Management of localized prostate cancer in senior adults: the crucial role of comorbidity

Metastatic Castration-Resistant Prostate Cancer: Advances in Treatment and Symptom Management

OPINION STATEMENT

The management of metastatic castrate-resistant prostate cancer (mCRPC) has evolved in the past decade due to substantial advances in understanding the genomic landscape and biology underpinning this form of prostate cancer. The implementation of various therapeutic agents has improved overall survival but despite the promising advances in therapeutic options, mCRPC remains incurable. The focus of treatment should be not only to improve survival but also to preserve the patient's quality of life (QoL) and ameliorate cancer-related symptoms such as pain. The choice and sequence of therapy for mCRPC patients are complex and influenced by various factors, such as side effects, disease burden, treatment history, comorbidities, patient preference and, more recently, the presence of actionable genomic alterations or biomarkers. Docetaxel is the first-line treatment for chemo-naïve patients with good performance status and those who have yet to progress on docetaxel in the castration-sensitive setting. Novel androgen agents (NHAs), such as abiraterone and enzalutamide, are effective treatment options that are utilized as second-line options. These medications can be considered upfront in frail patients or patients who are NHA naïve. Current guidelines recommend genetic testing in mCRPC for mutations in DNA repair deficiency genes to inform treatment decisions, as for example in breast cancer gene mutation testing. Other potential biomarkers being investigated include phosphatase and tensin homologues and homologous recombination repair genes. Despite a growing number of studies incorporating biomarkers in their trial designs, to date, only olaparib in the PROFOUND study and lutetium-177 in the VISION trial have improved survival. This is an unmet need, and future trials should focus on biomarker-guided treatment strategies. The advent of novel noncytotoxic agents has enhanced targeted drug delivery and improved treatment responses with favourable toxicity profiling. Trials should continue to incorporate and report health-related QoL scores and functional assessments into their trial designs.

Alterations of Sexual and Erectile Functions after Brachytherapy for Prostate Cancer Based on Patient-Reported Questionnaires

The aim of the study was to compare the side effects of high-dose-rate brachytherapy (HDRBT) and low-dose-rate brachytherapy (LDRBT), with a particular focus on the effects on sexual functions and sexual well-being (PROMOBRA study, NCT02258087). Localized low-risk and low-intermediate-risk prostate cancer patients were treated with mono LDR (N = 123, 145 Gy dose) or mono HDR brachytherapy (N = 117, 19/21 Gy). Prior to the treatment and during follow-up (at 3, 6, 9, 12, 18, and 24 months after treatment, and then annually after two years), patients completed patient-reported outcome measurement (PROM) questionnaires EORTC QLQ-PR-25, International Index of Erectile Function (IIEF), and IIEF-5 (SHIM). We compared the patients in different group breakdowns (HDR vs. LDR, hormone naïve and hormone-receiving HDR vs. LDR, hormone naïve and hormone-receiving patients in general, and 19 Gy HDR vs. 21 Gy HDR). In the hormone-naive LDR group, erectile function, orgasm function, sexual desire, satisfaction with intercourse, and overall satisfaction functions significantly decreased compared to baseline throughout the whole follow-up period. However, there were significant decreases in function at a maximum of three time points after HDR therapy without hormone therapy. In hormone-receiving patients, the orgasm function was significantly better in the HDR group at multiple time points compared to the baseline, and sexual desire improved at four time points. According to our results, both LDRBT and HDRBT can be safely administered to patients with localized prostate cancer. In hormone-naive patients, the HDR group showed only recovering decreases in sexual functions, while the LDR group showed a lasting decline in multiple areas. Thus, HDR appears to be more advantageous to hormone-naive patients.

Molecular Targeted Therapies in Metastatic Prostate Cancer: Recent Advances and Future Challenges

Prostate cancer is the most frequent malignant tumor in men, and, despite the great improvements in survival in patients with localized cancer, the prognosis for metastatic disease remains poor. Novel molecular targeted therapies, which block specific molecules or signaling pathways in tumor cells or in their microenvironment, have shown encouraging results in metastatic castration-resistant prostate cancer. Among these therapeutic approaches, prostate-specific membrane antigen-targeted radionuclide therapies and DNA repair inhibitors represent the most promising ones, with some therapeutic protocols already approved by the FDA, whereas therapies targeting tumor neovascularization and immune checkpoint inhibitors have not yet demonstrated clear clinical benefits. In this review, the most relevant studies and clinical trials on this topic are illustrated and discussed, together with future research directions and challenges.

Cardiovascular outcomes among patients with castration-resistant prostate cancer: A comparative safety study using US administrative claims data

BACKGROUND

Cardiovascular conditions are the most prevalent comorbidity among patients with prostate cancer, regardless of treatment. Additionally, cardiovascular risk has been shown to increase following exposure to certain treatments for advanced prostate cancer. There is conflicting evidence on risk of overall and specific cardiovascular outcomes among men treated for metastatic castrate resistant prostate cancer (CRPC). We, therefore, sought to compare incidence of serious cardiovascular events among CRPC patients treated with abiraterone acetate plus predniso(lo)ne (AAP) and enzalutamide (ENZ), the two most widely used CRPC therapies.

METHODS

Using US administrative claims data, we selected CRPC patients newly exposed to either treatment after August 31, 2012, with prior androgen deprivation therapy (ADT). We assessed incidence of hospitalization for heart failure (HHF), ischemic stroke, and acute myocardial infarction (AMI) during the period 30-days after AAP or ENZ initiation to discontinuation, outcome occurrence, death, or disenrollment. We matched treatment groups on propensity-scores (PSs) to control for observed confounding to estimate the average treatment effect among the treated (AAP) using conditional Cox proportional hazards models. To account for residual bias, we calibrated our estimates against a distribution of effect estimates from 124 negative-control outcomes.

RESULTS

The HHF analysis included 2322 (45.1%) AAP initiators and 2827 (54.9%) ENZ initiators. In this analysis, the median follow-up times among AAP and ENZ initiators (after PS matching) were 144 and 122 days, respectively. The empirically calibrated hazard ratio (HR) estimate for HHF was 2.56 (95% confidence interval [CI]: 1.32, 4.94). Corresponding HRs for AMI and ischemic stroke were 1.94 (95% CI: 0.90, 4.18) and 1.25 (95% CI: 0.54, 2.85), respectively.

CONCLUSIONS

Our study sought to quantify risk of HHF, AMI and ischemic stroke among CRPC patients initiating AAP relative to ENZ within a national administrative claims database. Increased risk for HHF among AAP compared to ENZ users was observed. The difference in myocardial infarction did not attain statistical significance after controlling for residual bias, and no differences were noted in ischemic stroke between the two treatments. These findings confirm labeled warnings and precautions for AAP for HHF and contribute to the comparative real-world evidence on AAP relative to ENZ.

STAT3 signaling in prostate cancer progression and therapy resistance: An oncogenic pathway with diverse functions

The categorization of cancers demonstrates that prostate cancer is the most common malignancy in men and it causes high death annually. Prostate cancer patients are diagnosed mainly via biomarkers such as PSA test and patients show poor prognosis. Prostate cancer cells rapidly diffuse into different parts of body and their metastasis is also a reason for death. Current therapies for prostate cancer patients include chemotherapy, surgery and radiotherapy as well as targeted therapy. The progression of prostate cancer cells is regulated by different factors that STAT3 signaling is among them. Growth factors and cytokines such as IL-6 can induce STAT3 signaling and it shows carcinogenic impact. Activation of STAT3 signaling occurs in prostate cancer and it promotes malignant behavior of tumor cells. Induction of STAT3 signaling increases glycolysis and proliferation of prostate cancer cells and prevents apoptosis. Furthermore, STAT3 signaling induces EMT mechanism in increasing cancer metastasis. Activation of STAT3 signaling stimulates drug resistance and the limitation of current works is lack of experiment related to role of STAT3 signaling in radio-resistance in prostate tumor. Calcitriol, capsazepine and β-elemonic are among the compounds capable of targeting STAT3 signaling and its inhibition in prostate cancer therapy. In addition to natural products, small molecules targeting STAT3 signaling have been developed in prostate cancer therapy.

Prostate cancer: Therapeutic prospect with herbal medicine

Prostate cancer (PCa) is a major cause of morbidity and mortality in men worldwide. A geographic variation on the burden of the disease suggested that the environment, genetic makeup, lifestyle, and food habits modulate one's susceptibility to the disease. Although it has been generally thought to be an older age disease, and awareness and timely execution of screening programs have managed to contain the disease in the older population over the last decades, the incidence is still increasing in the population younger than 50. Existing treatment is efficient for PCa that is localized and responsive to androgen. However, the androgen resistant and metastatic PCa are challenging to treat. Conventional radiation and chemotherapies are associated with severe side effects in addition to being exorbitantly expensive. Many isolated phytochemicals and extracts of plants used in traditional medicine are known for their safety and diverse healing properties, including many with varying levels of anti-PCa activities. Many of the phytochemicals discussed here, as shown by many laboratories, inhibit tumor cell growth and proliferation by interfering with the components in the pathways responsible for the enhanced proliferation, metabolism, angiogenesis, invasion, and metastasis in the prostate cells while upregulating the mechanisms of cell death and cell cycle arrest. Notably, many of these agents simultaneously target multiple cellular pathways. We analyzed the available literature and provided an update on this issue in this review article.

Intraoperative changes in whole-blood viscosity in patients undergoing robot-assisted laparoscopic prostatectomy in the steep Trendelenburg position with pneumoperitoneum: a prospective nonrandomized observational cohort study

Background

The aim of this study was to investigate the effect of the steep Trendelenburg position (STP) with pneumoperitoneum on whole-blood viscosity (WBV) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). The study also analyzed the associations of clinical patient-specific and time-dependent variables with WBV and recorded postoperative outcomes.

Methods

Fifty-eight adult male patients (ASA physical status of I or II) undergoing elective RALP were prospectively analyzed in this study. WBV was intraoperatively measured three times: at the beginning of surgery in the supine position without pneumoperitoneum; after 30 min in the STP with pneumoperitoneum; and at the end of surgery in the supine position without pneumoperitoneum. The WBV at a high shear rate (300 s^− 1) was recorded as systolic blood viscosity (SBV) and that at a low shear rate (5 s^− 1) was recorded as diastolic blood viscosity (DBV). Systolic blood hyperviscosity was defined as > 13.0 cP at 300 s^− 1 and diastolic blood hyperviscosity was defined as > 4.1 cP at 5 s^− 1.

Results

The WBV and incidences of systolic and diastolic blood hyperviscosity significantly increased from the supine position without pneumoperitoneum to the STP with pneumoperitoneum. When RALP was performed in the STP with pneumoperitoneum, 12 patients (27.3%) who had normal SBV at the beginning of surgery and 11 patients (26.8%) who had normal DBV at the beginning of surgery developed new systolic and diastolic blood hyperviscosity, respectively. The degree of increase in WBV after positioning with the STP and pneumoperitoneum was higher in the patients with hyperviscosity than in those without hyperviscosity at the beginning of surgery. Higher preoperative body mass index (BMI) and hematocrit level were associated with the development of both systolic and diastolic blood hyperviscosity in the STP with pneumoperitoneum. All patients were postoperatively discharged without fatal complications.

Conclusions

Changes in surgical position may influence WBV, and higher preoperative BMI and hematocrit level are independent factors associated with the risk of hyperviscosity during RALP in the STP with pneumoperitoneum.

Trial registration

Clinical Research Information Service, Republic of Korea, approval number: KCT0003295 on October 25, 2018.

Trends in the incidence and mortality of cancer in Saudi Arabia

Objectives:

To analyze the overall trends in cancer incidence and mortality in Saudi Arabia between 1990 and 2016.

Methods:

Data were retrieved through a Global Burden of Disease (GBD, 2016) database (Viz Hub) that is developed by the Institute for Health Metrics and Evaluation at the University of Washington.

Results:

The incidence of cancer increased around 26-fold for thyroid cancer; approximately 10-fold in breast, colon, bladder and uterine cancers; 8-fold for prostate cancer; 5-fold for renal cancer; 4-fold for pancreatic and ovarian cancer; 3.5-fold for lung cancer; 3-fold for liver cancer, and 2 folds for lymphoma, leukemia and gastric cancer. There was also an increase in the percentage of mortality due to cancer during this period. However, we noticed that the percentage of deaths due to cancer decreased after 70 years of age in Saudi Arabia population.

Conclusion:

The increases in the incidence of different types of cancer in the past decade could be due to the revolutionary change in socioeconomic status that has occurred in Saudi Arabia; therefore, a national plan should be established for cancer prevention, screening and therapy. Concerning mortality, the decrease in its percentage among elderly people could be due to biological factors that should be investigated in the future.

Effects of 25- and 30-degree Trendelenburg positions on intraocular pressure changes during robot-assisted radical prostatectomy

Background

The objective of this study was to assess the effects of 25-degree and 30-degree Trendelenburg positions on intraocular pressure (IOP) changes during robot-assisted radical prostatectomy (RARP).

Materials and methods

This prospective study involved a total of 30 consecutive patients undergoing RARP. All participants were randomly divided into two groups: Trendelenburg position with the head down at 25 degrees or 30 degrees. In addition to representative operative outcomes, IOP was measured at six discrete time points; Time 1 (T1): before induction of general anesthesia, patients in a horizontal supine position; T2: after induction of general anesthesia, patients in a horizontal supine position; T3: 1 hour after adopting the Trendelenburg position; T4: 2 hours after adopting the Trendelenburg position; T5: after pneumoperitoneum resolution in the Trendelenburg position; T6: anesthetized before awakening in a supine position.

Results

The total and console operative times, estimated blood loss, and intravenous fluid intake during RARP did not significantly differ between the two groups. While the IOP values measured at the same time points were similar between the two groups, the 25-degree Trendelenburg position significantly attenuated the IOP change from T1 to T3, T4, and T5 compared with those at 30 degrees.

Conclusions

These findings suggest that RARP in the 25-degree Trendelenburg position may reduce the risks of position-related ophthalmic complications without increasing the difficulty of the surgical procedure.

Comorbidity assessment in localized prostate cancer: a systematic review protocol

The objective of this study is to review and summarize the methods and tools used to measure comorbidity in localized prostate cancer (PCa) and in particular to assess whether these tools are adequately validated and reliable for determining the impact of comorbidity on survival and treatment decisions for this disease.Specifically, the review questions are.

Safety and feasibility of robot-assisted radical prostatectomy for clinically localized prostate cancer in elderly Japanese patients

BACKGROUND

This study was conducted to assess the safety and feasibility of robot-assisted radical prostatectomy (RARP) for elderly Japanese (aged ≥ 70 years) patients with clinically localized prostate cancer (PCa).

METHODS

From April 2012 to March 2016, a total of 302 consecutive patients with clinically localized PCa underwent RARP at our institute. In this series, 109 (36.1%) and 193 (63.9%) of the patients were divided into older (aged ≥ 70 years) and younger (aged <70 years) groups, respectively. The correlation between the categorized patient age and various clinicopathological factors, including preoperative characteristics, perioperative outcome, and urinary continence outcome after RARP, was retrospectively analyzed.

RESULTS

Except for age and Gleason score at biopsy, there was no difference in the preoperative features between the two groups. A nonnerve-sparing RARP was performed more often in the younger group; however, other perioperative variables in the elderly group were comparable to those in the younger group. Similarly, the urinary continence rates at 1 month, 3 months, and 6 months after the surgery were equally favorable in the younger and older groups.

CONCLUSION

RARP may be a reasonable therapeutic option for elderly patients with PCa and provides comparable perioperative and functional outcomes to those in younger patients.

Outcomes of patients older than 75 years with non-metastatic prostate cancer

Objective

Prostate cancer in elderly patients was formerly treated with androgen deprivation therapy. Since the latter of the 1990s new technologies were introduced into treatments, then strategies have varied. We aimed to observe the outcomes of elderly patients treated during transition period and compare each stage with others.

Methods

During 2008 and 2010, 255 patients with prostate cancer older than 75 years were sequentially treated. With exception of patients with bone and/or visceral metastasis, outcomes of 199 patients with localized and locally advanced stages were examined. Complete records were obtained by the end of 2015.

Results

In total, 122 (61%), 28 (14%), 37 (19%) and 12 (6%) of patients were in stages T1c-T2a, T2b-c, T3 and T4, respectively. Patients generally presented with abnormal screening or lower urinary tract symptom. Seventy-one percent of patients received androgen deprivation therapy as monotherapy and 22% of the radiation-treated patients added androgen deprivation therapy. Patients in stage T1c-T2a and T2b-c showed a favorable prognosis. Some cancer death appeared in patients with T3 and T4 during observation periods. Twenty-seven percent of patients died from prostate cancer-independent complications: pneumonia, heart disease, and brain vascular disease. Tendency is similar to that of Japanese elderly male population. No remarkable side effects from androgen deprivation therapy were noticed.

Conclusion

Elderly patients with localized prostate cancer showed favorable prognosis by androgen deprivation therapy with/without radiation, thus efficacy of androgen deprivation therapy is suitable to elderly patients with applicable stages. Prognosis of patients with locally advanced stage is serious and remains to be improved.

Identifying New Candidate Genes and Chemicals Related to Prostate Cancer Using a Hybrid Network and Shortest Path Approach

Prostate cancer is a type of cancer that occurs in the male prostate, a gland in the male reproductive system. Because prostate cancer cells may spread to other parts of the body and can influence human reproduction, understanding the mechanisms underlying this disease is critical for designing effective treatments. The identification of as many genes and chemicals related to prostate cancer as possible will enhance our understanding of this disease. In this study, we proposed a computational method to identify new candidate genes and chemicals based on currently known genes and chemicals related to prostate cancer by applying a shortest path approach in a hybrid network. The hybrid network was constructed according to information concerning chemical-chemical interactions, chemical-protein interactions, and protein-protein interactions. Many of the obtained genes and chemicals are associated with prostate cancer.

Evidence that selenium binding protein 1 is a tumor suppressor in prostate cancer

Selenium-Binding Protein 1 (SBP1, SELENBP1, hSP56) is a selenium-associated protein shown to be at lower levels in tumors, and its lower levels are frequently predictive of a poor clinical outcome. Distinguishing indolent from aggressive prostate cancer is a major challenge in disease management. Associations between SBP1 levels, tumor grade, and disease recurrence following prostatectomy were investigated by duplex immunofluorescence imaging using a tissue microarray containing tissue from 202 prostate cancer patients who experienced biochemical (PSA) recurrence after prostatectomy and 202 matched control patients whose cancer did not recur. Samples were matched by age, ethnicity, pathological stage and Gleason grade, and images were quantified using the Vectra multispectral imaging system. Fluorescent labels were targeted for SBP1 and cytokeratins 8/18 to restrict scoring to tumor cells, and cell-by-cell quantification of SBP1 in the nucleus and cytoplasm was performed. Nuclear SBP1 levels and the nuclear to cytoplasm ratio were inversely associated with tumor grade using linear regression analysis. Following classification of samples into quartiles based on the SBP1 levels among controls, tumors in the lowest quartile were more than twice as likely to recur compared to those in any other quartile. Inducible ectopic SBP1 expression reduced the ability of HCT-116 human tumor cells to grow in soft agar, a measure of transformation, without affecting proliferation. Cells expressing SBP1 also demonstrated a robust induction in the phosphorylation of the p53 tumor suppressor at serine 15. These data indicate that loss of SBP1 may play an independent contributing role in prostate cancer progression and its levels might be useful in distinguishing indolent from aggressive disease.

The incidence rate of prostate cancer in Saudi Arabia: an observational descriptive epidemiological analysis of data from the Saudi Cancer Registry 2001-2008

BACKGROUND

This study presents descriptive epidemiological data related to prostate cancer cases diagnosed from 2001 to 2008 among Saudi men, including the frequency and percentage of cases, the crude incidence rate (CIR) and the age-standardised incidence rate (ASIR) adjusted by region and year of diagnosis.

METHODS

This is a retrospective descriptive epidemiological analysis of all Saudi prostate cancer cases recorded in the Saudi Cancer Registry (SCR) between January 2001 and December 2008. Statistical analyses were conducted using descriptive statistics, the Poisson regression model, a simple linear regression model and analysis of variance with the Statistical Package for the Social Sciences version 20.0 (SPSS).

RESULTS

A total of 1739 cases were registered in the SCR between January 2001 and December 2008. The eastern region of Saudi Arabia had the highest overall ASIR at 10.1 per 100,000 men, followed by Riyadh at 7.1 and Makkah at 5.2, while Jizan and Najran had the lowest average ASIRs at 1.4 and at 2.0, respectively. The Poisson regression model for the region of Jizan shows that the incidence rate ratio (IRR) was significantly higher (p < 0.001); for the regions of Riyadh at 3.43 times (95% CI, 3.13-3.73), followed by Makkah at 2.56 (95% CI, 2.38-2.74) and the eastern province at 1.93 (95% CI, 1.64-2.23). The annual prediction of the CIR of prostate cancer in Saudi Arabia could be defined by the equation 1.53 + (0.094 × Years), and the prediction of the ASIR could be defined by the equation 2.98 + (0.182 × Years).

CONCLUSION

There was a steady increase in the CIRs and ASIRs for prostate cancer between 2001 and 2008. The eastern region, Riyadh and Makkah had the highest overall ASIR in Saudi Arabia. Further effective screening programmes and active treatment measures are needed to control prostate cancer disease among Saudi men.

Comorbidity and survival of Danish prostate cancer patients from 2000-2011: a population-based cohort study

Objective

We investigated temporal changes in overall survival among prostate cancer (PC) patients and the impact of comorbidity on all-cause mortality.

Methods

We conducted a population-based cohort study in the Central Denmark Region (1.2 million inhabitants). Using medical registries, we identified 7,654 PC patients with first-time PC diagnosis within the period 2000–2011 and their corresponding comorbidities within 10 years prior to the PC diagnosis. We estimated 1- and 5-year survival in four consecutive calendar periods using a hybrid analysis and plotted Kaplan–Meier survival curves. We used Cox proportional hazards regression to compute 1- and 5-year age-adjusted mortality rate ratios (MRRs) for different comorbidity levels. All estimates are reported with their corresponding 95% confidence intervals (CI).

Results

The annual number of PC cases doubled over the 12-year study period. Men aged <70 years accounted for the largest proportional increase (from 33% to 47%). The proportion of patients within each comorbidity category remained constant over time. One-year survival increased from 82% (CI: 80%–84%) in 2000–2002 to 92% (CI: 90%–93%) in 2009–2011, while 5-year survival increased from 43% (CI: 40%–46%) to 65% (CI: 62%–67%) during the same time intervals. Improvements in 5-year survival were most prominent among patients aged <80 years and among those with no comorbidity (from 51% to 73%) and medium comorbidity (from 32% to 54%). Improvements in survival were much smaller for those with high comorbidity (from 33% to 39%). The 1-year age-adjusted MRR for patients with high comorbidity (relative to patients with no comorbidity) increased over time from 1.84 (CI: 1.19–2.84) to 3.67 (CI: 2.49–5.41), while the 5-year age-adjusted MRR increased from 1.73 (CI: 1.34–2.23) to 2.38 (CI: 1.93–2.94).

Conclusion

Overall survival of PC improved substantially during 2000–2011, although primarily among men with low comorbidity. All-cause mortality was highest among PC patients with high comorbidity, and their relative 1- and 5-year mortality increased over time compared to those without comorbidity.

Age remains the major predictor of curative treatment non-receipt for localised prostate cancer: a population-based study

Background:

Geriatric oncology guidelines state that fit older men with prostate cancer should receive curative treatment. In a population-based study, we investigated associations between age and non-receipt of curative treatment in men with localised prostate cancer, and the effect of clinical variables on this in different age groups.

Methods:

Clinically localised prostate cancers (T1–T2N0M0) diagnosed from 2002 to 2008 among men aged ⩾40 years, with hospital in-patient episode(s) within 1 year post-diagnosis, were included (n=5456). Clinical and socio-demographic variables were obtained from cancer registrations. Comorbidity was determined from hospital episode data. Logistic regression was used to investigate associations between age and non-receipt of treatment, adjusting for confounders; the outcome was non-receipt of curative treatment (radical prostatectomy or radiotherapy).

Results:

The percentage who did not receive curative treatment was 9.2%, 14.3%, 48.2% and 91.7% for men aged 40–59, 60–69, 70–79 and 80+ years, respectively. After adjusting for clinical and socio-demographic factors, age remained the main determinant of treatment non-receipt. Men aged 70–79 had a significant five-fold increased risk of not having curative treatment compared with men aged 60–69 (odds ratio (OR)=5.5; 95% confidence interval 4.7, 6.5). In age-stratified analyses, clinical factors had a higher weight for men aged 60–69 than in other age strata. Over time, non-receipt of curative treatment increased among men aged 40–59 and decreased among men aged 70–79.

Conclusion:

Age remains the dominant factor in determining non-receipt of curative treatment. There have been some changes in clinical practice over time, but whether these will impact on prostate cancer mortality remains to be established.

[Management of prostate cancer in the elderly]

The management of prostate cancer in elderly patients is a topic of controversial discussion. The current guidelines recommend diagnosis and treatment of prostate cancer only in patients with a life expectancy of more than 10 years. Especially in elderly patients pre-existing comorbidities play a crucial role in life expectancy. In clinical practice mostly patient age alone is considered for the treatment decision; however, a guideline-based therapy of prostate cancer should also be offered to elderly patients. The treatment decision should be based on patient general health status and the oncological risk. The patient individual health status can be determined on the basis of comorbidities present and patient nutritional and performance status. For an optimal therapy regime the oncological risk has to be considered in treatment decisions. The aim of this article is to give an overview of risk stratification and treatment options for localized and metastatic prostate cancer in elderly patients.

Impact of race on survival in patients with clinically nonmetastatic prostate cancer who deferred primary treatment

BACKGROUND

Prostate cancer (PCa) racial disparity studies typically focus on survival differences after curative treatment. The authors of this report hypothesized that comparing mortality rates between African American (AA) and Caucasian American (CA) patients who deferred primary treatment for clinically nonmetastatic PCa may provide a better assessment of the impact of race on the natural course of PCa.

METHODS

The pathology database of the New York Veterans Administration Medical Center (VAMC), an equal access-of-care facility, was searched for patients with biopsy-proven PCa. Inclusion criteria included 1) no evidence of metastatic disease or death within 3 years after diagnosis, 2) no primary treatment, and 3) a minimum of 5 years of follow-up for survivors.

RESULTS

In total, 518 patients met inclusion criteria between 1990 and 2005. AA patients were younger (P = .02) and had higher median prostate-specific antigen (PSA) levels (P = .001) at the time of diagnosis compared with CA patients. In a multivariate model, higher Gleason score and PSA level were associated with increased mortality (P = .001 and P = .03, respectively), but race was not a predictor of death from PCa.

CONCLUSIONS

The current data suggested that race did not have a major impact on survival in patients with PCa who deferred primary treatment for clinically nonmetastatic disease.

Impact of age at diagnosis on prostate cancer treatment and survival

PURPOSE

Older men are more likely to be diagnosed with high-risk prostate cancer and to have lower overall survival. As a result, age often plays a role in treatment choice. However, the relationships among age, disease risk, and prostate cancer-specific survival have not been well established.

PATIENTS AND METHODS

We studied men in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database with complete risk, treatment, and follow-up information. High-risk patients were identified by using the validated Cancer of the Prostate Risk Assessment (CAPRA) score. Competing risks regression was used to identify the independent impact of age on cancer-specific survival. We also analyzed the effect of local treatment on survival among older men with high-risk disease.

RESULTS

In all, 26% of men age ≥ 75 years presented with high-risk disease (CAPRA score 6 to 10). Treatment varied markedly with age across risk strata; older men were more likely to receive androgen deprivation monotherapy. Controlling for treatment modality alone, or for treatment and risk, age did not independently predict cancer-specific survival. Furthermore, controlling for age, comorbidity, and risk, older men with high-risk tumors receiving local therapy had a 46% reduction in mortality compared with those treated conservatively.

CONCLUSION

Older patients are more likely to have high-risk prostate cancer at diagnosis and less likely to receive local therapy. Indeed, underuse of potentially curative local therapy among older men with high-risk disease may in part explain observed differences in cancer-specific survival across age strata. These findings support making decisions regarding treatment on the basis of disease risk and life expectancy rather than on chronologic age.

Synergic effect of α-tocopherol and naringenin in transglutaminase-induced differentiation of human prostate cancer cells

Prostate cancer is the second most common cancer in men worldwide. Its prevention and treatment remain a challenge to clinicians. Thus, there is an urgent need to discover novel, less toxic, and more effective therapies for patients. Many vitamins and related chemicals, including vitamin E, (tocopherols) have shown their anti-cancer activities as anti-oxidants, activators of transcription factors or factors influencing epigenetic events. Although laboratory tests including the use of animal models showed that this vitamin may have anticancer properties, whether it can effectively prevent the development and/or progression of prostate cancer in humans remains to be intensively studied. This review provides up-to-date information regarding the recent outcomes of laboratory, epidemiology and/or clinical trials on the effects of tocopherols on prostate cancer development, along with our last observations on a combined treatment of a prostate cancer cell line (PC-3) with two natural antineoplastic compounds, naringenin (NG) and α-tocopherol (α-TOC). We report the synergic effect of α-TOC and NG in transglutaminase-induced differentiation of human PC-3 prostate cancer cells. While our results are based on one histological class of tumor, the most significant implication of this observation is that establishes a new way in the screening for detecting new differentiative antineoplastic agents.

Prostate cancer in the elderly

Prostate cancer is the most frequent malignancy in men and predominantly in elderly men. The issue of prostate cancer is likely to assume greater importance with progressive aging of the population. With frequent use of PSA testing most patients were diagnosed with localized cancer even in senior adults. Cancer-specific mortality is low in elderly men with prostate cancer and is dependent on the aggressiveness of the tumor. Currently, no established guidelines for the management of prostate cancer in the elderly exist, and treatment of senior adults with localized cancer is not optimal. While elderly men with indolent disease will not benefit from curative treatment, some patients with aggressive cancers will progress if not adequately treated. Comorbidity is the main predictor of life expectancy in the elderly. In everyday clinical practice, treatment decisions are much more influenced by age than by comorbidity. Curative treatment is an effective treatment option for selected elderly with localized prostate cancer. Conversely, most elderly men with prostate cancer received hormonal therapy, although the benefit of hormonal therapy in localized cancer is not clear and is associated with severe toxicities in some patients. In conclusion, there is a need for more risk stratified approaches for the management of prostate cancer in the elderly to avoid unnecessary intervention in men who unlikely benefit from such intervention, and allow treatment in those who might benefit from it.

Longitudinal assessment of BMI in relation to ADT use among early stage prostate cancer survivors

INTRODUCTION

The use of androgen deprivation therapy (ADT) for prostate cancer is on the rise, but its adverse side effects may include increased fat mass and decreased lean muscle mass. The net effect of ADT on BMI is unknown.

METHODS

Primary, incident cases of early stage prostate cancer (n = 473) were identified from the Buffalo VA Medical Center tumor registry and matched to body size, demographic, comorbidity, and treatment exposure data from veteran medical records. Multilevel modeling was used to assess the association between ADT and changes in BMI.

RESULTS

On average, survivors were overweight at diagnosis and showed small, non-significant changes in BMI over time. However, among those survivors with a history of ADT, a significant decrease of 0.05 BMI units per year was associated with each additional dose of ADT (p < 0.001). When the association between BMI rate of change and ADT was allowed to vary with respect to age, additional doses of ADT predicted stronger decreases in BMI for younger survivors as compared to older survivors (p < 0.05). Neither a history of surgery nor radiation influenced the association between ADT use and BMI.

CONCLUSIONS

Declines in BMI in relation to ADT exposure may be reflective of unfavorable changes in body composition, especially decreased muscle mass, that is most pronounced in younger survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors on ADT may benefit from close monitoring of physical functioning and referral for exercise interventions to preserve muscle mass and improve health related quality of life.

Second cancers as competing causes of death after radical prostatectomy

PURPOSE

We analyzed the risk of dying of a second cancer after radical prostatectomy for clinically localized prostate cancer.

MATERIALS AND METHODS

We studied 1,910 patients who consecutively underwent radical prostatectomy between 1992 and 2004. These patients had a median age of 65 years, a median prostate specific antigen of 7.6 ng/ml and a median followup of 5.9 years. Overall disease specific, comorbid, second cancer specific and other mortality data were used as study end points in competing risk analyses. Fatal second cancers were subdivided into 10 categories. The numbers of observed deaths from second cancers were compared with expected rates using cancer registry data.

RESULTS

The risk of dying of a second cancer within 10 years after radical prostatectomy was 4.1%. This death rate was lower than that of comorbidity (5.8%) and prostate cancer (5.4%). Among second cancers colorectal cancer (0.74%), lung cancer (0.69%) and lymphoma, myeloma or leukemia (0.66%) were the most common causes of death after 10 years. Whereas the mortality rates from the other second cancers were within the expected range, fatal lung cancer occurred significantly less frequently than expected.

CONCLUSIONS

The low probability of dying of a second malignancy within 10 years after surgery (about 4%) and the nevertheless relatively large contribution of second cancers to competing mortality (about 40%) reflect the good general health status of men selected for radical prostatectomy.

Cause of death in older men after the diagnosis of prostate cancer

OBJECTIVES

To compare survival and cause of death in men aged 65 and older diagnosed with prostate cancer and with survival and cause of death in a noncancer control population.

DESIGN

Retrospective cohort from a population-based tumor registry linked to Medicare claims data.

SETTING

Eleven regions of the Surveillance, Epidemiology and End Results (SEER) Tumor Registry.

PARTICIPANTS

Men aged 65 to 84 (N=208,601) diagnosed with prostate cancer from 1988 through 2002 formed the basis for different analytical cohorts.

MEASUREMENTS

Survival as a function of stage and tumor grade (low, Gleason grade<7; moderate, grade=7; and high, grade=8-10) was compared with survival in men without any cancer using Cox proportional hazards regression. Cause of death according to stage and tumor grade were compared using chi-square statistics.

RESULTS

Men with early-stage prostate cancer and with low- to moderate-grade tumors (59.1% of the entire sample) experienced a survival not substantially worse than men without prostate cancer. In those men, cardiovascular disease and other cancers were the leading causes of death.

CONCLUSION

The excellent survival of older men with early-stage, low- to moderate-grade prostate cancer, along with the patterns of causes of death, implies that this population would be well served by an ongoing focus on screening and prevention of cardiovascular disease and other cancers.