Cardiovascular Events and Androgen Receptor Signaling Inhibitors in Advanced Prostate Cancer: A Systematic Review and Meta-Analysis

Importance

Cardiovascular (CV) events remain a substantial cause of mortality among men with advanced and metastatic prostate cancer (PCa). The introduction of novel androgen receptor signaling inhibitors (ARSI) has transformed the treatment landscape of PCa in recent years; however, their associated CV toxic effects remains unclear.

Objective

To assess the incidence of CV events with addition of ARSI to standard of care (SOC) in locally advanced (M0) and metastatic (M1) PCa.

Data Sources

Systematic searches of PubMed, Scopus, Web of Science, EMBASE, and ClinicalTrials.gov were performed from inception up to May 2023.

Study Selection

Randomized clinical trials of ARSI agents (abiraterone, apalutamide, darolutamide, enzalutamide) that reported CV events among individuals with M0 and M1, hormone-sensitive prostate cancer (HSPC) and castration-resistant prostate cancer (CRPC).

Data Extraction and Synthesis

A systematic review was performed in accordance with PRISMA guidance. Two authors screened and independently evaluated studies eligible for inclusion. Data extraction and bias assessment was subsequently performed.

Main Outcomes and Measures

A random-effects meta-analysis was performed to estimate risk ratios for the incidence of all grade and grade 3 or higher CV events (primary outcomes), in addition to hypertension, acute coronary syndrome (ACS), cardiac dysrhythmia, CV death, cerebrovascular event, and venous thromboembolism (secondary outcomes). Sources of heterogeneity were explored using meta-regression.

Results

There were 24 studies (n = 22 166 patients; median age range, 63-77 years; median follow-up time range, 3.9-96 months) eligible for inclusion. ARSI therapy was associated with increased risk of all grade CV event (risk ratio [RR], 1.75; 95% CI, 1.50-2.04; P < .001) and grade 3 or higher CV events (RR, 2.10; 95%, 1.72-2.55; P < .001). ARSI therapy also was associated with increased risk for grade 3 or higher events for hypertension (RR, 2.25; 95% CI, 1.74-2.90; P < .001), ACS (RR, 1.93; 95% CI, 1.43-1.60; P < .01), cardiac dysrhythmia (RR, 1.64; 95% CI, 1.23-2.17; P < .001), cerebrovascular events (RR, 1.86; 95% CI, 1.34-2.59; P < .001) and for CV-related death (RR, 2.02; 95% CI, 1.32-3.10; P = .001). Subgroup analysis demonstrated increased risk of all CV events across the disease spectrum (M0 HSPC: RR, 2.26; 95% CI, 1.36-3.75; P = .002; M1 HSPC: RR, 1.85; 95% CI, 1.47-2.31; P < .001; M0 CRPC: RR, 1.79; 95% CI, 1.13-2.81; P = .01; M1 CRPC: RR, 1.46; 95% CI, 1.16-1.83; P = .001).

Conclusions and Relevance

This systematic review and meta-analysis found that the addition of ARSIs to traditional ADT was associated with increased risk of CV events across the prostate cancer disease spectrum. These results suggest that patients with prostate cancer should be advised about and monitored for the potential of increased risk of CV events with initiation of ARSI therapy alongside conventional hormonal therapy.

Cardiovascular Impact of Androgen Deprivation Therapy: from Basic Biology to Clinical Practice

PURPOSE OF THE REVIEW

There have been increasing reports of cardiovascular complications of androgen deprivation therapy (ADT) leading to worse outcomes among patients with prostate cancer. While this may result from the direct effects of androgen suppression in the cardiovascular systems, there are ADT-type-specific distinct cardiovascular complications suggestive of mechanisms beyond androgen-mediated. Thus, it is critical to understand the biological and clinical impact of ADT on the cardiovascular system.

RECENT FINDINGS

Gonadotropin-releasing hormone (GnRH) agonists cause increased cardiovascular events compared to GnRH antagonists. Androgen receptor antagonists are linked to an increased risk of long QT syndrome, torsades de pointes, and sudden cardiac death. Androgen synthesis inhibitors are associated with increased rates of hypertension, atrial tachyarrhythmia, and, in rare incidences, heart failure. ADT increases the risk of cardiovascular disease. The risk among ADT drugs differs and must be evaluated to develop a medically optimal plan for prostate cancer patients.

Correlations between salivary- and blood-derived gonadal hormone assessments and implications for inclusion of female participants in research studies

Even in the 21st century, female participants continue to be underrepresented in human physiology research. This underrepresentation is attributable in part to the perception that the inclusion of females is more time consuming, less convenient, and more expensive relative to males because of the need to account for the menstrual cycle in cardiovascular study designs. Accounting for menstrual cycle-induced fluctuations in gonadal hormones is important, given established roles in governing vascular function and evidence that failure to consider gonadal hormone fluctuations can result in misinterpretations of biomarkers of cardiovascular disease. Thus, for cardiovascular researchers, the inclusion of females in research studies implies a necessity to predict, quantify, and/or track indexes of menstrual cycle-induced changes in hormones. It is here that methodologies are lacking. Gold standard measurement requires venous blood samples, but this technique is invasive and can become both expensive and technically preclusive when serial measurements are required. To this end, saliva-derived measures of gonadal hormones provide a means of simple, noninvasive hormone tracking. To investigate the feasibility of this technique as a means of facilitating research designs that take the menstrual cycle into account, the purpose of this review was to examine literature comparing salivary and blood concentrations of the primary gonadal hormones that fluctuate across the menstrual cycle: estradiol and progesterone. The data indicate that there appear to be valid and promising applications of salivary gonadal hormone monitoring, which may aid in the inclusion of female participants in cardiovascular research studies.

The occurrence of hypogonadotropic hypogonadism in Chinese men with type 2 diabetes

CONTEXT

The previous studies showed that hypogonadotropic hypogonadism (HH) occurred commonly in men with type 2 diabetes. However, since all the cohorts tested were from American and European studies, the occurrence of HH/nongonadal illness (NGI) in Chinese populations is unclear.

OBJECTIVE

The study aimed to explore the occurrence of HH/NGI in Chinese men with type 2 diabetes. Furthermore, the correlative factors and predictors of hypogonadism were investigated.

DESIGN

We conducted a cross-sectional study of 637 Chinese men with type 2 diabetes aged 20-75 years in our clinic. The prevalence of HH/NGI was investigated by measuring serum total testosterone (TT), sex hormone-binding globulin (SHBG), luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in the enrolled subjects. Free testosterone (FT) was calculated by using SHBG and TT levels and hypogonadism was defined as TT lower than 10.4 nmol/L and calculated FT (cFT) lower than 0.225 nmol/L. The LH cut-off value for defining HH/NGI was 9.4 mIU/ml.

RESULTS

The results suggested that 31.9% of male Chinese type 2 diabetes patients had hypogonadism and 26.5% of subjects in our cohort were determined as HH/NGI. The occurrence of hypogonadism was markedly correlated with body mass index (BMI). There was a significant association between TT, cFT and SHBG levels with BMI. TT levels are inversely correlated with BMI and homeostasis model assessment-estimated insulin resistance (HOMA-IR) while positively related with SHBG. The cFT levels were inversely correlated with age, LH, FSH, BMI and HOMA-IR. Multiple regression analysis suggested that SHBG, BMI and HOMA-IR were significant predictors of TT and cFT.

CONCLUSION

Our present study offered the first evidence that the occurrence of HH/NGI in Chinese male type 2 diabetes was 26.5%. TT and cFT were significantly correlated with BMI, SHBG and HOMA-IR in Chinese men with type 2 diabetes.

Sexual dimorphism in cardiac remodeling: the molecular mechanisms ruled by sex hormones in the heart

Heart failure (HF) is growing in prevalence, due to an increase in aging and comorbidities. Heart failure with reduced ejection fraction (HFrEF) is more common in men, whereas heart failure with preserved ejection fraction (HFpEF) has a higher prevalence in women. However, the reasons for these epidemiological trends are not clear yet. Since HFpEF affects mostly postmenopausal women, sex hormones should play a pivotal role in HFpEF development. Furthermore, for HFpEF, contrary to HFrEF, effective therapeutic approaches are missing. Interestingly, studies evidenced that some therapies can have better results in women than in HFpEF men, emphasizing the necessity of understanding these observations at a molecular level. Thus, herein, we review the molecular mechanisms of estrogen and androgen actions in the heart in physiological conditions and explain how its dysregulation can lead to disease development. This clarification is essential in the road for an effective personalized management of HF, particularly HFpEF, towards the development of sex-specific therapeutic approaches.

Endogenous testosterone does not improve prediction of incident cardiovascular disease in a community-based cohort of adult men: results from the Tehran Lipid and Glucose Study

Introduction: To explore the predictive value of testosterone added to the Framingham Risk Score (FRS) for cardiovascular disease (CVD).Methods: Among 816 men, 30-70 years/old, without prevalent CVD, from a community-based cohort (Tehran Lipid and Glucose Study), we assessed the predictive value of testosterone with incident CVD, using three multivariate Cox proportional-hazards models. Model I: FRS variables; model II: Model I plus total testosterone; model III: Model II plus Systolic blood pressure (SBP) * total testosterone (the best fit interaction-term between testosterone and FRS variables). Discriminations and goodness-of-fit were assessed by the C-statistic and the approach of Grønnesby, respectively. p Value <.05 was significant.Results: During 12 years of follow-up, 121 CVD events occurred. In all models, age, treated SBP, smoking, and diabetes were associated with increased CVD (p values <.05). Neither testosterone (models II and III), nor SBP * testosterone (model III) were associated with CVD (p values >.05). The C-statistics for models I, II, and III were 0.819, 0.820, and 0.821, respectively, indicating no significant improvement in the discrimination power. The models' goodness-of-fit did not improve compared with the FRS.Conclusion: Testosterone could not add to the predictive value of FRS for CVD in men, either directly, or through interactions with FRS variables.

The potential role of testosterone in hypertension and target organ damage in hypertensive postmenopausal women

Objective: The aim of this study was to confirm the potential role of testosterone in hypertension and target organ damage (TOD) in hypertensive postmenopausal women.

Methods: A matched group study was conducted. One hundred sixty-one hypertensive postmenopausal women between 45 and 65 years of age were enrolled as group 1. Another 161 age-matched hypertensive men were enrolled as group 2. Ambulatory blood pressure monitoring, echocardiographic imaging, vascular function, sex hormones and clinical characteristics were evaluated. Quantitative data were analyzed using independent Student’s t-test and multiple regression analysis.

Results: The mean and load level of blood pressure were lower in women than in men (P<0.05), except for the mean level and load of the nocturnal systolic blood pressure (SBP) (123.77±15.72 mmHg vs 126.35±15.64 mmHg, and 50.43±30.31% vs 55.35±28.51%, P>0.05). However, the carotid-femoral pulse wave velocity (cf-PWV) in women was higher than that in men (9.68±2.23 m/s vs 8.03±2.82 m/s, P<0.05). The ratio of the early diastolic mitral peak flow velocity to early diastolic mitral annular velocity (E/Em) was obviously impaired (13.06±3.53 vs 12.05±3.68, P<0.05) in women. Furthermore, in women, a positive correlation was found between testosterone and cf-PWV (γ=0.157, P=0.046), and Cf-PWV was positively related to the mean level of nighttime SBP (γ=0.210, P=0.008). Moreover, nocturnal SBP was a risk factor for E/Em (γ=0.156, P=0.048, P<0.05).

Conclusion: Testosterone may play a role in the correlation between hypertension and TOD in hypertensive postmenopausal women.

Clinical Trial number: This research study was registered under the ClinicalTrials.gov PRS Website (NCT03451747).

Basal Endogenous Steroid Hormones, Sex Hormone-Binding Globulin, Physical Fitness, and Health Risk Factors in Young Adult Men

Purpose: Few large-scale population-based studies have adequately examined the relationships between steroid hormones, health status and physical fitness. The purpose of the study was to describe the relationship of serum basal endogenous steroid hormones (testosterone, TES; empirical free testosterone, EFT; cortisol, COR) and sex hormone-binding globulin (SHBG) to body composition, cardiovascular risk factors, and physical fitness in young healthy men.

Methods: Male reservists (25 ± 4 years, N = 846) participated in the study. Basal TES, EFT, COR, and SHBG were measured in morning fasted blood. Stepwise regression analyses were used to examine associations between individual hormones to four separate categories: (1) body composition; (2) cardiovascular risk factors; (3) relative, and (4) absolute physical fitness.

Results: Higher TES, EFT, and SHBG were associated with lower waist circumference (TES: β = -0.239, p < 0.001; EFT: β = -0.385, p < 0.001), % body fat (TES: β = -0.163, p = 0.003), and body mass index (SHBG: β = -0.435, p < 0.001). Lower cardiovascular risk factors were associated with higher TES, EFT and SHBG concentrations, especially between SHBG and triglycerides (β = -0.277, p < 0.001) and HDL (β = 0.154, p < 0.001). Greater maximal relative aerobic capacity was concurrent with higher TES, EFT, and SHBG (β = 0.171, 0.113, 0.263, p < 0.001, =0.005, <0.001, respectively).

Conclusion: Higher basal concentrations of TES, EFT, and SHBG were weakly associated with healthier body composition, fewer cardiovascular risk factors and greater relative aerobic capacity in healthy young men. It would be interesting to investigate whether these relationships are still evident after a few decades, and how different training modes (endurance, strength or their combination) positively affect physical fitness, body composition and their regulatory mechanisms over the decades.

Cardiovascular safety of abiraterone acetate in metastatic castration-resistant prostate cancer patients: a prospective evaluation

AIM

The aim of this study is to evaluate cardiotoxicity of abiraterone acetate (AA) in metastatic castration-resistant prostate cancer patients (pts) with cardiovascular comorbidities or coronary artery disease (CAD) risk factors.

PATIENTS & METHODS

We prospectively analyzed pts receiving AA in order to evaluate correlations between cardiotoxicity onset and CAD risk factors or cardiovascular comorbidities.

RESULTS

Eighty-seven pts were enrolled, with median treatment duration of 9 months (1-44). At baseline, 84 pts (96%) had CAD risk factors. During treatment four pts (4; 6%) developed hypertension and 26 pts (30%) worsened the preexisting hypertension. Median left ventricular ejection fraction were 64 and 63% at baseline and after treatment, respectively.

CONCLUSION

AA appears to be safe in pts with cardiovascular comorbidities or CAD risk factors.

Cardiovascular toxicities of systemic treatments of prostate cancer

Prostate cancer is the most common cancer in men, with an incidence that is expected to increase in the coming years. Prostate cancer is usually diagnosed in men >65 years of age, thus the concurrent presence of cardiovascular diseases might influence the treatment, owing to the increased risk of cardiovascular mortality. The introduction of new drugs, such as abiraterone and enzalutamide for the management of metastatic disease has created further interest in treatment-related cardiovascular toxicities, although limited data from trials specifically designed to identify cardiovascular toxicities of these agents are currently available. The only available data are derived from published phase II-III study reports, expanded access or compassionate use programmes and meta-analyses of the effects of systemic therapies that are already approved for use in clinical practice or are in the early phases of development. These data are conflicting, although they seem to suggest that certain drugs are associated with an increased risk of cardiovascular adverse events. Clinical trial methodology could be improved by the enrolment of greater numbers of patients >65 years of age, and the use of comprehensive cardiological evaluations. Moreover, closer collaboration between oncologists and cardiologists is essential for the identification and/or management of cardiovascular adverse events in patients with prostate cancer.

Ninety day toxicity and toxicokinetics of fluorochloridone after oral administration in rats

The ninety day toxicity and toxicokinetics of fluorochloridone (FLC) were accessed in Wistar rats. Animals were gavaged with FLC at doses of 31.25 mg/kg, 125 mg/kg and 500 mg/kg for ninety days, followed by thirty days for recovery. On the 1st, 60th, 75th and 90th days of the dosing phase, plasma of ten animals of all groups treated with FLC was collected for toxicokinetic analysis of FLC by an UPLC-MS/MS method. Numerous changes in body weight, hematology, serum chemistry, and organ weight ratios were observed by the 45th and 90th dosing day. Most changes in groups treated with FLC were absent on the last recovery day. Testis and epididymis lesions were consistently seen in histopathological observations on the 45th, 90th dosing day and the last recovery day. Repeated administration of FLC increased the level of testosterone in serum in male rats on the 90th dosing day. FLC plasma concentrations could be detected in all animal drug-treated groups during the dosing phase, and a dose proportional relationship was seen between FLC dose and AUC or C_max. This study will support future studies on the mechanism of FLC-induced toxicity.

Quantifying observational evidence for risk of fatal and nonfatal cardiovascular disease following androgen deprivation therapy for prostate cancer: a meta-analysis

CONTEXT

Whether androgen deprivation therapy (ADT) for men with prostate cancer (PCa) increases the risk of cardiovascular disease (CVD) remains controversial. Pooled analyses using data from randomised controlled trials suggest no increased risk of fatal CVD following ADT, but no pooled analyses exist for observational studies.

OBJECTIVE

To perform a meta-analysis using observational data on ADT and risk of CVD events in men with PCa.

EVIDENCE ACQUISITION

PubMed and Embase were searched using predefined inclusion criteria to perform meta-analyses on associations between types of ADT and nonfatal and fatal CVD outcomes using information from observational studies. Random effects meta-analyses were conducted to estimate relative risks (RRs) and 95% confidence intervals (CIs).

EVIDENCE SYNTHESIS

A total of eight observational studies were identified studying at least one type of ADT and a nonfatal or fatal CVD outcome. The RR for risk of any type of nonfatal CVD was 1.38 (95% CI, 1.29-1.48) for men with PCa on gonadotropin-releasing hormone (GnRH) agonists, compared with men not treated with ADT. When analysing nonfatal ischemic heart disease only, the RR was 1.39 (95% CI, 1.26-1.54). The associations between GnRH agonists and nonfatal or fatal myocardial infarction or stroke were even stronger: RR: 1.57 (95% CI, 1.26-1.94) and RR: 1.51 (95% CI, 1.24-1.84), respectively. The results for other types of ADT in relation to the risk of any nonfatal CVD were RR: 1.44 (95% CI, 1.28-1.62) for orchiectomy and RR: 1.21 (95% CI, 1.07-1.367) for antiandrogens.

CONCLUSIONS

Observational data show a consistent positive association between ADT and the risk of CVD. This finding supports the need for future randomised trials of PCa patients that include older patients and men with multiple comorbidities to better reflect the general population.

PATIENT SUMMARY

We investigated all the available data from observational studies on hormonal treatment for prostate cancer and its possible cardiovascular adverse effects. We found consistent evidence that this treatment may increase the risk of cardiovascular disease.