Causes of death in men with prostate cancer: an analysis of 50 000 men from the Thames Cancer Registry

Current Systemic Therapy in Men with Metastatic Castration-Sensitive Prostate Cancer

PURPOSE OF REVIEW

This review aims to explore the evolving landscape of treatments available for metastatic castration-sensitive prostate cancer (mCSPC) patients.

RECENT FINDINGS

In less than a decade, evidence was chronologically provided that (1) systemic treatment intensification with docetaxel improves outcomes, including survival, in men with mCSPC, (2) then that these outcomes are also improved when a second-generation androgen receptor pathway inhibitor (ARPI) is combined with androgen deprivation therapy (ADT), and (3) using a "triplet systemic therapy," which consists in the combination of ADT, an ARPI and docetaxel, further improves outcomes, including survival. Radiotherapy to the prostate combined with ADT alone is now recommended in men with low-volume mCSPC. Combining prostate radiotherapy and intensified systemic treatment including abiraterone may be synergistic as suggested in the PEACE-1 trial. Also, the role of metastases-directed local therapies (mostly stereotactic radiotherapy) is currently being assessed in phase 3 trials. Finally, the integration of biomarkers (e.g. BRCA2 gene alterations, PTEN loss, PSMA expression) for decision making is not currently established, though trials are also currently underway. Importantly, most evidence currently available was obtained in men with de novo metastases, while for those with metastatic relapse after definitive local treatment, the role of treatment intensification is less well established. Treatment intensification is nowadays the standard of care for patients with de novo mCSPC as it leads to outcomes improvement, including survival, and the standard of care is evolving almost on a yearly basis.

A Repurposing Programme Evaluating Transdermal Oestradiol Patches for the Treatment of Prostate Cancer Within the PATCH and STAMPEDE Trials: Current Results and Adapting Trial Design

AIMS

Androgen deprivation therapy (ADT), usually achieved with luteinising hormone releasing hormone analogues (LHRHa), is central to prostate cancer management. LHRHa reduce both testosterone and oestrogen and are associated with significant long-term toxicity. Previous use of oral oestrogens as ADT was curtailed because of cardiovascular toxicity. Transdermal oestrogen (tE2) patches are a potential alternative ADT, supressing testosterone without the associated oestrogen-depletion toxicities (osteoporosis, hot flushes, metabolic abnormalities) and avoiding cardiovascular toxicity, and we here describe their evaluation in men with prostate cancer.

MATERIALS AND METHODS

The PATCH (NCT00303784) adaptive trials programme (incorporating recruitment through the STAMPEDE [NCT00268476] platform) is evaluating the safety and efficacy of tE2 patches as ADT for men with prostate cancer. An initial randomised (LHRHa versus tE2) phase II study (n = 251) with cardiovascular toxicity as the primary outcome measure has expanded into a phase III evaluation. Those with locally advanced (M0) or metastatic (M1) prostate cancer are eligible. To reflect changes in both management and prognosis, the PATCH programme is now evaluating these cohorts separately.

RESULTS

Recruitment is complete, with 1362 and 1128 in the M0 and M1 cohorts, respectively. Rates of androgen suppression with tE2 were equivalent to LHRHa, with improved metabolic parameters, quality of life and bone health indices (mean absolute change in lumbar spine bone mineral density of -3.0% for LHRHa and +7.9% for tE2 with an estimated difference between arms of 9.3% (95% confidence interval 5.3-13.4). Importantly, rates of cardiovascular events were not significantly different between the two arms and the time to first cardiovascular event did not differ between treatment groups (hazard ratio 1.11, 95% confidence interval 0.80-1.53; P = 0.54). Oncological outcomes are awaited.

FUTURE

Efficacy results for the M0 cohort (primary outcome measure metastases-free survival) are expected in the final quarter of 2023. For M1 patients (primary outcome measure - overall survival), analysis using restricted mean survival time is being explored. Allied translational work on longitudinal samples is underway.

Cardiovascular risk of gonadotropin-releasing hormone antagonist versus agonist in men with prostate cancer: an observational study in Taiwan

BACKGROUND

The impact of gonadotropin-releasing hormone (GnRH) antagonist and agonist (GnRHa) treatment on cardiovascular disease (CVD) risk in prostate cancer (PCa) remains inconclusive due to conflicting findings. We compared the effects of GnRH antagonist and GnRHa treatments on CVD risk in patients with PCa and pre-existing CVD, in a Taiwan population-based database.

METHODS

We assessed the risk of major adverse CV events (MACE: ischemic heart disease [IHD], stroke, congestive heart failure [CHF] or all cause deaths) and composite CV events (IHD, stroke, CHF or CV deaths) occurring ≥90 days after androgen deprivation therapy (ADT) initiation in patients with PCa after 90 days of treatment with either GnRH antagonist (degarelix; n = 499) or GnRHa (goserelin, leuprolide, triptorelin; n = 15,127). Patients identified with pre-existing CVD had received cardiac therapy for IHD, reported a stroke or CHF within a year before ADT initiation. Adjusted hazard ratios (aHR) and 95% confidence interval (CI) were obtained for MACE and composite CV events risk after adjusting for age, baseline status of diabetes, hypertension and treatments received.

RESULTS

All GnRH antagonist-treated patients showed lower risk of composite CV events than the GnRHa-treated patients. The lower composite CV events risk associated with GnRH antagonist was also observed in patients with metastasis at diagnosis (aHR 0.16; 95% CI, 0.04-0.38; p = 0.013) and those receiving ADT for more than six months (aHR 0.30; 95% CI, 0.16-0.54; p < 0.0001). In patients with pre-existing CVD, the MACE risk was 33% lower (aHR 0.67; 95% CI, 0.46-0.96; p = 0.0299) and composite CV events risk was 84% lower (aHR 0.16; 95% CI, 0.05-0.50; p = 0.0017) in GnRH antagonist-treated than the GnRHa-treated patients.

CONCLUSIONS

In patients with PCa and pre-existing CVD, GnRH antagonist use was associated with lower risks for composite CV events and MACE compared with GnRHa.

Causes of Death after Prostate Cancer Diagnosis: A Population-Based Study

Background

Mortality from noncancer causes in patients with prostate cancer (PCa) is unclear. This study assesses the causes and risks of noncancer death with each follow-up time period after PCa diagnosis.

Methods

Data from the Surveillance, Epidemiology, and End Results (SEER) program were analyzed for noncancer causes of death in PCa patients from 2000 to 2016. The standard mortality ratio (SMR) was calculated for noncancer mortality.

Results

Altogether, 752,352 patients with PCa were identified, and 180,862 (24.0%) died during follow-up. The largest proportion of deaths from noncancer causes (36%) occurred within 5 to 10 years after diagnosis. The most common causes of noncancer death are cardiovascular and cerebrovascular diseases and chronic obstructive pulmonary disease (COPD). Compared with the general age-matched male population, patients with PCa had a higher risk of death from any noncancer cause within 5 years, in particular other infectious diseases and suicide and self-inflicted injury. However, the risk of death from noncancer causes of PCa for more than 5 years is lower, except for Alzheimer's disease and hypertension from 5 to 10 years after diagnosis. In addition, the risk of death from noncancer causes was influenced by treatment, ethnicity, and staging differences. In particular, compared with the general population, many noncancer causes of death have higher risk of death in patients with or without treatment within 1 to 5 years after diagnosis, whereas patients undergoing radical prostatectomy (RP) with or without radiotherapy (RT) or chemotherapy (CTx) are not at high risk of death from COPD, pneumonia and influenza, nephritis, nephrotic syndrome and nephrosis, septicemia, and atherosclerosis.

Conclusion

The risk of death from noncancer causes gradually decreased in all patients with PCa during each follow-up period after diagnosis In addition, the risk of dying from noncancer causes are influenced by differences in stage, ethnicity, and treatment. In particular, patients undergoing RP±RT/CTx and RT/CTx have a lower risk of death compared to the general population. These findings provide important implications for the healthcare management of patients with PCa.

All-Cause Mortality Risk in National Prostate Cancer Cohort: An Impact of Population-Based Prostate Cancer Screening

The aim of this study is to evaluate all-cause mortality risk differences before and during prostate cancer screening, with a profound focus on the differences between screened and not-screened patient groups. Prostate cancer cases diagnosed between 1998 and 2016 were identified from the population-based Lithuanian Cancer Registry and linked with screening status in the National Health Insurance Fund database. The analysis was stratified by a period of diagnosis and screening status. Standardized mortality ratios (SMRs) were used to assess all-cause and cause-specific mortality risk. The SMRs were calculated by dividing the observed number of deaths among prostate cancer patients by the expected number of deaths from the general population. All-cause SMR (1.45 (95% CI 1.42-1.48)) in the pre-screening period was higher compared to the screening period (SMR = 1.17 (95% CI 1.15-1.19)). An increased all-cause mortality risk among prostate cancer patients was observed in the not-screened patient population (SMR = 1.76 (95% CI 1.71-1.82)), while all-cause mortality risk in the screened patient population was similar to the general population (SMR = 1.00 (95% CI 0.97-1.02)). Screened patients with localized stage of disease had lower all-cause mortality risk than the general population (SMR = 0.72 (95% CI 0.70-0.75)). In conclusion, men with prostate cancer in Lithuania had excess all-cause mortality risk compared to the general population. The all-cause mortality risk among screened patients was not higher than expected.

Association of Health-Care System with Prostate Cancer-Specific Mortality in African American and Non-Hispanic White Men

BACKGROUND

Disparities in prostate cancer-specific mortality (PCSM) between African American and non-Hispanic White (White) patients have been attributed to biological and systemic factors. We evaluated drivers of these disparities in the Surveillance, Epidemiology and End Results (SEER) national registry and an equal-access system, the Veterans Health Administration (VHA).

METHODS

We identified African American and White patients diagnosed with prostate cancer between 2004-2015 in SEER (N = 311,691) and the VHA (N = 90,749). We analyzed the association between race and metastatic disease at presentation using multivariable logistic regression adjusting for sociodemographic factors, and PCSM using sequential competing-risks regression adjusting for disease and sociodemographic factors.

RESULTS

The median follow-up was 5.3 years in SEER and 4.7 years in the VHA. African American men were more likely than White men to present with metastatic disease in SEER (adjusted odds ratio = 1.23, 95% confidence interval [CI] = 1.17-1.30), but not in the VHA (adjusted odds ratio = 1.07, 95% CI = 0.98-1.17). African American versus White race was associated with an increased risk of PCSM in SEER (subdistribution hazard ratio [SHR] = 1.32, 95% CI = 1.10-1.60), but not in the VHA (SHR = 1.00, 95% CI: 0.93-1.08). Adjusting for disease extent, PSA, and Gleason score eliminated the association between race and PCSM in SEER (aSHR 1.04, 95% CI 0.93-1.16).

CONCLUSIONS

Racial disparities in PCSM were present in a nationally representative registry, but not in an equal-access healthcare system, due to differences in advanced disease at presentation. Strategies to increase healthcare access may bridge the racial disparity in outcomes. Longer follow-up is needed to fully assess mortality outcomes.Disparities between African American and non-Hispanic White (White) patients in cancer-specific mortality have been described across numerous cancer types and healthcare systems[1-5]. The survival gap between African American and White patients with prostate cancer has been well-characterized, with two-fold higher prostate cancer-specific mortality (PCSM) rates among African American patients depending on the setting[1, 6-10]. This disparity has been attributed to differences in prostate cancer biology in African American men, in addition to systemic factors in mediating this disparity, such as differential access to healthcare, Prostate-Specific Antigen (PSA) screening, and distrust in the healthcare system[1, 11-16].The Veterans Health Administration (VHA) is a relatively equal-access healthcare system that treats a large, ethnically diverse population of veterans. The Surveillance, Epidemiology and End Results (SEER) program is a national cancer registry program that collects data from the general United States (US) population. The goals of the present investigation were to 1) Compare PCSM between African American and White men within SEER and the VHA and 2) Identify modifiable system-level contributors to these disparities. We hypothesized that PCSM would be comparable among African American and White men in an equal-access setting, the VHA, but not in a national registry, SEER, and that this disparity in SEER would be in part driven by more advanced disease at presentation.

Canadian Urological Association guideline on androgen deprivation therapy: Adverse events and management strategies

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Prostate Cancer Survival and Mortality according to a 13-year retrospective cohort study in Brazil: Competing-Risk Analysis

OBJECTIVE

To analyze cancer-specific mortality (CSM) and other-cause mortality (OCM) among patients with prostate cancer that initiated treatment in the Brazilian Unified Health System (SUS), between 2002 and 2010, in Brazil.

METHODS

Retrospective observational study that used the National Oncological Database, which was developed by record-linkage techniques used to integrate data from SUS Information Systems, namely: Outpatient (SIA-SUS), Hospital (SIH-SUS), and Mortality (SIM-SUS). Cancer-specific and other-cause survival probabilities were estimated by the time elapsed between the date of the first treatment until the patients' deaths or the end of the study, from 2002 until 2015. The Fine-Gray model for competing risk was used to estimate factors associated with patients' risk of death.

RESULTS

Of the 112,856 studied patients, the average age was 70.5 years, 21% died due to prostate cancer, and 25% due to other causes. Specific survival in 160 months was 75%, and other-cause survival was 67%. For CSM, the main factors associated with patients' risk of death were: stage IV (AHR = 2.91; 95%CI 2.73 - 3.11), systemic treatment (AHR = 2.10; 95%CI 2.00 - 2.22), and combined surgery (AHR = 2.30, 95%CI 2.18 - 2.42). As for OCM, the main factors associated with patients' risk of death were age and comorbidities.

CONCLUSION

The analyzed patients with prostate cancer were older and died mainly from other causes, probably due to the presence of comorbidities associated with the tumor.

Presenting stage and risk group in men dying of prostate cancer

Introduction

Prostate cancer remains the 3rd leading cause of cancer-related mortality in Canadian men, and yet screening for prostate cancer continues to be controversial because the majority of men diagnosed with prostate cancer do not die of the disease. It also remains uncertain whether treatment of cases that can be treated with curative intent alters the mortality rate. There are very few studies describing the presenting stage, risk groups, and survival after diagnosis for men dying of prostate cancer in the literature. In this study, we explored these characteristics for all men who died of prostate cancer in British Columbia between 2013 and 2015.

Methods

The population-based BC Cancer databases were used to identify all patients diagnosed between January 2013 and December 2015 who died of prostate cancer. Patient, tumour, and treatment characteristics were collected, and the risk grouping for each tumour was determined. The proportion of cases in each risk group at the time of diagnosis was determined. Survival time from diagnosis to death was calculated for all patients and for each risk group using the Kaplan-Meier method.

Results

A total of 1256 patients died of prostate cancer. Of patients who presented with metastatic disease, 57.2% presented with a Gleason score of 8 or more, compared with only 35.7% of patients who presented with nonmetastatic disease (p < 0.0001). The presenting stage and risk group of those dying of prostate cancer were as follows: 32% metastatic disease, 3% regional (defined as node-positive), 39% localized high risk, 9% localized intermediate risk, 4% localized low risk, 6% localized not otherwise specified, and 7% unknown. Therefore, 80.3% of those with a known risk group presented with either localized high-risk, regional, or metastatic disease at diagnosis. The median survival times from diagnosis to death were 12 years for localized low-risk, 10 years for localized intermediate-risk, 6.5 years for localized high-risk, 4 years for regional, and 1.7 years for metastatic disease at diagnosis.

Conclusions

This population-based analysis demonstrates that patients with localized high-risk, regional, or metastatic disease at diagnosis constitute the overwhelming majority of patients who die of prostate cancer in British Columbia. Unless these disease states can reliably be identified at an earlier low- or intermediate-risk localized state in the future, it is unlikely that treatment of localized low- and intermediate-risk cancer will have an impact on survival. Furthermore, patients with de novo metastatic disease had identifiable risk factors of a higher prostate-specific antigen and Gleason score. Further studies are required to confirm these results.

Conditional Relative Survival and Competing Mortality of Patients with Prostate Cancer in Korea: A Nationwide Cohort Study

BACKGROUND

Conditional relative survival (CRS) and competing mortality are important survivorship issues after cancer treatment. We aimed to investigate them among patients with prostate cancer treated by various modalities.

METHODS

Using a nationwide population-based database, we calculated 5-year CRS conditioned on 1 through 5 years survival after diagnosis. These rates were stratified by age, sex, socioeconomic status, comorbidities, and treatment received. Cause of death and estimated cause-specific mortality were also described and considered with competing risks.

RESULTS

A total of 81,773 patients newly diagnosed with primary prostate cancer from 2007 to 2013 were identified. The 5-year CRS was 81.1% at baseline, but increased gradually up to 95.4% at 4 years and exceeded 100% at 5 years after diagnosis, suggesting no excess mortality compared with the general population. However, this pattern differed by treatment received. Patients who underwent androgen deprivation therapy showed 5-year CRS of only 88.4% at 5 years after diagnosis, implying persistent excess mortality. Prostate cancer constituted around one-third of deaths, while other cancers were the main cause of death within <2 years after diagnosis. Noncancer-related deaths, including cardiovascular disease and respiratory disease, increased with time since diagnosis.

CONCLUSIONS

CRS rates for patients with prostate cancer improved over time and exceeded that of the general population at 5 years. Other cancers were the main cause of death in the earlier survivorship phase, and deaths from noncancer causes gradually increased over time.

IMPACT

Our findings will help patients and clinicians make evidence-based decisions on the basis of a patient's dynamic risk profile.

Health care utilization by men with prostate cancer during the year before their death: A 2015 population-based study

INTRODUCTION

To study the characteristics and health care utilization of men with prostate cancer (PCa) during their last year and last month of life, as these data have been rarely reported to date.

SUBJECTS AND METHOD

Men covered by the national health Insurance general scheme (77% of the French population) treated for PCa (2014-2015), who died in 2015 were identified in the national health data system, including reimbursed hospital and outpatient care, and their causes of death.

RESULTS

A total of 11,193 men (mean age: 81 years, SD: 9.6) were included. Almost 58% of these men died in a short-stay hospital (SSH), 4% died in hospital-at-home, 9% died in Rehab, 9% died in skilled nursing homes and 21% died at home. During the last year of life, almost all men were hospitalised at least once in SSH and 47% received hospital palliative care (HPC), immediately prior to death in 8% of cases. During the last month of life, 76% of men were hospitalised at least once in SSH, 43% attended an emergency department and 14% were admitted to intensive care, 7% received a chemotherapy session, and 24% received an antineoplastic agent dispensed by a retail pharmacy. Cancer was the main cause of death for 63% of men, corresponding to PCa in 40% of cases, and cardiovascular disease was the main cause of death for 13% of men with marked variations according to age, place of death, and use of HPC. The mean cost reimbursed per man during the last year of life was €38,750 (€48,601 including HPC).

CONCLUSIONS

In France, end-of-life management of men with PCa, regardless of the cause of death, is centered on SSH and HPC, essentially at the time of death. Certain indicators of end-of-life management were particular high.

LEVEL OF EVIDENCE

4.

Who Dies From Prostate Cancer? An Analysis of the Surveillance, Epidemiology and End Results Database

AIMS

To characterise the presenting features of those who ultimately die from prostate cancer (PCa).

MATERIALS AND METHODS

The study population consisted of patients in the Surveillance, Epidemiology and End Results (SEER) Program database diagnosed with PCa between 1990 and 2015. Patients were assigned to the following clinical risk groups: low-risk localised (LRL), intermediate-risk localised (IRL), high-risk localised (HRL), node-positive and metastatic (M1). Before 2004, in the absence of prostate-specific antigen (PSA) and Gleason score data, patients with cT1-T2aN0M0 and low-grade PCa were classified as LRL, those with cT3-4N0M0 or high-grade PCa were classified as HRL and all others with N0M0 disease were classified as IRL. The primary aim was to describe the risk group distribution of those who ultimately died from PCa compared with those who were diagnosed with PCa over the study period. A secondary aim was to estimate PCa-specific survival (PCSS) and evaluate the association of risk group with PCSS.

RESULTS

Among a total of 811 487 patients who were diagnosed with PCa, data sufficient for risk group determination were present in 635 733 patients. The median follow-up was 83 months. The overall risk group distribution at diagnosis was as follows: LRL 10.5%, IRL 49.7%, HRL 34.8%, node-positive 1.5% and M1 3.5%. The risk group distribution of those who died from PCa was 3.9%, 29.4%, 40.9%, 3.2% and 22.8%, respectively. Compared with LRL PCa, the adjusted hazard ratio (95% confidence interval) for PCSS was 1.40 (1.33-1.46) in IRL, 3.76 (3.60-3.93) in HRL, 11.87 (11.14-12.65) in node-positive and 37.12 (35.43-38.88) in M1.

CONCLUSIONS

In this large contemporary cohort, patients with M1, node-positive and HRL disease accounted for two-thirds of all deaths from PCa. De novo metastatic PCa was associated with an approximately 40-fold increased risk of death from PCa compared with LRL PCa. Efforts to improve PCSS will therefore depend largely on improvements in therapy in those with M1, node-positive and HRL disease.

Extended follow-up for prostate cancer incidence and mortality among participants in the Prostate, Lung, Colorectal and Ovarian randomized cancer screening trial

OBJECTIVE

To examine prostate cancer (PCa) incidence and mortality by arm in the randomized Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial.

PATIENTS AND METHODS

Patients aged 55-74 years at 10 screening centres were randomized between 1993 and 2001 to an intervention or usual care arm. Patients in the intervention arm received six annual prostate-specific antigen (PSA) tests and four annual digital rectal examinations. The patients were followed for PCa incidence and for mortality via active follow-up processes and by linkage to state cancer registries and the National Death Index. For cancers identified through active follow-up, trial abstractors recorded the mode of diagnosis (screen-detected, symptomatic, other).

RESULTS

A total of 38 340 patients were randomized to the intervention arm and 38 343 to a usual care arm. The median follow-up for mortality was 16.9 (intervention) and 16.7 years (usual care). There were 333 (intervention) and 352 (usual care) PCa cancer deaths, giving rates (per 10 000 person-years) of 5.5 and 5.9, respectively, and a rate ratio (RR) of 0.93 (95% confidence interval [CI] 0.81-1.08; P = 0.38). The RR for overall PCa incidence was 1.05 (95% CI 1.01-1.09). The RRs by Gleason category were 1.17 (95% CI 1.11-1.23) for Gleason 2-6, 1.00 (95% CI 0.93-1.07) for Gleason 7 and 0.89 (95% CI 0.80-0.99) for Gleason 8-10 disease. By mode of detection, during the trial's screening phase, 13% of intervention arm vs 27% of usual care arm cases were symptomatic; post-screening, these percentages were 18% in each arm.

CONCLUSION

After almost 17 years of median follow-up, there was no significant reduction in PCa mortality in the intervention compared with the usual care arm. There was a significant increase in Gleason 2-6 disease and a significant reduction in Gleason 8-10 disease in the intervention compared with the usual care arm.

Causes of death in men with prostate cancer: Results from the Danish Prostate Cancer Registry (DAPROCAdata)

BACKGROUND

Current knowledge of the validity of registry data on prostate cancer-specific death is limited. We aimed to determine the underlying cause of death among Danish men with prostate cancer, to estimate the level of misattribution of prostate cancer death, and to examine the risk of death from prostate cancer when accounting for competing risk of death.

MATERIAL AND METHODS

We investigated a nationwide cohort of 15,878 prostate cancer patients diagnosed in 2010-2014; with 3343 deaths occurring through 2016. Blinded medical chart review was carried out for 670 deaths and compared to the national cause of death registry. Five death categories were defined: 1) prostate cancer-specific death, 2) other unspecified urological cancer death, 3) other cancer death 4) cardiovascular disease death, and 5) other causes of death. Competing risk analyses compared Cox cause-specific and Fine-Gray regression models.

RESULTS

Chart review attributed 51.2% of deaths to prostate cancer, 17.0% to cardiovascular disease, and 16.7% to other causes. The Danish Register of Causes of Death attributed 71.7% of deaths to prostate cancer when including all registered contributing causes of death, and 57.0% of deaths when including only the primary registered cause of death. The probability of death by prostate cancer was 10% at 2-year survival.

CONCLUSIONS

More than half of the deceased men in our study cohort died of their prostate cancer disease within a mean of 2.4 years of follow up. Data from the death registry is prone to misclassification, potentially overestimating the proportion of deaths from prostate cancer.

The risk of prostate cancer mortality and cardiovascular mortality of nonmetastatic prostate cancer patients: A population-based retrospective cohort study

PURPOSE

To assess the risk of prostate cancer (PCa) specific mortality (PCSM) compared to cardiovascular disease mortality (CVDM), or other-cause mortality (OCM) of men with nonmetastatic PCa according to PCa risk groups, primary treatment, and age.

PATIENTS AND METHODS

This retrospective population-based cohort study identified 1,908 nonmetastatic PCa patients in the cancer registry Zurich and Zug, diagnosed between 2000 and 2009 living in the City of Zurich. Multiple imputation methods were applied to handle missing PCa information. Fine and Gray competing risk regression analysis was used to estimate subdistribution hazard ratios for the outcomes PCSM, CVDM, or OCM RESULTS: Ten years after diagnosis the cumulative probability of PCSM and CVDM was 16.4% and 10.0%, respectively. We observed an increased adjusted risk of PCSM in men treated with androgen deprivation therapy (ADT) compared to surgery, but could not observe an association between ADT and CVDM. The probability of PCSM was significantly higher for patients on active surveillance or watchful waiting, compared to surgery. Age and PCa risk categories were positively associated with risk of PCSM, whereas there was no evidence for an association with CVDM or OCM based on risk groups.

CONCLUSIONS

Overall, men with PCa were more likely to die from non-PCa related outcomes. Nevertheless, the analyses showed a high proportion of PCSM among men on ADT, older men and men with a high-risk tumor. However, further research is needed to understand comprehensively the benefits of the respective treatments.

Diagnostic characteristics of lethal prostate cancer

BACKGROUND

The diagnostic characteristics of men who eventually die from prostate cancer (PCa) and the extent to which early diagnostic strategies have affected these characteristics are unclear. We aimed to investigate trends in survival and clinical presentation at diagnosis in men who eventually died from PCa.

PATIENTS AND METHODS

Based on the national database, the Danish Prostate Cancer Registry, a nationwide population-based study of all 19,487 men who died from PCa in Denmark between 1995 and 2013 was conducted. Trends in median survival and trends in age, prostate-specific antigen (PSA), clinical stage, and Gleason score (GS) at diagnosis were analysed.

RESULTS

A total of 46.9%, 16.8%, and 36.3% had metastatic (M+), locally advanced/lymph node positive (LaN+), and localised disease, respectively, at diagnosis. Only 0.15% had localised disease, GS ≤ 6 and PSA<10. Over time, the proportion of men with M+ disease at diagnosis decreased from 54.0-38.3% (p < 0.0001), whereas the proportion LaN + disease increased from 8.6-27.3% (p < 0.0001). The proportion of localised disease remained stable at 33.2-41.9%. Median survival increased 2.11 years from 1.88 (95% CI: 1.68-2.08) in 1995 to 3.99 (95% CI: 3.71-4.28) years in 2013, p < 0.0001.

CONCLUSIONS

In a large population-based study, the results confirmed concurrent literature that the majority of men who eventually died from PCa had LaN+ or M+ disease at diagnosis. The proportion of men with M+ disease at diagnosis decreased significantly over time, parallelled by an increase in median survival. Taken together, this indicates a lead-time effect on survival, which presently, however, is not substantial enough to result in a reduced PCa-specific mortality.

True Incidence of Gleason 6 Pathology in Patients with Metastatic Castration Resistant Prostate Cancer (mCRPC)

INTRODUCTION

Recent evidence from histology studies regarding random prostate biopsies hint toward a relationship between higher biopsy Gleason score and the development of metastatic castration resistant prostate cancer (mCRPC). However, prostate biopsy underestimates final pathology in about one-third of patients. We evaluated the final whole gland pathology from radical prostatectomy exclusively in order to assess the true risk of progressing to the mCRPC state for patients with confirmed Gleason ≤6 prostate cancer.

METHODS

Patients with confirmed mCRPC from our outpatient clinic were retrospectively evaluated with regard to whole gland pathology and the occurrence of Gleason 6 histology from 1995 to 2015. Conversely, patients with confirmed Gleason 6 pathology from our institutional database were followed up for the development of mCRPC from 2001 to 2015. Kaplan-Meier analysis and the log rank test were applied for survival analysis. The binomial test was used to evaluate occurrence rates of Gleason ≤6 pathologies in mCRPC patients.

RESULTS

Out of 62 patients with mCRPC none had confirmed Gleason 6 pathology on whole gland histology of the prostate. Out of 86 patients with confirmed Gleason 6 pathology none developed an mCRPC over the follow-up period.

CONCLUSION

The development of mCRPC in patients with true Gleason 6 pathology is very rare and could not be confirmed in our series. This finding may have important implications in future treatment planning.

The impact of diabetes and other metabolic disorders on prostate cancer prognosis

AIMS

To investigate the impact of diabetes mellitus (DM) and other metabolic disorders on the survival of men with prostate cancer (PCa).

METHODS

We conducted a retrospective cohort-study based on 715 men with PCa, originally enrolled in an Italian case-control study between 1995 and 2002. Anthropometric measures, self-reported medical conditions, and Gleason score were assessed at enrollment. Adjusted hazard ratios (HRs) of death, with 95% confidence intervals (95% CIs), were estimated using Fine and Gray's regression model.

RESULTS

After a median follow-up of 11.6years, 244 (34.1%) deaths occurred, 77 (31.6%) due to PCa. Excess mortality from all causes was reported in PCa patients with DM (HR=1.56, 95% CI: 1.03-2.36), which increased to 1.76 (95% CI: 0.99-3.13) when at least two out of three metabolic disorders (i.e., waist circumference ≥102cm, drug-treated hypertension, and hypercholesterolemia) were additionally present. The impact of metabolic disorders was stronger on non-PCa-specific mortality with HRs equal to 2.21 (95% CI: 1.38-3.54) for DM, 1.45 (95% CI: 0.97-2.19) for waist circumference ≥102cm, and 1.63 (95% CI: 1.19-2.22) for drug-treated hypertension.

CONCLUSIONS

DM and other metabolic disorders unfavorably affected the survival of PCa patients, mainly impacting on the risk of death from causes other than PCa.

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.

Lycopene, tomato products and prostate cancer-specific mortality among men diagnosed with nonmetastatic prostate cancer in the Cancer Prevention Study II Nutrition Cohort

While dietary lycopene and tomato products have been inversely associated with prostate cancer incidence, there is limited evidence for an association between consumption of lycopene and tomato products and prostate-cancer specific mortality (PCSM). We examined the associations of prediagnosis and postdiagnosis dietary lycopene and tomato product intake with PCSM in a large prospective cohort. This analysis included men diagnosed with nonmetastatic prostate cancer between enrollment in the Cancer Prevention Study II Nutrition Cohort in 1992 or 1993 and June 2011. Prediagnosis dietary data, collected at baseline, were available for 8,898 men, of whom 526 died of prostate cancer through 2012. Postdiagnosis dietary data, collected on follow-up surveys in 1999 and/or 2003, were available for 5,643 men, of whom 363 died of prostate cancer through 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for PCSM. Neither prediagnosis nor postdiagnosis dietary lycopene intake was associated with PCSM (fourth vs. first quartile HR = 1.00, 95% CI 0.78-1.28; HR = 1.22, 95% CI 0.91-1.64, respectively). Similarly, neither prediagnosis nor postdiagnosis consumption of tomato products was associated with PCSM. Among men with high-risk cancers (T3-T4 or Gleason score 8-10, or nodal involvement), consistently reporting lycopene intake ≥ median on both postdiagnosis surveys was associated with lower PCSM (HR = 0.41, 95% CI 0.17-0.99, based on ten PCSM cases consistently ≥ median intake) compared to consistently reporting intake < median. Future studies are needed to confirm the potential inverse association of consistently high lycopene intake with PCSM among men with high-risk prostate cancers.

Characterizations of Clinical and Therapeutic Histories for Men With Prostate Cancer-Specific Mortality

BACKGROUND

Careful descriptions of men with prostate cancer (PCa)-specific mortality are scant in nontrial settings. The present retrospective review describes the clinical characteristics, timelines, and treatment histories from initial presentation to death in a cohort of men with metastatic, castrate-resistant PCa (mCRPC). Unique to the present study is the unequivocal attribution of PCa death by a single experienced clinician.

PATIENTS AND METHODS

A total of 119 patients who had been treated at Tulane Cancer Center and had died of mCRPC from 2008 to 2015 were studied through a retrospective review of the medical records.

RESULTS

The median age at diagnosis was 65 years (range, 40-85 years), and 34.4% of the patients presented with metastatic disease (stage M1). Of these patients, 56% had received definitive primary therapy, all had received androgen-deprivation therapy, and 52% had received docetaxel. The patients had received a median of 7 (1-14) systemic therapies before death. Most were secondary hormonal manipulations after the diagnosis of mCRPC (median, 4; range, 0-9). The median survival was 69 months (range, 5-270 months) after diagnosis, and the median age at death was 73 years (range, 47-95 years). The presence of metastases at diagnosis was a significant predictor of early death (hazard ratio, 4.33; P < .001), and definitive primary therapy was a significant predictor of longer survival (P < .001). The median survival for patients presenting with metastases was 39 months (range, 5-235 months) compared with 100 months (range, 6-270 months) for those with localized disease (P < .001). The median age at diagnosis between the docetaxel- and non-docetaxel-treated patients was significantly different at 62 and 71 years, respectively (P = .002).

CONCLUSION

The present retrospective analysis provides initial views clarifying the clinical characteristics of men dying of mCRPC and the therapies they received before death. Additional data are needed in multi-institutional settings to confirm these findings.

Evaluating variation in use of definitive therapy and risk-adjusted prostate cancer mortality in England and the USA

OBJECTIVES

Prostate cancer mortality (PCM) in the USA is among the lowest in the world, whereas PCM in England is among the highest in Europe. This paper aims to assess the association of variation in use of definitive therapy on risk-adjusted PCM in England as compared with the USA.

DESIGN

Observational study.

SETTING

Cancer registry data from England and the USA.

PARTICIPANTS

Men diagnosed with non-metastatic prostate cancer (PCa) in England and the USA between 2004 and 2008.

OUTCOME MEASURES

Competing-risks survival analyses to estimate subhazard ratios (SHR) of PCM adjusted for age, ethnicity, year of diagnosis, Gleason score (GS) and clinical tumour (cT) stage.

RESULTS

222,163 men were eligible for inclusion. Compared with American patients, English patients were more likely to present at an older age (70-79 years: England 44.2%, USA 29.3%, p<0.001), with higher tumour stage (cT3-T4: England 25.1%, USA 8.6%, p<0.001) and higher GS (GS 8-10: England 20.7%, USA 11.2%, p<0.001). They were also less likely to receive definitive therapy (England 38%, USA 77%, p<0.001). English patients were more likely to die of PCa (SHR=1.9, 95% CI 1.7 to 2.0, p<0.001). However, this difference was no longer statistically significant when also adjusted for use of definitive therapy (SHR=1.0, 95% CI 1.0 to 1.1, p=0.3).

CONCLUSIONS

Risk-adjusted PCM is significantly higher in England compared with the USA. This difference may be explained by less frequent use of definitive therapy in England.

A co-clinical platform to accelerate cancer treatment optimization

Sophistication in DNA and RNA sequencing technology is unraveling the tremendous genetic and molecular complexity of human cancer. However, the rate at which this knowledge is being translated into patient care is too slow. To this end, we have designed and implemented a new translational platform, 'The Co-Clinical Trial Project', where data obtained in genetically engineered mouse models (GEMMs) of human cancer treated with protocols identical to those of ongoing clinical trials or with therapies already established in patients serve to rapidly: (i) stratify patients in terms of response and resistance on the basis of genetic and molecular criteria; (ii) identify mechanisms responsible for tumor resistance; and (iii) evaluate the effectiveness of drug combinations to overcome such resistance based on mechanistic understanding.

Who dies from prostate cancer?

BACKGROUND

During the last 30 years, there has been a major shift in initial staging in prostate cancer (CaP) in Western countries, with the incidence of metastases at diagnosis decreasing from over 50% in the 1970s to currently less than 10%. Yet, CaP is still the second cause of cancer death in men. We used two monthly curated databases of patients with castration-resistant prostate cancer (CRPC) to describe the natural history of patients dying of CaP in the modern era.

METHODS

The outcome of 190 men with metastatic CRPC treated from 2008 to 2011 was studied. The characteristics of the patients who died from CaP (n = 113 patients, 61%) were analyzed.

RESULTS

All 113 patients who died of CaP were assessable for the presence of metastases at diagnosis. Sixty-three patients (56%) had detectable metastases at diagnosis: 67%, 11% and 43% had bone, visceral and lymph node metastases, respectively. The median time to CRPC was 16 months and median overall survival (OS) was 5.2 years.Among the patients with localized CaP at diagnosis (n = 50, 44%), 46% had T stage ⩾ 3 and 38% had a Gleason score ⩾ 8. Overall, 64% of patients were classified as having a high-risk CaP. Only 26% who died from CaP had a Gleason score ⩽ 6. Median OS was 8.8 years.

CONCLUSIONS

In the modern era, approximately half of the patients who die from CaP have metastases at diagnosis. The paradigm of progression from localized disease to metastasis and eventually death is only represented in the other half, although possible initial screening and staging errors ought to be taken into consideration. More efforts are needed to conduct trials in patients with newly diagnosed metastatic CaP.