcohol-related and tobacco-related cancers and in elderly patients, highlighting the need for more prevention, diagnosis, and treatment efforts.

A population-based study examining the influence of a specialized rapid-access cancer clinic on initial treatment choice in localized prostate cancer

INTRODUCTION

Treatment decisions in localized prostate cancer are complicated by the available choices. A rapid-access cancer clinic (RAC) has been unique to Calgary, AB, since 2007. This RAC offers multidisciplinary prostate cancer education by a urologist, medical oncologist, and radiation oncologist. It is hypothesized that treatment utilization data from decisions taken at RAC may serve to benchmark the appropriateness of treatment decisions on a population level.

METHODS

Records of patients with clinically localized prostate cancer in Alberta between October 1, 2007 and September 30, 2009 were reviewed with ethics approval. Records were linked to the Alberta Cancer Registry database. Clinical, treatment, and health services characteristics pertaining to patients attending RAC were compared to the general population. The primary endpoint was utilization rates of each initial treatment.

RESULTS

During this two-year period, 2838 patients were diagnosed with localized prostate cancer; 375 attended RAC. The utilization rates among RAC patients vs. the whole Alberta population were: prostatectomy 60.3% (95% confidence interval [CI] 55.3-65.2) vs. 48.0% (95% CI 47.1-50.7; χ² p<0.001); active surveillance 16.0% (95% CI 12.3-19.7%) vs. 13.5% (95% CI 12.2-15.8; χ² p=0.214); radiotherapy 11.7% (95% CI 8.5-15.0) vs. 18.0% (95% CI 16.9-20.5; χ² p=0.002); and hormone therapy 8.0% (95% CI 5.2-10.8) vs. 17.4% (95% CI 16.1-18.9; χ² p<0.001).

CONCLUSIONS

A specialized clinic for localized prostate cancer may be associated with a higher likelihood of receiving surgery or active surveillance as initial treatment compared to the prostate cancer population in Alberta.

Recent views of heavy metals as possible risk factors and potential preventive and therapeutic agents in prostate cancer

Prostate cancer is the most common cancer in men in many industrialized countries. A role for androgens in prostate tumor progression is well recognized, while estrogens may cooperate with androgens in prostate carcinogenesis. The incidence of prostate cancer is highly variable in the different countries, suggesting an important role of environmental factors. Heavy metals are common environmental contaminants and some of them are confirmed or suspected human carcinogens. Some metals are endowed with estrogenic and/or androgenic activities and may play a role as cancer risk factors through this mechanism. Moreover, prostate cancer may present alterations in the intracellular balance of trace metals, such as zinc and copper, which are involved in several regulatory proteins. Herein, we review the possible role of environmental heavy metals and of metal-dyshomeostasis in prostate cancer development and promotion as well as the potential use of some metals in the prevention and therapy of prostate cancer.

Salvage Low Dose Rate Brachytherapy For Recurrent Prostate Cancer After External Beam Radiotherapy: Results From A Single Institution With Focus On Toxicity And Functional Outcomes

Background/aim:

Low dose rate brachytherapy has been used as salvage therapy for locally recurrent prostate cancer (PC) after primary external beam radiation therapy (EBRT), along with surgery and cryotherapy. All these techniques, in particular, when applied to the whole gland, involve a relatively high risk of toxicity and may worsen the patient’s quality of life. Our aim is to evaluate the results of whole-gland salvage brachytherapy (SBT) after primary EBRT in terms of toxicity, functional outcomes, and efficacy.

Materials and methods:

We retrospectively reviewed clinical data on 19 patients consecutively treated with SBT at our institution between June 2012 and November 2015. Local recurrences were identified with 11C-choline positron emission tomography/computed tomography and pelvic magnetic resonance imaging after biochemical recurrence according to Phoenix criteria (prostate-specific antigen nadir + 2). Low dose rate brachytherapy was performed by ¹²⁵I permanent seeds implantation to the whole prostate gland, with a prescription dose of 130 Gy. At the time of SBT, only 2 patients were receiving androgen deprivation therapy. Acute and late toxicities were recorded using the CTCAE 4.0 scoring system. Quality of life was assessed using IPSS (International Prostate Symptoms Score) and IIEF (International Index of Erectile Function) questionnaires at baseline and 6, 12, and 24 months after SBT, and the respective mean values were compared using Student t test. Biochemical relapse-free survival (BRFS) was also calculated.

Results:

Median follow-up after SBT was 24 months. Of 19 patients, 2 patients experienced a G3 cystitis (10.2%) and 1 patient experienced a G4 proctitis (5.3%), respectively. Mean pre-SBT IPSS scores and 6, 12, and 24 months after SBT were 5.84, 10.22, 15.72, and 8.10, respectively. Mean pre-SBT IIEF scores and 6, 12, and 24 months after SBT were 8.42, 3.55, 7.89, and 6.40, respectively. At the time of analysis, only 2 patients showed a biochemical relapse (3-year BRFS 85.2%). The Student t test demonstrated a worsening of functional outcome 6 months and 1 year after treatment but a subsequent improvement 2 years after SBT.

Conclusions:

Salvage brachytherapy for recurrent PC after primary EBRT seems to be a feasible treatment for selected patients. Our series revealed a severe toxicity peak 6 months and 1 year after local re-treatment and then they decrease. Early BRFS rates are good. However, these are very preliminary results so further patient accrual, long-term follow-up, and prospective trials are needed in the future.

Differential side effects profile in patients with mCRPC treated with abiraterone or enzalutamide: a meta-analysis of randomized controlled trials

BACKGROUND

Abiraterone and enzalutamide are currently approved for mCRPC patients. Both drugs have distinct mechanisms of action and may have different toxicity profile. There are limited data comparing the side effects of abiraterone and enzalutamide. We performed a meta-analysis of randomized controlled trials (RCT) to better characterize the risk of adverse events associated with both drugs.

METHODS

We performed a literature search on MEDLINE for studies reporting abiraterone and enzalutamide side effects from January 1966 to July 31, 2015. Abstracts presented at ASCO meetings from 2004 to 2015 were selected manually. Phase III RCT were included in analysis. We assessed the risk of adverse events reported in RCT by performing two meta-analyses: abiraterone-prednisone vs. placebo-prednisone (2,283 pts) and enzalutamide vs. placebo (2,914 pts). Summary of incidence, relative-risks (RR), and 95% confidence intervals (CI) were calculated using random-effects or fixed-effects models based on the heterogeneity of included studies.

RESULTS

Overall, enzalutamide was not associated with all-grade (RR 1.06 - 95% CI 0.67-1.65) or grade ≥3 (RR 0.81 - 95% CI 0.28-2.33) cardiovascular events, but was associated with increased risk of all-grade fatigue (RR 1.29 - 95% CI 1.15-1.44). On the other hand, abiraterone was associated with increased risk of all-grade (RR 1.28 - 95% CI 1.06-1.55) and grade ≥3 (RR 1.76 - 95% CI 1.12-2.75) cardiovascular events, but was not associated with all-grade (RR 0.85 - 95% CI 0.58-1.23) or grade ≥3 (RR 1.07 - 95% CI 0.97-1.19) fatigue.

CONCLUSIONS

In this meta-analysis, abiraterone was associated with an increased risk of cardiovascular events, while enzalutamide was associated with an increased risk of fatigue.

A Pooled Analysis of 15 Prospective Cohort Studies on the Association between Fruit, Vegetable, and Mature Bean Consumption and Risk of Prostate Cancer

Background: Relationships between fruit, vegetable, and mature bean consumption and prostate cancer risk are unclear.Methods: We examined associations between fruit and vegetable groups, specific fruits and vegetables, and mature bean consumption and prostate cancer risk overall, by stage and grade, and for prostate cancer mortality in a pooled analysis of 15 prospective cohorts, including 52,680 total cases and 3,205 prostate cancer-related deaths among 842,149 men. Diet was measured by a food frequency questionnaire or similar instrument at baseline. We calculated study-specific relative risks using Cox proportional hazards regression, and then pooled these estimates using a random effects model.Results: We did not observe any statistically significant associations for advanced prostate cancer or prostate cancer mortality with any food group (including total fruits and vegetables, total fruits, total vegetables, fruit and vegetable juice, cruciferous vegetables, and tomato products), nor specific fruit and vegetables. In addition, we observed few statistically significant results for other prostate cancer outcomes. Pooled multivariable relative risks comparing the highest versus lowest quantiles across all fruit and vegetable exposures and prostate cancer outcomes ranged from 0.89 to 1.09. There was no evidence of effect modification for any association by age or body mass index.Conclusions: Results from this large, international, pooled analysis do not support a strong role of collective groupings of fruits, vegetables, or mature beans in prostate cancer.Impact: Further investigation of other dietary exposures, especially indicators of bioavailable nutrient intake or specific phytochemicals, should be considered for prostate cancer risk. Cancer Epidemiol Biomarkers Prev; 26(8); 1276-87. ©2017 AACR.

Stage-specific mortality and survival trends of prostate cancer patients in Finland before and after introduction of PSA

BACKGROUND

The early diagnosis and right treatment strategy of localized prostate cancer (PCa) remains problematic. In order to characterize the survival of PCa patients, we compared patients' all-cause and cancer-specific mortalities between pre- and post-PSA periods by stage in Finland.

MATERIAL AND METHODS

All PCa cases diagnosed in Finland between 1985 and 2013 (N = 91,329) were identified from the Finnish Cancer Registry (FCR). PCa stage at diagnosis was defined as localized, local node positive or metastasized. Standardized mortality ratios (SMRs), and relative and cause-specific survival were assessed by stage and introduction of PSA testing. The main limitation was the high proportion of men with unknown stage (28%).

RESULTS

A clear decreasing trend in the SMR of PCa patients was evident when pre- and post-PSA eras were compared: for localized PCa, the SMR was 1.43 (95%CI 1.38-1.48) in 1985-1989 and 0.98 (95%CI 0.95-1.01) in 2000-2004, and for metastasized PCa, the SMRs were 4.51 (95%CI 4.30-4.72) and 3.01 (95%CI 2.89-3.12), respectively. Difference between cause-specific and relative survival was pronounced in localized PCa in post-PSA period: 10-year relative survival was 94.6% (95%CI 91.4-97.8) and cause-specific 84.2% (95%CI 82.9-85.5%). In metastasized PCa the difference was not that significant.

CONCLUSIONS

From 1985 to 2009, the SMR among men diagnosed with PCa decreased significantly in Finland. Among men with localized PCa, the SMR decreased even below that of the Finnish male population. This and the increased difference between relative and cause-specific survival reflects most likely selection of men to opportunistic PSA testing. The results highlight the importance of caution in the use of PSA testing in healthy men.

Salvage prostate re-irradiation using high-dose-rate brachytherapy or focal stereotactic body radiotherapy for local recurrence after definitive radiation therapy

Background

Optimal management of locally recurrent prostate cancer after definitive radiation therapy is still challenging. With the development of highly accurate radiotherapy devices, prostate salvage re-irradiation might generate lower toxicity rates than classical salvage therapies. We retrospectively evaluated the toxicity and the feasibility of a prostate re-irradiation after definitive radiation therapy failure. Two modalities were investigated: high-dose-rate brachytherapy (HDRB) on whole prostate gland and focal stereotactic radiotherapy (SBRT) using CyberKnife® linac.

Methods

Between 2011 and 2015, 28 patients with imaged and/or biopsy-proven intra-prostatic recurrence of cancer after definitive radiation therapy underwent a salvage re-irradiation using HDRB (n = 10) or focal SBRT (n = 18). The schedule of re-irradiation was 35 Gy in 5 fractions.

Biological response (defined as post-salvage radiation PSA variation) and biochemical no-evidence of disease (bNED) were evaluated in the whole cohort. For patients who had a positive biological response after salvage radiation, biochemical recurrence (BCR) and survival after salvage radiotherapy were evaluated. Post-salvage toxicities were assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.03 and were compared to baseline status.

Results

Within a median follow-up of 22.5 months (IQR = 8–42), 9 (90%) patients experienced a positive biological response after salvage HDRB and 5 (50%) remained bNED at the end of the follow-up. Among patients who initially responded to salvage HDRB, the BCR rate was 44.4% after a median interval of 19.5 months (IQR = 11.5–26). Only one patient experienced a transient grade 3 urinary complication.

In the SBRT group, the median follow-up was 14.5 months (IQR = 7–23) and 10 (55.6%) out of the 18 patients remained bNED. Among the 15 patients who initially responded to salvage SBRT, 5 (33.3%) experienced a BCR. One patient experienced a transient grade 4 urinary complication.

At the end of the follow-up, all evaluated patients had a urinary status grade variation ≤ +1 grade. No grade 3–4 digestive toxicity was observed.

Conclusions

Salvage prostate re-irradiation for locally recurrent cancer is feasible and generate low toxicities rates when using with HDRB or focal SBRT. However, further investigations are necessary to confirm these findings and to determine predictive features for patients who might benefit from such an approach.

Trends in net survival from prostate cancer in six European Latin countries: results from the SUDCAN population-based study

Cancer survival is a key measure of the effectiveness of a health-care system. European Latin countries have some differences in their health system; therefore, it is of interest to compare them in terms of survival from cancer. Prostate cancer data from six countries (Belgium, France, Italy, Portugal, Spain, and Switzerland) were extracted from the EUROCARE-5 database (end of follow-up: 1 January 2009). First, the net survival (NS) was studied over the 2000-2004 period using the Pohar-Perme estimator. For trend analyses, the study period was specific to each country. Trends in NS over the 1989-2004 period and changes in the pattern of cancer excess mortality rate until 5 years after the diagnosis were examined using a multivariate excess mortality rate model. A striking increase in survival from prostate cancer occurred in European Latin countries at all ages studied. In the last period of the study, there was little difference in age-standardized NSs from prostate cancer between the six countries. The trends of the survival followed those of the incidence (except in Spain in the elderly); the increases in incidence were the highest at ages 60-70 years and, in the elderly (around 80 years), the incidence did not increase in Switzerland. The increases in NS can mainly be explained by lead-time and overdiagnosis effects. The epidemiological interpretability of the changes in prostate cancer survival in Latin countries is strongly compromised by the biases inherent to the extensive prostate-specific antigen testing.

New analysis reexamines the value of cancer care in the United States compared to Western Europe

Despite sharp increases in spending on cancer treatment since 1970 in the United States compared to Western Europe, US cancer mortality rates have decreased only modestly. This has raised questions about the additional value of US cancer care derived from this additional spending. We calculated the number of US cancer deaths averted, compared to the situation in Western Europe, between 1982 and 2010 for twelve cancer types. We also assessed the value of US cancer care, compared to that in Western Europe, by estimating the ratio of additional spending on cancer to the number of quality-adjusted life-years saved. Compared to Western Europe, for three of the four costliest US cancers-breast, colorectal, and prostate-there were approximately 67,000, 265,000, and 60,000 averted US deaths, respectively, and for lung cancer there were roughly 1,120,000 excess deaths in the study period. The ratio of incremental cost to quality-adjusted life-years saved equaled $402,000 for breast cancer, $110,000 for colorectal cancer, and $1,979,000 for prostate cancer-amounts that exceed most accepted thresholds for cost-effective medical care. The United States lost quality-adjusted life-years despite additional spending for lung cancer: -$19,000 per quality-adjusted life-year saved. Our results suggest that cancer care in the United States may provide less value than corresponding cancer care in Western Europe for many leading cancers.

Clinicopathological and Prognostic Factors in 106 Prostate Cancer Patients Aged ≤55 Years: A Single-Center Study in China

Background

Early-onset prostate cancer patients (aged ≤55 years) from Western countries have been well characterized in previous studies. However, the clinicopathological and prognostic characteristics of early-onset Chinese prostate cancer patients have not yet been assessed. This study aimed to examine the clinicopathological and prognostic factors of prostate cancer patients aged ≤55 years in a single Chinese center.

Material/Methods

One hundred six prostate cancer patients aged ≤55 years with complete clinicopathological data who were treated at our hospital between January 2000 and June 2014 were selected for this study. Survival rate was investigated by Kaplan-Meier analysis, and prognostic factors were examined by univariate and multivariate analysis.

Results

The median time from the onset of symptoms to diagnosis was 3.5 months (range, 2–55 months). The median time after endocrine therapy to development of androgen-independent prostate cancer was 10.5 months. A total of 54 patients died (50.9%), of whom 96.2% died from prostate cancer. The 1-, 3-, and 5-year overall survival rates were 88.7%, 66.2%, and 36.0%, respectively. Univariate and multivariate analysis showed that T staging, visceral metastasis, pathological pattern, and Gleason sum were independent prognostic factors in these patients.

Conclusions

Prostate cancer patients aged ≤55 years are often omitted or misdiagnosed in China. Furthermore, the pathology patterns in this age group were mostly complicated with a high degree of malignancy. Late staging, visceral metastasis, pathological pattern, and high Gleason score were independent prognostic factors in these patients. Comprehensive therapy combined with local therapy is an effective treatment strategy.

Prostate cancer burden in Central and South America

RATIONALE AND OBJECTIVE

The incidence of prostate cancer has increased in Central and South America (CSA) in the last few decades. We describe the geographical patterns and trends of prostate cancer in CSA.

METHODS

We obtained regional and national-level cancer incidence data from 48 population-based registries in 13 countries and nation-wide cancer deaths from the WHO mortality database for 18 countries. We estimated world population age-standardized incidence (ASR) and mortality (ASMR) rates per 100,000 person-years for 2003-2007 and the estimated annual percent change (EAPC) to describe time trends.

RESULTS

Prostate cancer was the most common cancer diagnosis and one of the leading causes of cancer deaths among males in most CSA countries. From 2003-2007, ASRs varied between countries (6-fold) and within countries (Brazil: 3-6-fold). French Guyana (147.1) and Brazil (91.4) had the highest ASRs whereas Mexico (28.9) and Cuba (24.3) had the lowest. ASMRs varied by 4-fold. Belize, Uruguay and Cuba (24.1-28.9) had the highest ASMRs while Peru, Nicaragua, and El Salvador (6.8-9.7) had the lowest. In Argentina, Brazil, Chile and Costa Rica prostate cancer incidence increased by 2.8-4.8% annually whereas mortality remained stable between 1997 and 2008.

CONCLUSION

The geographic and temporal variation of prostate cancer rates observed in CSA may in part reflect differences in diagnostic and registration practices, healthcare access, treatment and death certification, and public awareness. The incidence of prostate cancer is expected to increase given recent early detection activities and increased public awareness; however, the impact of these factors on mortality remains to be elucidated.

Salvage local therapy for radiation-recurrent prostate cancer - where are we?

INTRODUCTION

Prostate cancer is the most frequent cancer among males in Europe and a leading cause of cancer deaths, with similar proportion in other developed countries. For more than twenty years, external-beam radiation therapy, alongside with radical prostatectomy, has been used as a primary radical therapeutic approach for localized prostate cancer. Yet, EBRT failures relate to 22-69% following curative radiotherapy (± androgen deprivation therapy). Additionally, a proportion of these men will have a biopsy-proven local recurrence.

MATERIAL AND METHODS

The Medline and Web of Science databases were searched without a time limit during March 2016 using the terms 'prostate cancer' in conjunction with 'radiotherapy', 'recurrence', 'biochemical', 'salvage', 'brachytherapy', 'prostatectomy', 'HIFU', 'cryotherapy' and 'focal'. The search was limited to the English, Polish, German and Spanish literature.

RESULTS

Currently, salvage treatment after failed radiotherapy includes radical prostatectomy, brachytherapy and ablative whole-gland therapies, such as cryotherapy and high intensity focused ultrasound. New approaches, so called focal salvage therapy, involve ablation of only the zone of recurrence in order to decrease tissue injury and therefore to diminish morbidity.

CONCLUSIONS

At present no authoritative recommendations can be concluded because of the absence of randomized data with standardized definitions and protocols. Nevertheless, we believe that local salvage treatment should be at least considered in patients after biochemical relapse following radiotherapy.

Comparison of prostate cancer survival in Germany and the USA: can differences be attributed to differences in stage distributions?

OBJECTIVES

To better understand the influence of prostate-specific antigen (PSA) screening and other health system determinants on prognosis of prostate cancer, up-to-date relative survival (RS), stage distributions, and trends in survival and incidence in Germany were evaluated and compared with the United States of America (USA).

PATIENTS AND METHODS

Incidence and mortality rates for Germany and the USA for the period 1999-2010 were obtained from the Centre for Cancer Registry Data at the Robert Koch Institute and the USA Surveillance Epidemiology and End Results (SEER) database. For analyses on stage and survival, data from 12 population-based cancer registries in Germany and from the SEER-13 database were analysed. Patients (aged ≥ 15 years) diagnosed with prostate cancer (1997-2010) and mortality follow-up to December 2010 were included. The 5- and 10-year RS and survival trends (2002-2010) were calculated using standard and model-based period analysis.

RESULTS

Between 1999 and 2010, prostate cancer incidence decreased in the USA but increased in Germany. Nevertheless, incidence remained higher in the USA throughout the study period (99.8 vs 76.0 per 100,000 in 2010). The proportion of localised disease significantly increased from 51.9% (1998-2000) to 69.6% (2007-2010) in Germany and from 80.5% (1998-2000) to 82.6% (2007-2010) in the USA. Mortality slightly decreased in both countries (1999-2010). Overall, 5- and 10-year RS was lower in Germany (93.3%; 90.7%) than in the USA (99.4%; 99.6%) but comparable after adjustment for stage. The same patterns were seen in age-specific analyses. Improvements seen in prostate cancer survival between 2002-2004 and 2008-2010 (5-year RS: 87.4% and 91.2%; +3.8% units) in Germany disappeared after adjustment for stage (P = 0.8).

CONCLUSION

The survival increase in Germany and the survival advantage in the USA might be explained by differences in incidence and stage distributions over time and across countries. Effects of early detection or a lead-time bias due to the more widespread utilisation and earlier introduction of PSA testing in the USA are likely to explain the observed patterns.

Challenge of cancer in the elderly

Despite the sustained trend of decreasing overall cancer incidence, the number of elderly patients with cancer will considerably increase in the coming years, as the incidence of cancer is elevated 11-fold after the age of 65 years compared to adults up to 65 years. This soon-to-erupt tsunami of elderly patients with cancer requires adequate treatment, for which guidelines and evidence-based data are still scarce, given the longlasting under-representation of elderly patients with cancer in cancer trials. Older adults present not only with the physiological decreases of organ functions related to age, but also with an individual burden of comorbidities, other impairments and social factors that might impact on their potential for undergoing cancer care. Close collaboration with gerontologists and other health professionals to assess the personal resources and limitations of each person enables providing adequate therapy to elderly patients with cancer. There are promising achievements in each of the requirements listed, but a huge, holistic effort has still to be made.

Improved efficacy of mitoxantrone in patients with castration-resistant prostate cancer after vaccination with GM-CSF-transduced allogeneic prostate cancer cells

Previous vaccination studies in patients with castration-resistant prostate cancer (CRPC) showed improved survival without prolongation of progression-free survival (PFS). This might be explained by enhanced efficacy of subsequent therapies because of heightened immune status. We therefore evaluated the efficacy of chemotherapy in CRPC patients after immunotherapy. We retrospectively analyzed 28 patients who were treated with ipilimumab and GVAX, an allogeneic vaccine, and 21 patients who were randomized to GVAX or no vaccination. To study whether immune status was related to the efficacy of chemotherapy, frequencies of myeloid and lymphocyte subsets were determined. Of 28 patients treated with GVAX and ipilimumab, 23 patients received docetaxel and 13 patients mitoxantrone. Median PFS after docetaxel was 6.4 mo (range 0.8-11.2), while median PFS after mitoxantrone was markedly longer than expected (4.8 mo; range 1.4-13.7). High CD8+ICOS+ Tcell/Treg and pDC/mMDSC ratios were associated with relatively long PFS after mitoxantrone, suggesting a correlation between activated immune status and benefit of mitoxantrone. Analysis of 21 patients, randomized to GVAX or not, revealed a median PFS after docetaxel of 9.9 mo for vaccinated patients and 7.1 mo for unvaccinated patients. Interestingly, PFS after mitoxantrone (n = 14) was significantly longer in vaccinated patients as compared to controls (5.9 vs. 1.6 mo, p = 0.0048). In conclusion, mitoxantrone seems more effective in CRPC patients after immunotherapy, which may be related to the immune-stimulating effect of mitoxantrone in patients with heightened antitumor immunity. As this was a retrospective study with limited sample size, prospective studies are warranted to definitively show proof of principle.

Prostate cancer incidence in 43 populations worldwide: An analysis of time trends overall and by age group

Prostate cancer is a significant public health burden and a major cause of morbidity and mortality among men worldwide. Analyzing geographic patterns and temporal trends may help identify high-risk populations, suggest the degree of PSA testing, and provide clues to etiology. We used incidence data available from the International Agency for Research on Cancer (IARC) and certain cancer registries for 43 populations across five continents during a median period of 24 years. Trends in overall prostate cancer rates showed five distinct patterns ranging from generally monotonic increases to peaking of rates followed by declines, which coincide somewhat with changes in the prevalence of PSA testing. Trends in age-specific rates generally mirrored those in the overall rates, with several notable exceptions. For populations where overall rates increased rapidly and then peaked, exemplified in North America and Oceania, the highest incidence tended to be most pronounced and occurred during earlier calendar years among older men compared with younger ones. For populations with almost continual increases in overall rates, exemplified in Eastern Europe and Asia, peaks were evident among men aged ≥ 75 years in many instances. Rates for ages 45-54 years did not clearly stabilize or decline in the majority of studied populations. Global geographic variation remained substantial for both overall and age-specific incidence rates regardless of levels of PSA testing, with the lowest rates consistently in Asia. Explanations for the persistent geographic differences and the continuing increases of especially early-onset prostate cancer remain unclear.

Causes of death in men with localized prostate cancer: a nationwide, population-based study

OBJECTIVE

To detail the distribution of causes of death from localized prostate cancer (PCa).

PATIENTS AND METHODS

The database PCBase Sweden links the Swedish National Prostate Cancer Register with other nationwide population-based healthcare registers. We selected all 57 187 men diagnosed with localized PCa between 1997 and 2009 and their 114 374 PCa-free control subjects, matched according to age and county of residence. Mortality was calculated using competing risk regression analyses, taking into account PCa risk category, age and Charlson comorbidity index (CCI).

RESULTS

In men with low-risk PCa, all-cause mortality was lower compared with that in corresponding PCa-free men: 10-year all-cause mortality was 18% for men diagnosed at age 70 years, with a CCI score of 0, and 21% among corresponding control subjects. Of these cases, 31% died from cardiovascular disease (CVD) compared with 37% of the corresponding control subjects. For men with low-risk PCa, 10-year PCa-mortality was 0.4, 1 and 3% when diagnosed at age 50, 60 and 70 years, respectively. PCa was the third most common cause of death (18%), after CVD (31%) and other cancers (30%). By contrast, PCa was the most common cause of death in men with intermediate- and high-risk localized PCa.

CONCLUSIONS

Men with low-risk PCa had lower all-cause mortality than PCa-free men because of lower CVD mortality, driven by early detection selection; however, for men with intermediate- or high-risk disease, the rate of PCa death was substantial, irrespective of CCI score, and this was even more pronounced for those diagnosed at age 50 or 60 years.

Population health and status of epidemiology in Western European, Balkan and Baltic countries

BACKGROUND

This article is part of a series commissioned by the International Epidemiological Association, aimed at describing population health and epidemiological resources in the six World Health Organization (WHO) regions. It covers 32 of the 53 WHO European countries, namely the Western European countries, the Balkan countries and the Baltic countries.

METHODS

The burdens of mortality and morbidity and the patterns of risk factors and inequalities have been reviewed in order to identify health priorities and challenges. Literature and internet searches were conducted to stock-take epidemiological teaching, research activities, funding and scientific productivity.

FINDINGS

These countries have among the highest life expectancies worldwide. However, within- and between-country inequalities persist, which are largely due to inequalities in distribution of main health determinants. There is a long tradition of epidemiological research and teaching in most countries, in particular in the Western European countries. Cross-national networks and collaborations are increasing through the support of the European Union which fosters procedures to standardize educational systems across Europe and provides funding for epidemiological research through framework programmes. The number of Medline-indexed epidemiological research publications per year led by Western European countries has been increasing. The countries accounts for nearly a third of the global epidemiological publication.

CONCLUSIONS

Although population health has improved considerably overall, persistent within- and between-country inequalities continue to challenge national and European health institutions. More research, policy and action on the social determinants of health are required in the region. Epidemiological training, research and workforce in the Baltic and Balkan countries should be strengthened. European epidemiologists can play pivotal roles and must influence legislation concerning production and access to high-quality data.

Trends of prostate cancer incidence and mortality in Shanghai, China from 1973 to 2009

BACKGROUND

The incidence and mortality of prostate cancer (PCa) were historically low in China but have increased considerably in recent years. This study aimed to describe the detailed trend of PCa incidence and mortality in Shanghai, China.

MATERIAL AND METHODS

Incidence and mortality data of PCa in urban Shanghai during 1973 and 2009 were collected by the Shanghai Municipal Center for Disease Control and Prevention. Age standardized rates (ASR) of incidence and mortality were calculated based on the 1966 world standard population. Join point regression analysis was used to describe the trends and to identify specific time points when significant changes in incidence and mortality occurred.

RESULTS

The PCa incidence in Shanghai increased ~sixfold from an ASR of 2.13/100,000 in 1973 to 12.96/100,000 in 2009, and its rank ascended from the 17th to the 4th most common cancer during the period. The PCa mortality in Shanghai increased threefold from an ASR of 1.61/100,000 in 1973 to 4.97/100,000 in 2009, and its rank ascended from the 17th to the 6th most deadly cancer during this period. More specifically, the ASR of incidence increased slightly before 1991, sharply during1991-2004, and slightly after 2004, with annual percent changes (APC) of 2.2% (95% confidence interval: 0.3%-4.3%), 13.2% (11.4%-15.0%), and 3.2% (-0.3%-6.8%), respectively. The mortality trend was stable before 1985 and increased slowly but steadily after 1985, with APC of -0.6% (-4.4%-3.3%) and 5.3% (4.7%-6.0%), respectively. The increasing incidence and mortality rates were primarily observed in men ≥ 70 years.

CONCLUSION

The incidence and mortality of PCa have increased significantly in Shanghai, China over the past four decades.

Salvage image-guided intensity modulated or stereotactic body reirradiation of local recurrence of prostate cancer

OBJECTIVE

To retrospectively evaluate external beam reirradiation (re-EBRT) delivered to the prostate/prostatic bed for local recurrence, after radical or adjuvant/salvage radiotherapy (RT).

METHODS

32 patients received re-EBRT between February 2008 and October 2013. All patients had clinical/radiological local relapse in the prostate or prostatic bed and no distant metastasis. re-EBRT was delivered with selective RT technologies [stereotactic RT including CyberKnife(TM) (Accuray, Sunnyvale, CA); image-guidance and intensity-modulated RT etc.]. Toxicity was evaluated using the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer criteria. Biochemical control was assessed according to the Phoenix definition (NADIR + 2 ng ml(-1)).

RESULTS

Acute urinary toxicity: G0, 24 patients; G1, 6 patients; G2, 2 patients. Acute rectal toxicity: G0, 28 patients; G1, 2 patients; and G2, 1 patient. Late urinary toxicity (evaluated in 30 cases): G0, 23 patients; G1, 6 patients; G2, 1 patient. Late renal toxicity: G0, 25 patients; G1, 5 patients. A mean follow-up of 21.3 months after re-EBRT showed that 13 patients were free of cancer, 3 were alive with biochemical relapse and 12 patients were alive with clinically evident disease. Four patients had died: two of disease progression and two of other causes.

CONCLUSION

re-EBRT using modern technology is a feasible approach for local prostate cancer recurrence offering 2-year tumour control in about half of the patients. Toxicity of re-EBRT is low. Future studies are needed to identify the patients who would benefit most from this treatment.

ADVANCES IN KNOWLEDGE

Our series, based on experience in one hospital alone, shows that re-EBRT for local relapse of prostate cancer is feasible and offers a 2-year cure in about half of the patients.