Androgenic suppression combined with radiotherapy for the treatment of prostate adenocarcinoma: a systematic review

Racial disparities in new-onset diabetes mellitus in prostate cancer patients on androgen deprivation therapy: a retrospective analysis of TriNetX data

BACKGROUND

Prostate cancer (PCa) is the most common cancer in men in the US and androgen deprivation therapy (ADT) is the most frequently used systemic therapy for PCa. Data suggest that ADT is associated with an increased risk of new-onset diabetes mellitus (NODM) and cardiovascular complications. As the incidence and mortality of PCa are highest among the African American (AA) population, it is important to evaluate the difference in the incidence of NODM and ischemic heart disease (IHD) between AA men compared to Caucasian men.

METHODS

This is a retrospective cohort study utilizing the TriNetX database to assess NODM and IHD risk, risk difference, and risk ratio (RR) after recent ADT initiation in an AA cohort and a Caucasian cohort of patients with PCa. Propensity score matching (PSM) was performed by age, BMI, and confounding comorbidities.

RESULTS

After matching, the cohort included 1159 AA patients and 843 Caucasian patients with NODM after ADT initiation. The IHD cohort included 1269 AA patients and 1248 Caucasian patients. The risk of incidence of NODM is higher among AA men at 11.6% risk compared to Caucasian men at 7.4%. The risk difference is 4.1% (95% CI = 3.4, 4.9) p = 0.000. The RR is 1.56 (95% CI = 1.43, 1.70). In contrast, risk difference and risk ratio of IHD was not significant between AA and Caucasian groups.

CONCLUSION

ADT exposure increases the risk of NODM in men with PCa, especially among AA men compared with Caucasian men. Men receiving ADT should be monitored routinely for signs and symptoms of metabolic syndrome and diabetes. Targeted close monitoring of AA men on ADT would be critical to prevent and treat metabolic complications with potential of reducing disparities in PCa morbidity.

Extreme hypofractionated stereotactic radiotherapy for elderly prostate cancer patients: side effects preliminary analysis of a phase II trial

PURPOSE

Aim of this study is to evaluate safety and efficacy of SBRT in elderly patients affected by localized prostate cancer (PC).

MATERIAL AND METHODS

Men aged 70 years or older were enrolled and analyzed. The SBRT schedule was 35 Gy in 5 fractions administered in 1-2 weeks. According to risk group, androgen deprivation therapy (ADT) was prescribed. Urinary symptoms were evaluated at baseline using the International Prostate Symptom Score (IPSS). Genitourinary (GU) and gastrointestinal (GI) toxicities were assessed at the end of treatment, 2 weeks after SBRT and during follow-up using the Common Terminology Criteria for Adverse Events (CTCAE). PSA values were recorded before treatment and during follow-up as biochemical response criteria.

RESULTS

Between 07/2019 and 09/2021, 111 patients were enrolled. Median age was 77 years. At the end of treatment, no acute GU/GI toxicities ≥ G2 were observed. At 2-3 weeks after treatment, 3 patients reported G2 GU toxicity, while 14 patients referred G2 GI toxicity. During the last follow up, 26 and 2 patients reported, respectively, G1 and G2 GU toxicity, while 22 and 1 cases described, respectively, G1 and G2 GI toxicity. No late toxicities ≥ G3 were recorded. GU toxicity is related to absence of urethra sparing, increasing PTV volume, Dmax PTV and IPSS; GI toxicity is related to RT schedule (each other day is better than consecutive day), Dmax rectum and IPSS, At a median follow-up of 24 months, excellent biochemical disease control was achieved in all cases with median PSA of 0.5 ng/ml.

CONCLUSION

SBRT in elderly patients affected by PC is feasible and well tolerated with excellent biochemical disease control. Longer follow-up is needed to assess late toxicity profile and long-term clinical outcome.

Potential Risk of Other-Cause Mortality Due to Long-Term Androgen Deprivation Therapy in Elderly Patients with Clinically Localized Prostate Cancer Treated with Radiotherapy-A Confirmation Study

Androgen deprivation therapy (ADT) is used to improve overall survival (OS) in prostate cancer treatment; however, we encountered that long-term ADT in elderly patients may be related to high other-cause mortality (OCM). This study aimed to confirm the potential risk associated with long-term ADT in elderly patients using a different large cohort. A comparison analysis was conducted between the ≥2- and <2-year ADT groups using open, large data from 1840 patients with clinically localized prostate cancer treated with radiotherapy (1172 treated with high-dose-rate brachytherapy (HDR) + external beam radiotherapy (EBRT) and 668 treated with external beam radiotherapy). The OCM-free survival (OCMFS), overall survival, and prostate cancer-specific survival rates were measured. The 10-year OCMFS rates in patients aged ≥75 years were 94.6% and 86% in the <2- and ≥2-year ADT groups, respectively, but were 96.3% and 93.5% (p = 0.0006) in their younger counterparts. If dividing into HDR and EBRT groups. This inclination was found in brachytherapy group but not in EBRT group. The overall survival rate was also lower in the elderly patients in the ≥2-year ADT group than in the <2-year ADT group; however, the 10-year prostate cancer-specific survival rate was the same in both groups. Long-term ADT in elderly patients resulted in not only higher OCM rates but also poorer OS rates; therefore, longer-term ADT in elderly patients should be performed with meticulous care.

Effect of Androgen Deprivation Therapy on Other-Cause of Mortality in Elderly Patients with Clinically Localized Prostate Cancer Treated with Modern Radiotherapy: Is There a Negative Impact?

The influence of androgen deprivation therapy (ADT) on other-cause of mortality (OCM) was investigated in patients with localized prostate cancer treated with modern high-dose radiotherapy. A retrospective review was conducted on 1125 patients with localized prostate cancer treated with high-dose radiotherapy, including image-guided, intensity-modulated radiotherapy or brachytherapy with a median follow-up of 80.7 months. Overall survival rate was no different between ADT (+) and ADT (−) group in high-, intermediate-, and low-risk groups. OCM was found in 71 patients, consisting of 4% (10/258) in the ADT (−) group and 7% (61/858) in the ADT (+) group (p = 0.0422). The 10-year OCM-free survival rate (OCMFS), if divided by the duration of ADT (ADT naïve (ADT (−)), ADT <2-year, and ADT ≥2-year groups), showed statistical significance, and was 90.7%, 88.2%, and 78.6% (p = 0.0039) for the ADT (−), ADT <2-year, and ADT ≥2-year groups, respectively. In patients aged ≥75 years, 10-year OCMFS for ADT (−), ADT <2-, and ADT ≥2-year groups was 93.5% (at 115.6 months), 85.6%, and 60.7% (p = 0.0189), respectively, whereas it was 90.7%, 89.9%, and 89.0% (p = 0.4716), respectively, in their younger counterparts. In localized prostate cancer patients, treatment with longer ADT for ≥2 years potentially increases the risk of OCM, especially in patients aged ≥75 years.

High-dose-rate brachytherapy monotherapy versus low-dose-rate brachytherapy with or without external beam radiotherapy for clinically localized prostate cancer

BACKGROUND

To compare the outcome of high-dose-rate interstitial brachytherapy (HDR-BT) monotherapy and low-dose-rate brachytherapy (LDR-BT) with or without external beam radiotherapy (EBRT) for localized prostate cancer.

METHODS AND MATERIALS

We compared 352 patients treated with HDR-BT as monotherapy (median follow-up time 84 months, NCCN risk classification; low: intermediate: high = 28:145:179) and 486 patients with LDR-BT with or without EBRT (90 months, 194:254:38). HDR-BT treated advanced disease with more hormonal therapy than LDR-BT. LDR-BT excluded patients with T3b-T4 tumor and initial PSA >50 ng/ml. Inverse probability of treatment weighting (IPTW) involving propensity scores was used to reduce background selection bias.

RESULTS

The actuarial 5-year biochemical failure-free survival rates (bNED) were 92.9% and 95.6% (p = 0.25) in the HDR-BT and LDR-BT groups, respectively, and it was 100% and 97.3% (p = 0.99) in the low-risk, 95.6% and 94.3% (p = 0.19) in the intermediate, 89.6% and 94.9% (p = 0.26) in the high-risk groups, and 93.1% and 94.9% (p = 0.98) in selected high-risk group excluding T3b-4 and initial PSA ≥50. IPTW correction also indicated no difference in bNED between LDR-BT and HDR-BT groups. LDR-BT showed a higher incidence of genitourinary (GU) toxicity grade ≥2 than that of HDR-BT in the acute phase and grade 1 toxicity in late phase. Acute GU toxicity grade ≥1 predicted late GU toxicity grade ≥2. External beam radiotherapy plus LDR-BT elevated GI toxicity than LDR-BT only group. Accumulated incidence of late grade ≥2 GU and GU toxicity was equivalent between HDR-BT and LDR-BT. No grade 4 or 5 toxicities were detected in either modality.

CONCLUSION

HDR-BT monotherapy showed an equivalent outcome to that of LDR-BT with or without EBRT for low-, intermediate- and selected high-risk patients. LDR-BT showed equivalent incidence of grade ≥2 late GI and GU toxicities and higher grade ≥2 acute GU toxicity as that of HDR-BT as a monotherapy.

Efficacy characteristics of different therapeutic modalities for locally advanced prostate cancer: a Bayesian network meta-analysis of randomized controlled trials

Background

Though previous studies have investigated the efficacy characteristics of several different therapeutic modalities for locally advanced prostate cancer (LAPCa) patients, the available results remained unestablished. Therefore, the aim of this meta-analysis was conducted to clarify such differences.

Methods

The online PubMed, EMBASE and Web of Science were comprehensively searched for relevant studies published before September 1st, 2017, and eventually eleven relevant studies met the inclusion criteria. The hazard odds ratios (HRs) with 95% credible interval (CI) were utilized to evaluate the efficacy characteristics of several different therapeutic modalities for LAPCa patients by Markov chain Monte Carlo methods.

Results

Five different therapeutic modalities were ultimately enrolled to shed light on the efficacy characteristics for LAPCa patients and seven different clinical outcomes were finally analyzed in this study. The cumulative rank probability of overall survival (OS) or cancer-specific survival (CSS) from best to worst was radiotherapy (RT) + orchiectomy, RT + long-term androgen deprivation therapy (LTADT), RT + short-term androgen deprivation therapy (STADT), LTADT and RT; RT + LTADT, RT + orchiectomy, RT + STADT, LTADT and RT, respectively. Meanwhile, in the terms of progression-free survival (PFS), biochemical failure rate (BFR), disease-free survival (DFS), local progression rate (LPR) and metastasis rate (MR), RT + LTADT as well as RT + STADT had a higher, whereas RT alone or LTADT had a relatively lower treatment effect.

Conclusions

All in all, our results indicated that RT + LTADT or RT + orchiectomy was among the best two therapeutic regimens in the prognostic aspects of the patients with LAPCa. Furthermore, in consideration of reducing invasive treatment of eligible patients, RT + LTADT could yield better survival benefit of LAPCa patients, compared with others. In addition, the results of our analysis might provide a reference in the clinical selection. Larger sample sizes of strictly designed randomised controlled trials (RCTs) were wanted to validate our findings.

Racial, Socioeconomic, and Geographic Disparities in the Receipt, Timing to Initiation, and Duration of Adjuvant Androgen Deprivation Therapy in Men with Prostate Cancer

OBJECTIVE

This retrospective cohort study aims to examine the receipt, timing to initiation, and duration of androgen deprivation therapy (ADT) in men with prostate cancer by race/ethnicity, socioeconomic status, and geographic location.

METHODS

The study population are patients from Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, who were 66 years or older and newly diagnosed with stage III and IV prostate cancer in 1992-2009 and underwent radiation therapy, where ADT was proven to be highly beneficial and its use was considered as most appropriate (n = 12,170). We use logistic regression to examine the receipt of ADT and linear regression to study factors associated with time to ADT initiation while controlling for baseline characteristics.

RESULTS

Overall, 77% of eligible patients received at least one form of ADT in combination with radiation therapy, of which 12% underwent orchiectomy and the rest received ADT, and 77.2% of non-Hispanic white and 80.7% of Hispanic patients received ADT compared to 73.8% of non-Hispanic black. After adjustment for demographic and tumor characteristics, black men and men of other races are less likely to receive ADT compared to white counterparts (OR = 0.64 and 0.74, respectively). The median time from cancer diagnosis to ADT initiation is 2 months. Once initiated, men received a median of seven drug injections. After controlling for covariates, race/ethnicity and geographic location (SEER areas) are associated with early initiation of therapy. White, Hispanic men and men living in the South initiate ADT earlier.

CONCLUSION

Significant racial disparities exist in the receipt and use of this highly beneficial therapy, and there are geographic variations in the utilization of this therapy.

Moderate hypofractionated radiotherapy after prostatectomy for cancer patients: toxicity and clinical outcome

Background

After radical prostatectomy (RP) radiotherapy (RT) plays a role, both as adjuvant or salvage treatment. If negative features are present such as extracapsular extension, seminal vesicle invasion, lymph invasion, and positive surgical margins, RT after RP reduces the risk of recurrence, although it is associated with an increased risk of acute and late toxicities. An intensified RT delivered in a shortened time could improve clinical outcome and be safely combined with hormonal therapy (HT). The aim of this study was to determine the acute and late toxicities associated with hypofractionated RT and to assess the impact of the addition of HT to RT in high-risk prostate cancer (PC) patients on overall response and toxicity.

Materials and methods

Sixty-four PC patients undergoing RP were included in this retrospective study. All patients were recommended to receive adjuvant or salvage RT. Prescription doses were 62.5 Gy in 25 fractions to prostate bed, 56.25 Gy in 25 fractions to seminal vesicles bed, and 50 Gy in 25 fractions to pelvis if indicated. HT was administered to patients with additional adverse pathologic features including Gleason score >7, prostate-specific antigen >20 ng/mL before surgery, or prostate-specific antigen with rapid doubling time after relapse or nodal involvement. After completion of RT, patients were observed after 4 weeks, and then followed-up every 3–6 months. Acute and late toxicities were assessed using Common Terminology Criteria for Adverse Events v4 and Radiation Therapy Oncology Group scale, respectively.

Results

For acute toxicity, only grade 1 gastrointestinal and genitourinary toxicities were detected in 17% and 11% of patients, respectively. As regards late toxicity, only 5% of the patients developed grade 1 gastrointestinal adverse event; grade 1, grade 2, and grade 3 genitourinary toxicity was recorded in 5%, 3.3%, and 3.3% of patients, respectively. Two and 5 years overall survival were 98% and 96%, respectively. The curves stratified for treatment show a slight difference between patients receiving RT or RT+HT, but the differences did not reach statistical significance (p=0.133).

Conclusion

In patients with PC undergoing RP, hypofractionated RT may contribute to achieve a high overall survival with an acceptable toxicity profile. Combination of RT and HT is also well tolerated and efficacious.

Management of Biochemical Recurrence after Primary Curative Treatment for Prostate Cancer: A Review

How to manage patients with prostate cancer (PCa) with biochemical recurrence (BCR) following primary curative treatment is a controversial issue. Importantly, this prostate-specific antigen (PSA)-only recurrence is a surrogate neither of PCa-specific survival nor of overall survival. Physicians are therefore challenged with preventing or delaying the onset of clinical progression in those deemed at risk, while avoiding over-treating patients whose disease may never progress beyond PSA-only recurrence. Adjuvant therapy for radical prostatectomy (RP) or local radiotherapy (RT) has a role in certain at-risk patients, although it is not recommended in low-risk PCa owing to the significant side-effects associated with RT and androgen deprivation therapy (ADT). The recommendations for salvage therapy differ depending on whether BCR occurs after RP or primary RT, and in either case, definitive evidence regarding the best strategy is lacking. Options for treatment of BCR after RP are RT at least to the prostatic bed, complete or intermittent ADT, or observation; for BCR after RT, salvage RP, cryotherapy, complete or intermittent ADT, brachytherapy, high-intensity focused ultrasound (HIFU), or observation can be considered. Many patient- and cancer-specific factors need to be taken into account when deciding on the best strategy, and optimal management depends on the involvement of a multidisciplinary team, consultation with the patient themselves, and the adoption of an individualised approach. Improvements in imaging techniques may enable earlier detection of metastases, which will hopefully refine future management decisions.

Extreme hypofractionation for high-risk prostate cancer: Dosimetric correlations with rectal bleeding

PURPOSE

We explored the association of dosimetric parameters with late rectal bleeding among high-risk prostate cancer patients treated with hypofractionated simultaneous in-field boost (H-SIB) to prostate with nodal treatment.

METHODS AND MATERIALS

Rectal toxicity results and dose-volume histogram (DVH) information from patients treated on FASTR and SATURN were combined. Patients in both trials received long-term androgen deprivation and H-SIB with prescription dose 40 Gy to the prostate and proximal seminal vesicles and 25 Gy to the lymph nodes delivered over 5 weekly fractions using image guidance with cone beam computed tomography. Mean rectal DVH values at 5-Gy intervals and mean DVH curves were compared between patients with rectal bleeding (B) versus no bleeding (NB).

RESULTS

There were 12 B and 33 NB patients in the pooled group. Rectal bleeding was more frequent and of higher grade among FASTR patients (8/15, 5 grade 2 or higher) than among SATURN patients (4/30, all grade 1). For any bleeding (grade ≥1), individual dose-volume points in the 20 to 40 Gy range were significantly different (2-sided P < .05) between the B and NB groups, with the 40 Gy point being the most significant (B: V40 = 1.53%, standard deviation (SD), 1.32; NB: V40 = 0.69%, SD, 1.46; P = .006). For grade ≥2 bleeding, the V20 Gy was most significant (B: 68.4%, SD, 4.76; NB: 40.45%, SD, 13.9; P < .001).

CONCLUSIONS

The higher relative dose volumes to the rectum (V20-V40) were most strongly associated with clinically significant bleeding in this analysis and are consistent with findings of series that used H-SIB to treat prostate only. Differences in the prostate target volumes and planning margins likely account for the differences in the rates and grades of rectal bleeding observed between trials.

Pharmacotherapeutic Targeting of G Protein-Coupled Receptors in Oncology: Examples of Approved Therapies and Emerging Concepts

G protein-coupled receptors (GPCRs) are involved in numerous physio-pathological processes, including the stimulation of cancer progression. In this regard, it should be mentioned that although GPCRs may represent major pharmaceutical targets, only a few drugs acting as GPCR inhibitors are currently used in anti-tumor therapies. For instance, certain pro-malignancy effects mediated by GPCRs are actually counteracted by the use of small molecules and peptides that function as receptor antagonists or inverse agonists. Recently, humanized monoclonal antibodies targeting GPCRs have also been developed. Here, we review the current GPCR-targeted therapies for cancer treatment, summarizing the clinical studies that led to their official approval. We provide a broad overview of the mechanisms of action of the available anti-cancer drugs targeting gonadotropin-releasing hormone, somatostatin, chemokine, and Smoothened receptors. In addition, we discuss the anti-tumor potential of novel non-approved molecules and antibodies able to target some of the aforementioned GPCRs in different experimental models and clinical trials. Likewise, we focus on the repurposing in cancer patients of non-oncological GPCR-based drugs, elucidating the rationale behind this approach and providing clinical evidence on their safety and efficacy.

Androgen deprivation therapy in the treatment of locally advanced, nonmetastatic prostate cancer: practical experience and a review of the clinical trial evidence

Following new scientific insights, initial management for patients with high-risk nonmetastatic prostate cancer has changed considerably and rapidly over the last few years. Several clinical and pathologic variables should be taken into account when deciding the best treatment choice for those patients. These variables are summarized and discussed in detail. High radiation doses to the prostate are essential to achieve good local control in patients with high-risk nonmetastatic disease. Addition of androgen deprivation therapy (ADT) to radiation therapy has significantly improved overall survival and cancer-specific survival compared with radiation therapy alone without significantly increasing toxicity. Long-term neo(adjuvant) ADT (2-3 years) to radiation therapy significantly improved cancer-specific survival compared with short-term ADT (4-6 months). Radical prostatectomy with extended pelvic lymph node dissection is considered a reasonable option in experienced hands. ADT alone is an inappropriate treatment option for patients with high-risk nonmetastatic disease. Management decisions for these patients should be discussed by a multidisciplinary team.

The role of androgen deprivation therapy plus radiation therapy in patients with non-metastatic prostate cancer

INTRODUCTION

Androgen deprivation therapy (ADT) has a long and illustrious history in the treatment for prostate cancer and continues to be a mainstay treatment for locally advanced and high-risk patients. Because the survival for even high-risk prostate patients is lengthy, details of treatment such as duration and timing must be considered carefully and weighed against the various side effects.

AREAS COVERED

In the following article, we discuss the evolution of ADT from its initial applications in metastatic prostate cancer to its more recent incorporation into front line treatment in conjunction with radiation therapy (RT) for intermediate and high risk disease. We emphasize the results of phase III trials, which have defined the role of ADT in combination with RT in this patient population. We emphasize not only the potential benefits of ADT with RT, but also the potential risks, and underscore the need to consider both in order to maximize the therapeutic ration for each patient. Studies were identified via a search of PubMed as well as the bibliographies of articles discussed herein. Expert commentary: Even with advanced radiation techniques and dose escalation, adjuvant ADT continues to confer an overall survival benefit in intermediate and high-risk patients, although some evidence suggest that duration of treatment may be shortened, particularly for the high-risk group. The coming years will shed further information on this complicated topic with maturing of results from several ongoing trials.

Ten-year outcomes of intensity-modulated radiation therapy combined with neoadjuvant hormonal therapy for intermediate- and high-risk patients with T1c-T2N0M0 prostate cancer

BACKGROUND

We aimed to analyze the 10-year outcomes of intensity-modulated radiation therapy (IMRT) combined with neoadjuvant hormonal therapy (HT) for patients with intermediate- and high-risk T1c-T2N0M0 prostate cancer.

METHODS

Fifty patients with T1c-T2N0M0 prostate cancer, who were treated with high-dose IMRT combined with neoadjuvant HT, were evaluated. Of these patients, 19 and 31 were classified into the intermediate- and high-risk groups, respectively. Neoadjuvant HT was administered over a median duration of 6 months; 74 and 78 Gy in 2 Gy per fraction were essentially delivered to the intermediate- and high-risk cases, respectively. Adjuvant HT was not administered to any of the patients after the completion of IMRT.

RESULTS

Over a median follow-up period of 118 months, the 10-year prostate-specific antigen failure-free survival, prostate-specific antigen failure-free, salvage hormonal therapy-free, prostate cancer-specific survival, and overall survival rates were 70.2 %, 78.7 %, 89.2 %, 100 %, and 88.8 %, respectively. No grade 3 or higher acute or late toxicities were observed. The 10-year likelihoods of developing grade 2 late urinary and rectal toxicities were 13.7 % and 4.2 %, respectively. Compared with the outcomes of a cohort of historical controls who were locally irradiated with 70 Gy by three-dimensional conformal radiotherapy, the prostate-specific antigen failure-free rate was significantly better in the IMRT groups (78.7 % vs. 53.4 % at 10 years; p = 0.027).

CONCLUSIONS

High-dose IMRT combined with neoadjuvant HT achieved not only high prostate-specific antigen control, but also excellent survival outcomes with acceptable morbidities, for a Japanese cohort of intermediate- and high-risk T1c-T2N0M0 prostate cancer patients, and these results warrant further investigation.

[CLINICAL OUTCOMES OF EXTERNAL-BEAM RADIOTHERAPY COMBINED WITH NEOADJUVANT ANDROGEN DEPRIVATION THERAPY FOR HIGH-RISK PROSTATE CANCER]

(Purpose) We investigated the outcome of external-beam radiotherapy (EBRT) with neoadjuvant androgen deprivation therapy (NeoADT) for high-risk prostate cancer defined by National Comprehensive Cancer Network (NCCN) guideline. (Patients and method) From 2002 to 2013, 70 patients with high-risk prostate cancer (PSA ≥20 ng/ml or clinical T stage ≥T3a, Gleason score ≥8) were treated with NeoADT and EBRT. EBRT consisted of three-dimensional conformal or intensity modulated radiotherapy with or without whole-pelvic radiation. Biochemical failure was defined according to the Phoenix definition. Biochemical progression-free survival (bPFS) and overall survival (OS) were calculated by Kaplan-Meier method, and prognostic factors for bPFS were analyzed by using the Cox proportional hazard model. (Result) The median age and initial prostate-specific antigen (PSA) level were 72 years old and 25.2 ng/ml, respectively. 43 patients had PSA level ≥20 ng/ml, 51 patients had clinical stage ≥T3a, 27 patients had Gleason score ≥8. The number of risk factors patients possessed was 1 (RiskN-1) in 31 patients, 2 (RiskN-2) in 27 patients and 3 (RiskN-3) in 12 patients. Median EBRT dose and duration of Neo ADT were 74 Gy and13.0 months, respectively. Whole-pelvic radiation was administered in 7 patients. After median follow-up of 4.8 years, biochemical and clinical failure occurred in 23 and 2 patients, respectively. No patients died of cancer. Five-year/8-year bPFS and OS were 63%/54% and 100%/91%, respectively. In multivariate analysis, three high-risk factor of NCCN guideline (PSA, clinical stage, Gleason score) did not predict outcome after EBRT independently, but RiskN (-1 vs -2, 3, HR 35.35, 95%CI 2.51-498.05, p<0.01) and pre-EBRT PSA (continuous, hazard ratio 1.31, 95%CI 1.01-1.71, p<0.05) were the significant predictors of bPFS. Five-year/8-year bPFS in RiskN-1 group and RiskN-2 or -3 group were 89%/79% and 47%/39%, respectively. Grade 3/4 adverse events (CTCAE ver4.0-JCOG) occurred in 2 patients. (Conclusion) Median dose of 74 Gy EBRT with intermediate-term NeoADT was safe and beneficial for high-risk prostate cancer. The number of risk factors and pre-EBRT PSA level were the independent prognostic factors for biochemical progression-free survival.

Prostate Cancer for the Internist

In the United States, approximately 240,000 men are diagnosed annually with prostate cancer. Although effective treatment options are available for clinically localized cancer, the potential burdensome co-morbidities and attendant healthcare costs from over diagnosis and over treatment have escalated the discussion and controversy regarding appropriate screening, diagnosis, and optimal management of prostate cancer. Although the lifetime risk of developing prostate cancer is approximately 1 in 6 (~16%), the risk of dying from the disease is only ~2%. The discrepancy between the cancer incidence and lethality has led to widespread scrutiny of prostate cancer patient management, particularly for low-grade, low-stage (indolent) disease. The vast majority of men diagnosed with clinically localized prostate cancer are treated with interventional therapies despite studies demonstrating that even without treatment, prostate cancer-specific mortality is low.

A MedLine/PubMed search was performed using PICO format (Patient, Intervention, Comparison and Outcome) identifying all relevant articles. No restrictions were used for publication dates. The terms “Prostate Cancer”, “Screening”, “Mortality”, “Morbidity” yielded 307 results. “Diagnosis”, “Prognosis” and “Survival” yielded 1504 results. Further filters were applied to narrow down the results using keywords “Prostate cancer screening guidelines 2014”, “Beyond PSA”, “NCCN Guidelines prostate”, “MRI guided Prostate biopsy” yielding 72, 274, 54 and 568 results respectively. Of these, approximately 137 articles were found relevant and were reviewed. References from the reviewed articles were included in the final article.

Optimal duration of androgen deprivation therapy following radiation therapy in intermediate- or high-risk nonmetastatic prostate cancer: A systematic review and metaanalysis

Objectives:

To investigate current evidence on the optimal duration of adjuvant hormone deprivation for prostate cancer treated with radiation therapy with curative intent.

Materials and Methods:

A systematic search was performed in electronic databases. Data from randomized trials comparing different durations of hormone blockade was collected for pooled analysis. Overall survival, disease-free survival, disease-specific survival and toxicity were the outcomes of interest. Meta-analyses were performed using random-effects model.

Results:

Six studies met the eligibility criteria. For overall survival, the pooled data from the studies demonstrated a statistically significant benefit for longer hormone deprivation (Hazard Ratio 0.84; 95% CI 0.74 – 0.96). A statistically significant benefit was also found for disease-free survival (Hazard Ratio 0.74; 95% CI 0.62 – 0.89), and disease-specific survival (Hazard Ratio 0.73; 95% CI 0.62 – 0.85). Studies with longer blockade duration arm demonstrated greater benefit. Toxicity was low, with no increase in cardiovascular events.

Conclusions:

Longer duration of androgen deprivation combined to radiotherapy prolongs OS, DFS and DSS in patients with intermediate and high-risk non-metastatic prostate cancer. However, this evidence is based on trials using older radiation techniques, and further research of combination of androgen deprivation and new RT technologies may be warranted.

Cardiovascular events associated with androgen deprivation therapy in patients with prostate cancer: a systematic review and meta-analysis

CONTEXT

A recently published meta-analysis of randomized clinical trials (RCT) showed that androgen deprivation therapy (ADT) did not significantly increase cardiovascular mortality in prostate cancer patients. However, cardiovascular morbidity, which can impact quality of life, was not evaluated.

OBJECTIVE

To evaluate the risk of cardiovascular morbidity associated with ADT in patients with prostate cancer.

METHODS

We conducted a literature search from January 1960 to June 2012. RCT and large cohort studies that evaluated first-line endocrine therapy and ADT longer than 6 months were screened for inclusion.

RESULTS

In total, 126,898 patients were included in four cohort studies, and 10,760 patients were included in nine RCTs. Analysis of the RCTs showed no differences in the development of acute myocardial infarction (AMI) (OR 1.23; 95 % CI 0.92-1.64; I (2): 0 %) among the patients receiving ADT or not. The analysis of randomized studies that reported other nonfatal cardiovascular events demonstrated a significant increase in such events in the group receiving ADT (OR 1.55; 95 % CI 1.09-2.20; I (2): 0 %). When the large cohort studies were included in the analysis, an increased risk of AMI among men with ADT was found (OR 2.01, 95 % CI 1.90-2.13; I (2): 91,3 %).

CONCLUSION

The use of ADT in prostate cancer patients corresponded with a significant increase in cardiovascular morbidity associated with AMI and with nonfatal events. Therefore, ADT is linked to a significant negative impact on quality of life. Periodic cardiovascular evaluation is required for these patients.

An alternative pseudolikelihood method for multivariate random-effects meta-analysis

Recently, multivariate random-effects meta-analysis models have received a great deal of attention, despite its greater complexity compared to univariate meta-analyses. One of its advantages is its ability to account for the within-study and between-study correlations. However, the standard inference procedures, such as the maximum likelihood or maximum restricted likelihood inference, require the within-study correlations, which are usually unavailable. In addition, the standard inference procedures suffer from the problem of singular estimated covariance matrix. In this paper, we propose a pseudolikelihood method to overcome the aforementioned problems. The pseudolikelihood method does not require within-study correlations and is not prone to singular covariance matrix problem. In addition, it can properly estimate the covariance between pooled estimates for different outcomes, which enables valid inference on functions of pooled estimates, and can be applied to meta-analysis where some studies have outcomes missing completely at random. Simulation studies show that the pseudolikelihood method provides unbiased estimates for functions of pooled estimates, well-estimated standard errors, and confidence intervals with good coverage probability. Furthermore, the pseudolikelihood method is found to maintain high relative efficiency compared to that of the standard inferences with known within-study correlations. We illustrate the proposed method through three meta-analyses for comparison of prostate cancer treatment, for the association between paraoxonase 1 activities and coronary heart disease, and for the association between homocysteine level and coronary heart disease. © 2014 The Authors. Statistics in Medicine Published by John Wiley & Sons Ltd.

Advances in androgen receptor targeted therapy for prostate cancer

Prostate cancer (PCa) is the second leading cause of cancer death in men. Current research findings suggest that the androgen receptor (AR) and its signaling pathway contribute significantly to the progression of metastatic PCa. The AR is a ligand activated transcription factor, where androgens such as testosterone (T) and dihydroxytestosterone (DHT) act as the activating ligands. However in many metastatic PCa, the AR functions promiscuously and is constitutively active through multiple mechanisms. Inhibition of enzymes that take part in androgen synthesis or synthesizing antiandrogens that can inhibit the AR are two popular methods of impeding the androgen receptor signaling axis; however, the inhibition of androgen-independent activated AR function has not yet been fully exploited. This article focuses on the development of emerging novel agents that act at different steps along the androgen-AR signaling pathway to help improve the poor prognosis of PCa patients.

Multimodality therapy for patients with high-risk prostate cancer: current status and future directions

Prostate cancer is the most commonly diagnosed cancer and second most common cause of cancer death in American men. Although high-risk disease accounts for less than 15% of diagnoses, high-risk prostate cancer patients have a cancer-specific mortality rate of 15% at 10 years. There is currently no consensus on the optimal management of high-risk disease because (1) there are different primary modalities available (ie, surgery, radiation), for which there are no randomized trials comparing efficacy; and (2) unstandardized timing of different therapies (ie, neoadjuvant v concurrent v adjuvant), which makes comparisons of efficacy problematic. Increased understanding into the mechanisms leading to the formation of advanced metastatic disease has spurred the development of agents to target these pathways. However, new questions regarding optimal management of disease arise with regard to the role of these therapies in combination with "conventional" primary modalities for earlier stage, high-risk prostate cancer patients. In this article, we review the transforming world of multimodality therapy in high-risk prostate cancer.

The cardiovascular risk of gonadotropin releasing hormone agonists in men with prostate cancer: an unresolved controversy

Gonadotropin-releasing hormone agonists (GnRH) play an important role in the treatment of prostate cancer, improving significantly overall survival. GnRH agonists belong to androgen deprivation therapy (ADT) together with surgical castration and, recently, GnRH antagonists. ADT has several side effects, such as sexual dysfunction and osteoporosis. Recently, changes in body composition, obesity, insulin resistance, hyperglycemia, dyslipidemia, and hypertension have emerged as complications of ADT, perhaps responsible for cardiovascular events, but discussion is still open. Since the majority of men with prostate cancer die of conditions other than their malignancy, recognition of these adverse effects is important. This review serves to focus attention on the pathogenetic mechanisms of ADT-related cardiovascular toxicity with also reference to the possible direct role of GnRH agonist on the cardiac receptors. Furthermore, this paper would generate recommendations for the management of patients treated with GnRH agonists balancing the potential benefits against the possible risks in prostate cancer men.