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Sannala CKR, MacLean C, Larsen F, van Os S, Jadhav P, Shore N, Morgans AK, Okwuosa T, Gobburu J. A Model-Informed Drug Development Approach to Design a Phase 3 Trial of Teverelix Drug Product in Advanced Prostate Cancer Patients with Increased Cardiovascular Risk. Clin Pharmacol Drug Dev 2024; 13:915-929. [PMID: 38757461 DOI: 10.1002/cpdd.1415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/16/2024] [Indexed: 05/18/2024]
Abstract
Teverelix drug product (DP) is a parenteral gonadotropin-releasing hormone (GnRH) antagonist that has been successfully tested in phase 2 trials for hormone-sensitive advanced prostate cancer (APC) and benign prostatic hyperplasia (BPH). In previous APC trials, teverelix DP was administered as intramuscular (IM) and subcutaneous (SC) injections, using a loading dose and (in a single trial) a maintenance dose. Our objective was to derive an optimal dosing regimen for phase 3 clinical development, using a pharmacometrics modeling approach. Data from 9 phase 2 studies (229 patients) was utilized to develop a population pharmacokinetic (PK) model that described the concentration profile accommodating both IM and SC routes of administration. A 2-compartment model with sequential first-order absorption (slow and fast) and lag times best described the PK profiles of teverelix following SC and IM administration. An indirect response model with inhibition of production rate was fit to describe testosterone (T) concentrations based on physiological relevance. The final population PK-pharmacodynamic model was used to conduct simulations of various candidate dosing regimens to select the optimal dosing regimen to achieve clinical castration (T < 0.5 ng/mL by day 28) and to sustain clinical castration for 26 weeks. Model simulation showed that a loading dose of 360 mg SC and 180 mg IM with a maintenance dose of 360 mg SC 6-weekly (Q6W) starting at day 28 can achieve a ≥95% castration rate up to 52 weeks. This dose regimen was selected for phase 3 clinical development, which includes cardiovascular safety assessment in comparison to a GnRH agonist.
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Affiliation(s)
| | | | | | | | | | - Neal Shore
- Carolina Urologic Research Center, Myrtle Beach, SC, USA
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Ulys A, Jankevicus F, Jievaltas M, Venckus R, Auskalnis S, Kardelis Z, Barisiene M, MacLean CM, van Os S, Larsen F. Efficacy, tolerability, and safety of teverelix DP in patients with advanced prostate cancer: A multicenter, open-label, phase 2 trial. Prostate 2024; 84:584-598. [PMID: 38311868 DOI: 10.1002/pros.24674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/11/2024] [Accepted: 01/23/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Teverelix drug product (DP) is a novel injectable gonadotropin-releasing hormone antagonist. METHODS An adaptive phase 2, open-label, multicenter trial was conducted in patients with advanced prostate cancer to evaluate the efficacy and safety of a combined subcutaneous (SC) and intramuscular (IM) loading dose regimen of teverelix DP of 120 mg SC + 120 mg IM (Group 1; N = 9) or 180 mg SC + 180 mg IM (Group 2; N = 41) administered at a single visit, followed by 6-weekly SC maintenance doses of 120 mg (Group 1) or 180 mg (Group 2), up to Day 168. The primary endpoint was the proportion of patients achieving castration levels with serum testosterone <0.5 ng/mL at Day 28 with a target castration rate of 90%. Injection sites were inspected by the investigator at every visit and reactions (ISRs) were proactively recorded. RESULTS The target castration rate was reached in Group 2 (97.5%) but not in Group 1 (62.5%). The castration rates were not maintained to Day 42 (Group 2: 82.5%; Group 1: 50.0%). Suppression of testosterone to castrate levels occurred rapidly (median time: 2 days for both groups). Suppression of testosterone, prostate-specific antigen, follicle-stimulating hormone, and luteinizing hormone was sustained throughout the treatment period, being more prominent with the higher dose. The adverse event (AE) profile was similar between groups. The most common AEs were injection-site induration (n = 40: 80.0%), injection-site erythema (n = 35: 70.0%), and hot flush (n = 21: 42.0%). Most ISRs were Grade 1. CONCLUSION Overall, the teverelix DP doses were generally well-tolerated but did not adequately maintain castration levels.
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Affiliation(s)
- Albertas Ulys
- Departments of Urology, National Cancer Institute, Vilnius, Lithuania
| | - Feliksas Jankevicus
- Faculty of Medicine, Departments of Urology, Vilnius University, Vilnius, Lithuania
| | - Mindaugas Jievaltas
- Urology Department, Medicine Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Raimundas Venckus
- Department of Surgery, Klaipeda University Hospital, Klaipeda, Lithuania
| | - Stasys Auskalnis
- Urology Department, Medicine Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Marija Barisiene
- Faculty of Medicine, Departments of Urology, Vilnius University, Vilnius, Lithuania
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Pinthus JH, Duivenvoorden WCM. Cardiovascular risk in ADT recipients: does the type of ADT matter? Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00832-0. [PMID: 38664503 DOI: 10.1038/s41391-024-00832-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/01/2024] [Accepted: 04/09/2024] [Indexed: 05/27/2024]
Affiliation(s)
- Jehonathan H Pinthus
- Department of Surgery, Division of Urology, Faculty of Medicine, McMaster University, Hamilton, ON, Canada.
- Research Institute of St. Joe's Hamilton, Hamilton, ON, Canada.
| | - Wilhelmina C M Duivenvoorden
- Department of Surgery, Division of Urology, Faculty of Medicine, McMaster University, Hamilton, ON, Canada
- Research Institute of St. Joe's Hamilton, Hamilton, ON, Canada
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Merseburger AS, Bakshi G, Chen DY, Chiong E, Jabbour M, Joung JY, Lai AYH, Lawrentschuk N, Le TA, Ng CF, Ng CT, Ong TA, Pang JST, Rabah DM, Ragavan N, Sase K, Suzuki H, Teo MMH, Uemura H, Woo HH. Cardiovascular disease risk assessment and multidisciplinary care in prostate cancer treatment with ADT: recommendations from the APMA PCCV expert network. World J Urol 2024; 42:156. [PMID: 38483562 PMCID: PMC10940372 DOI: 10.1007/s00345-024-04852-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/05/2024] [Indexed: 03/17/2024] Open
Abstract
PURPOSE Androgen deprivation therapy (ADT) is the mainstay approach for prostate cancer (PCa) management. However, the most commonly used ADT modality, gonadotropin-releasing hormone (GnRH) agonists, has been associated with an increased risk of cardiovascular disease (CVD). METHODS The PCa Cardiovascular (PCCV) Expert Network, consisting of multinational urologists, cardiologists and oncologists with expertise in managing PCa, convened to discuss challenges to routine cardiovascular risk assessment in PCa management, as well as how to mitigate such risks in the current treatment landscape. RESULTS The experts identified several barriers, including lack of awareness, time constraints, challenges in implementing risk assessment tools and difficulties in establishing multidisciplinary teams that include cardiologists. The experts subsequently provided practical recommendations to improve cardio-oncology care for patients with PCa receiving ADT, such as simplifying cardiovascular risk assessment, individualising treatment based on CVD risk categories, establishing multidisciplinary teams and referral networks and fostering active patient engagement. A streamlined cardiovascular risk-stratification tool and a referral/management guide were developed for seamless integration into urologists' practices and presented herein. The PCCV Expert Network agreed that currently available evidence indicates that GnRH antagonists are associated with a lower risk of CVD than that of GnRH agonists and that GnRH antagonists are preferred for patients with PCa and a high CVD risk. CONCLUSION In summary, this article provides insights and guidance to improve management for patients with PCa undergoing ADT.
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Affiliation(s)
- Axel S Merseburger
- Department of Urology, University Hospital Schleswig-Holstein, Lübeck, Germany.
| | - Ganesh Bakshi
- Department of Surgical Oncology, P. D. Hinduja Hospital and Medical Research Center, Mumbai, India
| | - Dong-Yi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Branch, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Edmund Chiong
- Department of Urology, National University Hospital, and Department of Surgery, National University of Singapore, Singapore, Singapore
| | - Michel Jabbour
- Division of Urology, Saint Georges Hospital, Balamand University, Achrafieh, Beirut, Lebanon
| | - Jae Young Joung
- Center for Urological Cancer, National Cancer Center, Goyang, South Korea
| | - Allen Yu-Hung Lai
- Global Health Program, College of Public Health, National Taiwan University, Taipei, Taiwan
- Ferring Pharmaceuticals, Singapore, Singapore
| | - Nathan Lawrentschuk
- Department of Urology and Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | | | - Chi Fai Ng
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Choon Ta Ng
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Teng Aik Ong
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jacob See-Tong Pang
- Division of Urology, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Danny M Rabah
- The Cancer Research Chair and Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Narasimhan Ragavan
- Department of Urology, The Tamil Nadu Dr MGR Medical University, Apollo Hospitals, Chennai, India
| | - Kazuhiro Sase
- Clinical Pharmacology and Regulatory Science, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroyoshi Suzuki
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | | | - Hiroji Uemura
- Yokohama City University Medical Center, Yokohama, Japan
| | - Henry H Woo
- Department of Urology, Blacktown Hospital, Blacktown, NSW, Australia
- Department of Uro-Oncology, Chris O.Brien Lifehouse, Camperdown, NSW, Australia
- College of Health and Medicine, Australian National University, Canberra, ACT, Australia
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Sentana-Lledo D, Morgans AK. Perspectives on the Cardiovascular and Metabolic Effects of Androgen Deprivation Therapy in Prostate Cancer. Curr Oncol Rep 2024; 26:299-306. [PMID: 38376624 DOI: 10.1007/s11912-024-01512-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) is the leading cause of non-cancer mortality in men with prostate cancer. This review summarizes the existing and emerging literature examining the cardiometabolic effects of androgen deprivation therapy (ADT) in prostate cancer. RECENT FINDINGS The evidence behind the metabolic effects of ADT is derived from older studies and has not been validated in modern cohorts. Most of the newer studies focus on the risk of cardiovascular disease (CVD) with ADT. Recently published studies like the HERO and PRONOUNCE trials have once again sparked debate about the effects of different types and durations of ADT on cardiovascular outcomes. The link between ADT and CVD is inherently complex with a majority of the evidence collected from population-based or non-randomized trials without enriching for high-risk populations. Ongoing clinical trials may provide more informative data to guide the cardiovascular care of prostate cancer survivors.
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Affiliation(s)
- Daniel Sentana-Lledo
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
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Cicione A, Nacchia A, Guercio A, Gravina C, Franco A, Grimaldi MC, Tema G, Lombardo R, Tubaro A, De Nunzio C. Cardiovascular adverse events-related to GnRH agonists and GnRH antagonists: analysis of real-life data from Eudra-Vigilance and Food and Drug Administration databases entries. Prostate Cancer Prostatic Dis 2023; 26:765-771. [PMID: 36641533 DOI: 10.1038/s41391-022-00640-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/27/2022] [Accepted: 12/30/2022] [Indexed: 01/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES GnRH agonists and GnRH antagonists are two of the mainstays of hormonal therapy (HT) for prostate cancer (PCa). These drugs are at increased risk of cardiovascular (CV) adverse events (AEs). Aim of our study was to compare real-life data on AEs associated with GnRH agonists and GnRH antagonists based on Eudra-Vigilance (EV) and Food and Drug Administration (FDA) reported AEs. MATERIALS AND METHODS EV and FDA databases were queried and the number of CV adverse events (AEs) for degarelix, buserelin, goserelin, leuprorelin, triptorelin until September 2021 were recorded. Specific CV AEs were recorded and data were analyzed per age and severity. pooled relative risk (PRR) was used to compare data between drugs. RESULTS CV events were reported in 315/5128 (6%) for Degarelix, in 55/628 for Buserelin (9%), in 843/12,145 (7%) for Goserelin, in 3395/71,160 (5%) for Leuprorelin and in 214/4969 (5%) for Triptorelin. In terms of specific CV disorders, Degarelix presented lower risk of hypertension (PRR 0.60 (95% CI 0.37-0.98), p = 0.04), of myocardial infarction (PRR 0.05 (95% CI 0.01-0.39), p < 0.01) and thrombosis (PRR 0.14 (0.02-1.07), p = 0.06) when compared to GnRH agonists. Overall, younger patients (<65 years) presented a very low risk of CV AEs. Side effects were classified as serious in 90-96% of the cases. Fatal AEs were 5-20% over the CV AEs and 0.2-1% over the total AEs. CONCLUSIONS Real-life data are consistent with registry studies regarding side effects related to HT. Real-life data suggest GnRH agonists are associated with higher CV AEs when compared to GnRH antagonists. Clinicians should consider these data when prescribing HT especially in patients with CV comorbidities.
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Affiliation(s)
- Antonio Cicione
- Department of Urology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Antonio Nacchia
- Department of Urology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Alessandro Guercio
- Department of Urology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Carmen Gravina
- Department of Urology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Antonio Franco
- Department of Urology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Giorgia Tema
- Department of Urology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Riccardo Lombardo
- Department of Urology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Andrea Tubaro
- Department of Urology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Cosimo De Nunzio
- Department of Urology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
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Shao YHJ, Hong JH, Chen CK, Huang CY. Cardiovascular risk of gonadotropin-releasing hormone antagonist versus agonist in men with prostate cancer: an observational study in Taiwan. Prostate Cancer Prostatic Dis 2023; 26:722-729. [PMID: 35662291 PMCID: PMC10638084 DOI: 10.1038/s41391-022-00555-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/16/2022] [Accepted: 05/25/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The impact of gonadotropin-releasing hormone (GnRH) antagonist and agonist (GnRHa) treatment on cardiovascular disease (CVD) risk in prostate cancer (PCa) remains inconclusive due to conflicting findings. We compared the effects of GnRH antagonist and GnRHa treatments on CVD risk in patients with PCa and pre-existing CVD, in a Taiwan population-based database. METHODS We assessed the risk of major adverse CV events (MACE: ischemic heart disease [IHD], stroke, congestive heart failure [CHF] or all cause deaths) and composite CV events (IHD, stroke, CHF or CV deaths) occurring ≥90 days after androgen deprivation therapy (ADT) initiation in patients with PCa after 90 days of treatment with either GnRH antagonist (degarelix; n = 499) or GnRHa (goserelin, leuprolide, triptorelin; n = 15,127). Patients identified with pre-existing CVD had received cardiac therapy for IHD, reported a stroke or CHF within a year before ADT initiation. Adjusted hazard ratios (aHR) and 95% confidence interval (CI) were obtained for MACE and composite CV events risk after adjusting for age, baseline status of diabetes, hypertension and treatments received. RESULTS All GnRH antagonist-treated patients showed lower risk of composite CV events than the GnRHa-treated patients. The lower composite CV events risk associated with GnRH antagonist was also observed in patients with metastasis at diagnosis (aHR 0.16; 95% CI, 0.04-0.38; p = 0.013) and those receiving ADT for more than six months (aHR 0.30; 95% CI, 0.16-0.54; p < 0.0001). In patients with pre-existing CVD, the MACE risk was 33% lower (aHR 0.67; 95% CI, 0.46-0.96; p = 0.0299) and composite CV events risk was 84% lower (aHR 0.16; 95% CI, 0.05-0.50; p = 0.0017) in GnRH antagonist-treated than the GnRHa-treated patients. CONCLUSIONS In patients with PCa and pre-existing CVD, GnRH antagonist use was associated with lower risks for composite CV events and MACE compared with GnRHa.
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Affiliation(s)
- Yu-Hsuan Joni Shao
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.
- Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei, Taiwan.
| | - Jian-Hua Hong
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Chun-Kai Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Hsinchu Branch, Hsinchu, Taiwan
| | - Chao-Yuan Huang
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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Nelson AJ, Lopes RD, Hong H, Hua K, Slovin S, Tan S, Nilsson J, Bhatt DL, Goodman SG, Evans CP, Clarke NW, Shore ND, Margel D, Klotz LH, Tombal B, Leong DP, Alexander JH, Higano CS. Cardiovascular Effects of GnRH Antagonists Compared With Agonists in Prostate Cancer: A Systematic Review. JACC CardioOncol 2023; 5:613-624. [PMID: 37969642 PMCID: PMC10635880 DOI: 10.1016/j.jaccao.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 11/17/2023] Open
Abstract
Background Androgen deprivation therapy is the cornerstone of treatment for patients with advanced prostate cancer. Meta-analysis of small, oncology-focused trials suggest gonadotropin-releasing hormone (GnRH) antagonists may be associated with fewer adverse cardiovascular outcomes compared with GnRH agonists. Objectives This study sought to determine whether GnRH antagonists were associated with fewer major adverse cardiovascular events compared with GnRH agonists. Methods Electronic databases were searched for all prospective, randomized trials comparing GnRH antagonists with agonists. The primary outcome was a major adverse cardiovascular event as defined by the following standardized Medical Dictionary for Regulatory Activities terms: "myocardial infarction," "central nervous system hemorrhages and cerebrovascular conditions," and all-cause mortality. Bayesian meta-analysis models with random effects were fitted. Results A total of 11 eligible studies of a maximum duration of 3 to 36 months (median = 12 months) enrolling 4,248 participants were included. Only 1 trial used a blinded, adjudicated event process, whereas potential bias persisted in all trials given their open-label design. A total of 152 patients with primary outcome events were observed, 76 of 2,655 (2.9%) in GnRH antagonist-treated participants and 76 of 1,593 (4.8%) in agonist-treated individuals. Compared with GnRH agonists, the pooled OR of GnRH antagonists for the primary endpoint was 0.57 (95% credible interval: 0.37-0.86) and 0.58 (95% credible interval: 0.32-1.08) for all-cause death. Conclusions Despite the addition of the largest, dedicated cardiovascular outcome trial, the volume and quality of available data to definitively answer this question remain suboptimal. Notwithstanding these limitations, the available data suggest that GnRH antagonists are associated with fewer cardiovascular events, and possibly mortality, compared with GnRH agonists.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Monash Heart, Monash Health, Melbourne, Victoria
| | - Renato D. Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Hwanhee Hong
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Kaiyuan Hua
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Susan Slovin
- Genitourinary Oncology Service, Department of Medicine, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sean Tan
- Monash Heart, Monash Health, Melbourne, Victoria
| | - Jan Nilsson
- Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Shaun G. Goodman
- Division of Cardiology, St. Michael’s Hospital, Department of Medicine, University of Toronto, Ontario, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher P. Evans
- Department of Urologic Surgery, University of California, Davis, Davis, California, USA
| | - Noel W. Clarke
- Department of Urology, The Christie and Salford Royal Hospitals, Manchester, United Kingdom
| | - Neal D. Shore
- Carolina Urologic Research Center, Myrtle Beach, South Carolina, USA
| | - David Margel
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel
| | - Laurence H. Klotz
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Bertrand Tombal
- Institut de Recherche Cliniques, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Darryl P. Leong
- Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Celestia S. Higano
- Division of Medical Oncology, University of Washington and Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
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Hamblen AJ, Bray JW, Hingorani M, Saxton JM. Physical activity and dietary considerations for prostate cancer patients: future research directions. Proc Nutr Soc 2023; 82:298-304. [PMID: 36606326 DOI: 10.1017/s0029665123000046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This review considers current evidence on physical activity and dietary behaviours in the context of prostate cancer prevention and survivorship outcomes. Prostate cancer is the second most common cancer amongst men, with over 1⋅4 million newly diagnosed cases globally each year. Due to earlier detection via screening and advances in treatments, survival rates are amongst the highest of all cancer populations. However, hormone treatments (i.e. androgen deprivation therapy) can lead to undesirable body composition changes, increased fatigue and reduced health-related quality of life, which can impair the overall wellbeing of men living with and beyond prostate cancer. Existing research has only provided limited evidence that physical activity and nutrition can impact a man's risk of prostate cancer but cohort studies suggest they can influence survival outcomes after diagnosis. Additionally, data from observational and intervention studies suggest that habitual physical activity (or structured exercise) and healthy diets can help to ameliorate hormone-related treatment side-effects. Current physical activity guidelines state that prostate cancer patients should complete at least three sessions of moderate-intensity aerobic exercise per week, along with two resistance exercise sessions, but dietary guidelines for prostate cancer patients are less well defined. In conclusion, regular physical activity and nutritional interventions may improve survival outcomes and attenuate some adverse side-effects of hormone treatments in men with prostate cancer. However, further research is required to improve our understanding of the health impacts of physical activity (including structured exercise) and nutrition in relation to prostate cancer prevention and survivorship.
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Affiliation(s)
- Andrew J Hamblen
- School of Sport, Exercise and Rehabilitation Sciences, University of Hull, Kingston upon Hull, UK
| | - James W Bray
- School of Sport, Exercise and Rehabilitation Sciences, University of Hull, Kingston upon Hull, UK
| | - Mohan Hingorani
- Department of Clinical Oncology, Queen's Centre of Oncology, Castle Hill Hospital, Hull Teaching Hospitals NHS Trust, Cottingham, UK
| | - John M Saxton
- School of Sport, Exercise and Rehabilitation Sciences, University of Hull, Kingston upon Hull, UK
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Dolmatova E, Waheed N, Olson BM, Patel SA, Mandawat A. The Intersection of Prostate Cancer and Hypertension: a Call to Action. Curr Treat Options Oncol 2023; 24:892-905. [PMID: 37191906 DOI: 10.1007/s11864-023-01094-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
OPINION STATEMENT With improvements in treatment and survival from prostate cancer, comorbid cardiac conditions will significantly impact overall morbidity and mortality from prostate cancer. Hypertension is a well-established cardiovascular risk factor that increases the risk of heart failure, myocardial infarction, and stroke. Therapies used in the treatment of prostate cancer, including GnRH agonists, GnRH antagonists, enzalutamide, abiraterone, and others, can directly or indirectly increase the risk of hypertension. In this paper, we review the evidence available on the incidence and mechanism of hypertension in prostate cancer patients. In addition, we provide recommendations on the assessment, treatment, and future directions for hypertension management in the prostate cancer population. We propose an individualized goal for blood pressure in prostate cancer patients, balancing the target goal of 130/80 mmHg with common comorbidities of frailty, orthostatic symptoms, and imbalance in this population. The presence of additional comorbidities (myocardial infarction, heart failure, renal disease, diabetes) can assist in preference of anti-hypertensive drugs.
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Affiliation(s)
| | - Nida Waheed
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - Sagar A Patel
- Emory University School of Medicine, Atlanta, GA, USA
| | - Anant Mandawat
- Emory University School of Medicine, Atlanta, GA, USA.
- Cardio-Oncology Center of Excellence, Emory University, 1365B Clifton Rd NE Suite 4000, Atlanta, GA, 30322, USA.
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Fradin J, Kim FJ, Lu-Yao GL, Storozynsky E, Kelly WK. Review of Cardiovascular Risk of Androgen Deprivation Therapy and the Influence of Race in Men with Prostate Cancer. Cancers (Basel) 2023; 15:2316. [PMID: 37190244 PMCID: PMC10136828 DOI: 10.3390/cancers15082316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
Androgen deprivation therapy is the cornerstone of prostate cancer therapy. Recent studies have revealed an association between androgen deprivation therapy and cardiovascular adverse effects such as myocardial infarction and stroke. This review summarizes the available research on the cardiovascular risk of men using androgen deprivation therapy. We also discuss racial disparities surrounding both prostate cancer and cardiovascular disease, emphasizing the importance of biological/molecular and socioeconomic factors in assessing baseline risk in patients beginning androgen ablation. Based on the literature, we provide recommendations for monitoring patients who are at high risk for a cardiovascular adverse event while being treated on androgen deprivation therapy. This review aims to present the current research on androgen deprivation therapy and cardiovascular toxicity with an emphasis on racial disparities and provides a framework for clinicians to decrease the cardiovascular morbidity in men that are being treated with hormone therapy.
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Affiliation(s)
- James Fradin
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Felix J. Kim
- Department of Pharmacology, Physiology, and Cancer Biology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Grace L. Lu-Yao
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Eugene Storozynsky
- Jefferson Heart Institute, Department of Medicine, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - William K. Kelly
- Department of Medical Oncology and Urology, Sidney Kimmel Cancer Center, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
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12
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Gu L, Li X, Liu W. Adverse cardiovascular effect following gonadotropin-releasing hormone antagonist versus GnRH agonist for prostate cancer treatment: A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1157857. [PMID: 37065739 PMCID: PMC10102515 DOI: 10.3389/fendo.2023.1157857] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
Background Androgen deprivation therapy is the mainstay of medical treatment for prostate cancer (Pca); however, it is associated with an increased risk of adverse cardiovascular (CV) events and death. To date, CV death has been the leading noncancer cause of death in Pca patients. Both GnRH antagonists (an emerging class of drugs) and GnRH agonists (most frequently prescribed) are efficacious against Pca. However, the adverse effects, especially the adverse CV effect between them remain unclear. Methods Through a literature search using MEDLINE, EMBASE and the Cochrane Library, all available studies comparing the safety of CV risk between GnRH antagonists and GnRH agonists in Pca patients were extracted. Comparisons of outcomes of interest between these two classes of drugs were calculated using the risk ratio (RR). Subgroup analyses were performed depending on the study design and preexisting CV disease at baseline. Results Nine randomized controlled clinical trials (RCTs) and five real-world observational studies comprising 62160 Pca patients were included in our meta-analysis. Patients receiving GnRH antagonists experienced fewer CV events (RR: 0.66, 95% CI:0.53-0.82, P<0.001), CV death (RR:0.4, 95% CI: 0.24-0.67, P<0.001) and myocardial infarctions (RR: 0.71, 95% CI: 0.52-0.96, P=0.03). No difference was found in the incidence of stroke and heart failure. Moreover, GnRH antagonists were associated with fewer CV events in patients with preexisting CV disease but not in those without preexisting CV disease in the RCT series. Conclusion GnRH antagonists appear to offer favorable safety in terms of adverse CV events and CV death compared with GnRH agonists among men diagnosed with Pca, especially those who had established CV disease at baseline. Systematic review registration https://inplasy.com/inplasy-2023-2-0009/, identifier INPLASY202320009.
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Affiliation(s)
- Li Gu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xurui Li
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wentao Liu
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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13
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Comez YI. Retreatment Plan Success through Patient Health Awareness, Health Behavior, and Access to Doctor after a Focal Therapy Procedure for Prostate Cancer. Am J Health Behav 2023; 47:116-129. [PMID: 36945097 DOI: 10.5993/ajhb.47.1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Objective: The research aimed to investigate the retreatment plan success through patient health awareness, health behavior, and access to a doctor when patients have in-field or outfield recurrence after a focal therapy procedure for prostate cancer. This research is initiated because many men are victims of prostate cancer. Methods: The research collected data from patient's focal therapy clinics for their treatment of prostate cancer. The data for this research was collected with a longitudinal design because a complete procedure of patient treatment was required in this study. Results: The findings disclosed that prostate cancer patients' retreatment can be a success when they have health awareness and access to a doctor for focal therapy. The model developed in this research is a significant contribution to the literature on patient satisfaction and prostate cancer treatment. The research has contributed remarkable implications to the theory by presenting a newly developed relationship with empirical evidence based on patients' responses. Conclusion: The study has presented a roadmap for the practical treatment of prostate cancer patients and treatment success for the patient's treatment in the future. Some future recommendations are also reported for future investigation and work on prostate cancer and retreatment success.
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14
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Dragomir A, Touma N, Hu J, Perreault S, Aprikian AG. Androgen Deprivation Therapy and Risk of Cardiovascular Disease in Patients With Prostate Cancer Based on Existence of Cardiovascular Risk. J Natl Compr Canc Netw 2023; 21:163-171. [PMID: 36791755 DOI: 10.6004/jnccn.2022.7083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 09/29/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND Controversy exists regarding the risk of cardiovascular disease (CVD) associated with androgen deprivation therapy (ADT) in patients with prostate cancer. We sought to evaluate the association between gonadotropin-releasing hormone (GnRH) agonists versus GnRH antagonist and the risk of CVD in patients with prostate cancer with or without prior CVD. PATIENTS AND METHODS Using administrative databases from Quebec, Canada, we identified first-time GnRH agonists and antagonist (degarelix) users between January 2012 and June 2016. Follow-up ended at the earliest of the following: first CVD event (myocardial infarction [MI], stroke, ischemic heart disease [IHD], arrhythmia, and heart failure [HF]); switch of GnRH group; death; or December 31, 2016. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to control for potential confounding. IPTW-Cox proportional hazards model accounting for competing risks was used to evaluate the association of interest. RESULTS Among 10,785 patients identified, 10,201 and 584 were on GnRH agonists and antagonist, respectively. Median age was 75 years (interquartile range, 69-81 years) for both groups. A total of 4,152 (40.7%) men in the GnRH agonists group and 281 (48.1%) men in the GnRH antagonist group had CVD in the 3-year period prior to ADT initiation. Risk of HF was decreased in the antagonist group compared with the GnRH agonist group among patients with prior CVD (hazard ratio [HR], 0.46; 95% CI, 0.26-0.79). Risk of IHD was decreased in the antagonist group in patients without prior CVD (HR, 0.26; 95% CI, 0.11-0.65). Use of antagonist was associated with an increased risk of arrhythmia among patients with no prior CVD (HR, 2.34; 95% CI, 1.63-3.36). CONCLUSIONS Compared with GnRH agonists, the GnRH antagonist was found to be associated with a decreased risk of HF, specifically among patients with prior CVD. Among those with no prior CVD, the GnRH antagonist was associated with a decreased risk of IHD but an increased risk of arrhythmia.
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Affiliation(s)
- Alice Dragomir
- Division of Urology, Department of Surgery, McGill University, Montreal, Canada.,Research Institute of McGill University Health Centre, Montreal, Canada
| | - Nawar Touma
- Faculty of Medicine, McGill University, Montreal, Canada
| | - Jason Hu
- Faculty of Medicine, McGill University, Montreal, Canada
| | | | - Armen G Aprikian
- Division of Urology, Department of Surgery, McGill University, Montreal, Canada.,Department of Oncology, McGill University Health Centre, Montreal, Canada
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15
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Oderda M, Bertetto O, Barbera G, Calleris G, Falcone M, Filippini C, Marquis A, Marra G, Montefusco G, Peretti F, Gontero P. Appropriateness and complications of androgen deprivation therapy for prostate cancer: Can we do better? A retrospective observational analysis from a referral center. Urologia 2023; 90:100-108. [PMID: 36703243 DOI: 10.1177/03915603221149502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Androgen deprivation therapy (ADT) is the key of medical treatment for advanced prostate cancer (PCa), especially in elderly patients. However, the adherence of ADT prescription to current guidelines is not optimal and must be balanced against possible side effects. Aim of this study was to evaluate the prescriptive appropriateness of ADT and ADT-related adverse events in a referral center for PCa. METHODS Five hundred fifty six patients who received an outpatient prescription for ADT from 2014 to 2018 were retrospectively identified from an administrative database. Only standard ADT was considered, including GnRH agonists, GnRH antagonists, and antiandrogens. Prescriptive appropriateness was defined according to the last European Association of Urology (EAU) guidelines. Our cohort was stratified according to age categories and patient follow-up was updated. RESULTS Four hundred twenty five patients were available for analysis. Mean age was 80 years; 96.3% of our patients fell in the "elderly" category. There was a predominance of GnRH agonists over the antagonists (84.9% vs 13%). 15.5% of ADTs did not have an appropriate indication according to guidelines. Patient compliance to ADT was evaluated as good in 372 (87.5%) cases. ADT-related complications were detected in 166 (39%) patients: bone, cardiovascular, and other complications were reported in 7.3%, 8.9%, and 19% of patients. Progression of disease was noted in 165 (38.8%) cases during ADT. At last follow-up, 124 (30.1%) patients were deceased. CONCLUSIONS In a referral center, most ADT prescriptions followed EAU guidelines, but a non-negligible proportion still did not fall within these indications, exposing patients to unnecessary side effects. Compliance to ADT was generally good with a predominant use of GnRH agonists. Tolerance to ADT was fair, even if standardized reports were lacking.
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Affiliation(s)
- Marco Oderda
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Oscar Bertetto
- Rete Oncologica del Piemonte e della Valle d'Aosta, Torino, Italy
| | - Giulia Barbera
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Giorgio Calleris
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Marco Falcone
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | | | - Alessandro Marquis
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Giancarlo Marra
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Gabriele Montefusco
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Federica Peretti
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
| | - Paolo Gontero
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy
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16
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Tisseverasinghe S, Tolba M, Saad F, Gravis G, Bahoric B, Niazi T. Should Prostate Cancer Patients With History of Cardiovascular Events Be Preferentially Treated With Luteinizing Hormone-Releasing Hormone Antagonists? J Clin Oncol 2022; 40:4173-4177. [PMID: 35862876 DOI: 10.1200/jco.22.00883] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Marwan Tolba
- Department of Radiation Oncology, McGill University, Montreal, QC, Canada
| | - Fred Saad
- Center Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Gwenaëlle Gravis
- Department of Medical Oncology, Institut Paoli-Calmettes, Aix-Marseille University, CRCM, Marseille, France
| | - Boris Bahoric
- Department of Radiation Oncology, McGill University, Montreal, QC, Canada
| | - Tamim Niazi
- Department of Radiation Oncology, McGill University, Montreal, QC, Canada
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17
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Ferreira VV, Ângelo I, Thomas B, Ghosh AK. Cardiovascular complications of treatment for prostate cancer. Br J Hosp Med (Lond) 2022; 83:1-12. [DOI: 10.12968/hmed.2022.0334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Prostate cancer, an androgen-dependent disease, is one of the leading causes of mortality in men. It can present as localised disease, locally advanced or distant metastatic disease. Treatment options for patients with prostate cancer include surgery, chemotherapy, brachytherapy, radiation therapy and hormonal therapy. There are multiple treatment options for each stage of the disease, but hormone therapy is usually reserved for advanced stages. Cardiovascular disease is the leading cause of death in patients with prostate cancer and both diseases share common risk factors. Hormone therapy improves prognosis in patients with more advanced disease, albeit at the cost of cardiovascular toxicity. Hormone therapy can be achieved with the use of agonists and antagonists of gonadotropin-releasing hormone receptors, androgen receptor blockers and enzyme inhibitors of androgen synthesis. Drug-specific cardiotoxicity caused by treatments for prostate cancer has not been fully elucidated. Cardiovascular disease in patients with prostate cancer is mainly managed via an ABCDE approach, a strategy to optimise common risk factors. With newer agents improving the prognosis for patients with prostate cancer, cardiovascular toxicity will have a greater impact on the outcomes of these patients. This article reviews cardiovascular risks associated with therapy for prostate cancer with a focus on hormonal therapy.
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Affiliation(s)
- Vera Vaz Ferreira
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Inês Ângelo
- Oncology Service, Centro Hospitalar Barreiro Montijo, Barreiro, Portugal
| | - Boban Thomas
- Heart Center, Hospital da Cruz Vermelha Portuguesa, Lisbon, Portugal
| | - Arjun K Ghosh
- Cardio-Oncology Service, Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- Cardio-Oncology Service, Hatter Cardiovascular Institute, University College London Hospital, London, UK
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18
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Reeves DJ, Rao VU. Update on cancer therapy-induced atherosclerosis. Curr Opin Cardiol 2022; 37:372-379. [PMID: 35731682 DOI: 10.1097/hco.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Recent advances in oncologic therapies have significantly improved overall survival for patients with malignancy. However, cardiovascular complications have not only increased in this population due to shared risk factors and pathophysiology, but also due to the therapies themselves. One key mechanism that warrants further attention is accelerated atherosclerosis due to these agents. RECENT FINDINGS Here we review recent studies focusing on four classes of anticancer agents with the potential to accelerate atherosclerosis, including breakpoint cluster region-Ableson (BCR-ABL) tyrosine kinase inhibitors, immunotherapies, androgen deprivation therapies, and vascular endothelial growth factor inhibitors. In addition to drug therapy, radiation therapy may also accelerate atherosclerosis. SUMMARY In order to optimize outcomes for patients with malignancy, enhanced efforts need to focus on mitigating common risk factors, but also recognizing enhanced atherosclerotic risk with certain oncologic therapies. For patients exposed to these agents, risk reduction with agents such as aspirin and/or statins prior to, during, and after cancer treatment may provide opportunities to improve overall outcomes.
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Affiliation(s)
- David J Reeves
- Division of Oncology, Franciscan Health and Butler University College of Pharmacy and Health Sciences
| | - Vijay U Rao
- Franciscan CardioOncology Center, IC-OS Center of Excellence, Indiana Heart Physicians, Franciscan Health, Indianapolis, Indiana, USA
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19
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Davey P, Alexandrou K. Assessment and Mitigation of Cardiovascular Risk for Prostate Cancer Patients: A Review of the Evidence. Int J Clin Pract 2022; 2022:2976811. [PMID: 35685515 PMCID: PMC9158798 DOI: 10.1155/2022/2976811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/31/2022] [Indexed: 11/29/2022] Open
Abstract
Background Cardiovascular disease (CVD) is a common comorbidity in patients with prostate cancer. In this review, we summarize the published literature on the association of cardiovascular risk with androgen deprivation therapy (ADT) treatment and explore the potential differences between the gonadotropin-releasing hormone (GnRH) agonists and antagonists and the molecular mechanisms that may be involved. We also provide a practical outlook on the identification of underlying CV risk and explore the different stratification tools available. Results While not definitive, the current evidence suggests that GnRH antagonists may be associated with lower rates of certain CV events vs agonists, particularly in patients with preexisting CVD. Risk reduction strategies such as lifestyle advice, consideration of ADT modality, and comedications may help to reduce CV risk factors and improve outcomes in prostate cancer patients receiving ADT. Conclusions Given all the data that is currently available, identification of baseline CV risk factors may be key to risk mitigation in patients with prostate cancer receiving ADT.
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Affiliation(s)
- Patrick Davey
- Northampton General Hospital, Cliftonville, Northampton NN1 5BD, UK
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20
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Forster RB, Engeland A, Kvåle R, Hjellvik V, Bjørge T. Association between medical androgen deprivation therapy and long-term cardiovascular disease and all-cause mortality in non-metastatic prostate cancer. Int J Cancer 2022; 151:1109-1119. [PMID: 35489025 PMCID: PMC9544783 DOI: 10.1002/ijc.34058] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/08/2022] [Accepted: 04/19/2022] [Indexed: 11/10/2022]
Abstract
Studies have suggested that prostate cancer (PCa) patients receiving androgen deprivation therapy (ADT) are at increased risk of developing or exacerbating cardiovascular disease (CVD). We aimed to explore the association between ADT for PCa and subsequent CVD and all‐cause mortality in this nationwide, longitudinal study. We also evaluated the role of cardiovascular risk and ADT duration to determine effect modification. Norwegian registry data were used to identify patients with PCa from 2008‐18 and who received primary ADT in the first year after diagnosis. The associations between ADT and composite cardiovascular events, and the individual components of myocardial infarction, stroke and heart failure, in addition to atrial fibrillation and all‐cause mortality, were explored using time‐varying Cox regression models. We included 30 923 PCa patients, of whom 8449 (27%) received primary ADT. Mean follow‐up was 2.9 and 3.8 years for CVD events and mortality, respectively. We found an association between ADT and composite CVD (adjusted HR 1.13: 95% CI 1.05‐1.21), myocardial infarction (1.18: 1.05‐1.32), stroke (1.21: 1.06‐1.38), heart failure (1.23: 1.13‐1.35) and all‐cause mortality (1.49: 1.39‐1.61). These associations persisted in those with low and moderate CVD risk and ADT longer than 7 months. A relationship between ADT and composite CVD and all‐cause mortality was observed, especially in those with moderate CVD risk and longer treatment duration. Future studies with more detailed cancer data are needed to verify the clinical relevance of these results, especially when considering all‐cause mortality within the context of treatment guidelines and benefits of ADT.
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Affiliation(s)
- R B Forster
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
| | - A Engeland
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - R Kvåle
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway.,Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - V Hjellvik
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - T Bjørge
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Cancer Registry of Norway, Oslo, Norway
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21
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DE Nunzio C, Fiori C, Fusco F, Gregori A, Pagliarulo V, Alongi F. Androgen deprivation therapy and cardiovascular risk in prostate cancer. Minerva Urol Nephrol 2022; 74:508-517. [PMID: 35470648 DOI: 10.23736/s2724-6051.22.04847-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Androgen-deprivation therapy (ADT), with or without palliative local treatments, is the standard of care for many patients with locally-advanced and/or metastatic prostate cancer. However, the possible cardiovascular (CV) risks associated with gonadotropin-releasing hormone (GnRH) antagonists and agonists continue to be the subject of concern, especially in a patient population that may already be at increased CV risk. EVIDENCE ACQUISITION The present review provides a narrative summary of the evidence regarding the CV risks associated with GnRH antagonists and agonists from randomized clinical trials (RCTs), real-world evidence, and meta-analyses. EVIDENCE SYNTHESIS From RCTs, it appears clear that there is a direct class effect for CV risk in patients with prostate cancer being administered GnRH agonists and antagonists, with the latter being associated with reduced CV risk. Real-world data and the available meta-analyses largely indicate that CV risk is lower with GnRH antagonists than with GnRH agonists. CONCLUSIONS A review of the pathophysiological mechanisms of gives further support to the possibility that GnRH antagonists are associated with lower CV risk than agonists. It can be highlighted that when treating patients with advanced or metastatic prostate cancer it is important to screen for underlying comorbidities prior to choosing the most appropriate therapy; moreover, patients should be closely monitored for factors associated with CV risk in order to optimize outcomes. Further studies are needed to define the most appropriate treatment according to the individual patient characteristics.
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Affiliation(s)
| | - Cristian Fiori
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Ferdinando Fusco
- Urology Unit, Department of Neurosciences, Science of Reproduction and Odontostomatology, University of Naples Federico II, Naples, Italy
| | | | | | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Ospedale Sacro Cuore Don Calabria, Negrar di Valpolicella, Verona, Italy.,University of Brescia, Brescia, Italy
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22
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Lehmann J, Kluike CW, Haider A, Haider KS, Baumann S, Flesch M, Gedamke M, Kägebein D. [Factors influencing the choice of androgen deprivation therapy for patients with hormone-sensitive prostate cancer : Results of the ProComD study]. Urologe A 2022; 61:173-182. [PMID: 34402941 PMCID: PMC8831365 DOI: 10.1007/s00120-021-01620-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND Androgen deprivation therapy (ADT) with a GnRH agonist or the GnRH antagonist degarelix is a central component in the treatment of prostate cancer (PCa). Little is currently known regarding the decision criteria. Knowledge of these could improve the success of treatment in the future. OBJECTIVES To identify factors influencing the treatment decision in patients with hormone-sensitive prostate cancer receiving ADT and to determine the incidence of concomitant disease in both treatment groups. METHODS The two-arm, prospective, non-interventional study "ProComD" was conducted from September 2014 to June 2019 at 80 study centers in Germany. After the therapy decision was made, patients with hormone-sensitive prostate cancer needing ADT were included in the study. Data were collected during routine visits. RESULTS Data from 413 patients were evaluated (degarelix N = 268; GnRH agonists N = 145). Key factors influencing the therapy decision for both treatment options included comorbidities (42% of all patients), compliance (64%), and age (81%). The source of information consulted most frequently regarding existing comorbidities was the patient's medical history conducted by the treating urologist themselves (65% in both groups). For patients with pre-existing cardiovascular diseases, the doctor's letter (45.8% degarelix vs. 38.9% GnRH agonists) or the medical history questionnaire (38.9% degarelix vs. 20% GnRH agonists) was additionally taken into account. CONCLUSION Comorbidities along with age and compliance are among the key factors influencing the treatment decisions made by urologists.
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Affiliation(s)
- J Lehmann
- Urologische Gemeinschaftspraxis Prüner Gang, Gesundheitszentrum Kiel-Mitte, Prüner Gang 15., 24103, Kiel, Deutschland.
| | - C W Kluike
- Urologie am Wasserturm, Lüneburg, Deutschland
| | - A Haider
- Praxis für Urologie und Andrologie, Bremerhaven, Deutschland
| | - K S Haider
- Praxis für Urologie und Andrologie, Bremerhaven, Deutschland
| | - S Baumann
- Praxisgemeinschaft für Urologie, Leipzig, Deutschland
| | - M Flesch
- Marienkrankenhaus, Soest, Deutschland
| | | | - D Kägebein
- Ferring Arzneimittel GmbH, Kiel, Deutschland
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23
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von Amsberg G, Thiele H, Merseburger A. [Cardiovascular side effects in patients undergoing androgen deprivation therapy: superiority of gonadotropin-releasing hormone antagonists? An update]. Urologe A 2021; 60:1450-1457. [PMID: 34213627 PMCID: PMC8568757 DOI: 10.1007/s00120-021-01583-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Androgen deprivation therapy (ADT) plays a crucial role in treatment of advanced prostate cancer (PCa). The additional application of new drugs results in prolonged overall survival, both in the hormone sensitive and castration resistant state. Consequently, the long-term use of ADT moves potential side effects into the focus of interest. In this context special consideration must be given to cardiovascular events. OBJECTIVES Review of current evidence on potential differences regarding the cardiovascular risk profile of gonadotropin-releasing hormone (GnRH) agonists compared to GnRH antagonists. METHODS Narrative review based on an expert consensus supported by a literature search in PubMed (MEDLINE) and the abstract databases of ASCO and ESMO was conducted for publications published between January 2015 and January 2021. Significant meta-analyses, randomized controlled trials (RCTs) and real-world data (RWD) revealing relevant results for clinical practice were taken into account. Selection of studies was performed based on the clinical relevance for everyday practice. RESULTS The search yielded three relevant meta-analyses, two prospective RCTs as well as three RWD publications that are of importance for clinical practice. Overall, a decreased incidence of cardiovascular events was reported for GnRH antagonists compared to GnRH agonists. Only one RWD publication described comparable rates of complications for both drug classes. CONCLUSION GnRH antagonists have a lower risk of treatment related cardiovascular events compared to GnRH agonists. Risks should be minimized by taking known cardiovascular risk factors into account before initiating therapy.
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Affiliation(s)
- Gunhild von Amsberg
- II. medizinische Klinik, Onkologisches Zentrum und Martini-Klinik, Universitätsklinik Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Holger Thiele
- Herzzentrum Leipzig, Universitätsklinik für Kardiologie, Leipzig, Deutschland
| | - Axel Merseburger
- Klinik für Urologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
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Lopes RD, Higano CS, Slovin SF, Nelson AJ, Bigelow R, Sørensen PS, Melloni C, Goodman SG, Evans CP, Nilsson J, Bhatt DL, Clarke NW, Olesen TK, Doyle-Olsen BT, Kristensen H, Arney L, Roe MT, Alexander JH. Cardiovascular Safety of Degarelix Versus Leuprolide in Patients With Prostate Cancer: The Primary Results of the PRONOUNCE Randomized Trial. Circulation 2021; 144:1295-1307. [PMID: 34459214 DOI: 10.1161/circulationaha.121.056810] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relative cardiovascular safety of gonadotropin-releasing hormone (GnRH) antagonists compared with GnRH agonists in men with prostate cancer and known atherosclerotic cardiovascular disease remains controversial. METHODS In this international, multicenter, prospective, randomized, open-label trial, men with prostate cancer and concomitant atherosclerotic cardiovascular disease were randomly assigned 1:1 to receive the GnRH antagonist degarelix or the GnRH agonist leuprolide for 12 months. The primary outcome was the time to first adjudicated major adverse cardiovascular event (composite of death, myocardial infarction, or stroke) through 12 months. RESULTS Because of slower-than-projected enrollment and fewer-than-projected primary outcome events, enrollment was stopped before the 900 planned participants were accrued. From May 3, 2016, to April 16, 2020, a total of 545 patients from 113 sites across 12 countries were randomly selected. Baseline characteristics were balanced between study groups. The median age was 73 years, 49.8% had localized prostate cancer; 26.3% had locally advanced disease, and 20.4% had metastatic disease. A major adverse cardiovascular event occurred in 15 (5.5%) patients assigned to degarelix and 11 (4.1%) patients assigned to leuprolide (hazard ratio, 1.28 [95% CI, 0.59-2.79]; P=0.53). CONCLUSIONS PRONOUNCE (A Trial Comparing Cardiovascular Safety of Degarelix Versus Leuprolide in Patients With Advanced Prostate Cancer and Cardiovascular Disease) is the first, international, randomized clinical trial to prospectively compare the cardiovascular safety of a GnRH antagonist and a GnRH agonist in patients with prostate cancer. The study was terminated prematurely because of the smaller than planned number of participants and events, and no difference in major adverse cardiovascular events at 1 year between patients assigned to degarelix or leuprolide was observed. The relative cardiovascular safety of GnRH antagonists and agonists remains unresolved. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02663908.
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Affiliation(s)
- Renato D Lopes
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
| | - Celestia S Higano
- Division of Medical Oncology, University of Washington and Fred Hutchinson Cancer Research Center, Seattle (C.S.H.)
| | - Susan F Slovin
- Genitourinary Oncology Service, Department of Medicine, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, NY (S.F.S.)
| | - Adam J Nelson
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
| | | | - Per S Sørensen
- Ferring Pharmaceuticals A/S, Copenhagen, Denmark (P.S.S., T.K.O., B.T.D.-O., H.K.)
| | - Chiara Melloni
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
- IQVIA, Durham, NC (C.M.)
| | - Shaun G Goodman
- Division of Cardiology, St. Michael's Hospital, Department of Medicine, University of Toronto, Ontario, Canada (S.G.G.)
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.G.G.)
| | - Christopher P Evans
- Department of Urologic Surgery, University of California, Davis, Sacramento (C.P.E.)
| | - Jan Nilsson
- Department of Clinical Sciences Malmö, Lund University, Sweden (J.N.)
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal Hospitals Manchester, United Kingdom (N.W.C.)
| | - Tine K Olesen
- Ferring Pharmaceuticals A/S, Copenhagen, Denmark (P.S.S., T.K.O., B.T.D.-O., H.K.)
| | | | - Henriette Kristensen
- Ferring Pharmaceuticals A/S, Copenhagen, Denmark (P.S.S., T.K.O., B.T.D.-O., H.K.)
| | - Lauren Arney
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
| | - Matthew T Roe
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
- Verana Health, San Francisco, CA (M.T.R.)
| | - John H Alexander
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
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Zengerling F, Jakob JJ, Schmidt S, Meerpohl JJ, Blümle A, Schmucker C, Mayer B, Kunath F. Degarelix for treating advanced hormone-sensitive prostate cancer. Cochrane Database Syst Rev 2021; 8:CD012548. [PMID: 34350976 PMCID: PMC8407409 DOI: 10.1002/14651858.cd012548.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Degarelix is a gonadotropin-releasing hormone antagonist that leads to medical castration used to treat men with advanced or metastatic prostate cancer, or both. It is unclear how its effects compare to standard androgen suppression therapy. OBJECTIVES To assess the effects of degree compared with standard androgen suppression therapy for men with advanced hormone-sensitive prostate cancer. SEARCH METHODS We searched multiple databases (CENTRAL, MEDLINE, Embase, Scopus, Web of Science, LILACS until September 2020), trial registries (until October 2020), and conference proceedings (until December 2020). We identified other potentially eligible trials by reference checking, citation searching, and contacting study authors. SELECTION CRITERIA We included randomized controlled trials comparing degarelix with standard androgen suppression therapy for men with advanced prostate cancer. DATA COLLECTION AND ANALYSIS Three review authors independently classified studies and abstracted data from the included studies. The primary outcomes were overall survival and serious adverse events. Secondary outcomes were quality of life, cancer-specific survival, clinical progression, other adverse events, and biochemical progression. We used a random-effects model for meta-analyses and assessed the certainty of evidence for the main outcomes according to GRADE. MAIN RESULTS We included 11 studies with a follow-up of between three and 14 months. We also identified five ongoing trials. Primary outcomes Data to evaluate overall survival were not available. Degarelix may result in little to no difference in serious adverse events compared to standard androgen suppression therapy (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.62 to 1.05; low-certainty evidence; 2750 participants). Based on 114 serious adverse events in the standard androgen suppression group, this corresponds to 23 fewer serious adverse events per 1000 participants (43 fewer to 6 more). We downgraded the certainty of evidence for study limitations and imprecision. Secondary outcomes Degarelix likely results in little to no difference in quality of life assessed with a variety of validated questionnaires (standardized mean difference 0.06 higher, 95% CI 0.05 lower to 0.18 higher; moderate-certainty evidence; 2887 participants), with higher scores reflecting better quality of life. We downgraded the certainty of evidence for study limitations. Data to evaluate cancer-specific survival were not available. The effects of degarelix on cardiovascular events are very uncertain (RR 0.15, 95% CI 0.04 to 0.61; very low-certainty evidence; 80 participants). We downgraded the certainty of evidence for study limitations, imprecision, and indirectness as this trial was conducted in a unique group of high-risk participants with pre-existing cardiovascular morbidities. Degarelix likely results in an increase in injection site pain (RR 15.68, 95% CI 7.41 to 33.17; moderate-certainty evidence; 2670 participants). Based on 30 participants per 1000 with injection site pain with standard androgen suppression therapy, this corresponds to 440 more injection site pains per 1000 participants (192 more to 965 more). We downgraded the certainty of evidence for study limitations. We did not identify any relevant subgroup differences for different degarelix maintenance doses. AUTHORS' CONCLUSIONS We did not find trial evidence for overall survival or cancer-specific survival comparing degarelix to standard androgen suppression, but serious adverse events and quality of life may be similar between groups. The effects of degarelix on cardiovascular events are very uncertain as the only eligible study had limitations, was small with few events, and was conducted in a high-risk population. Degarelix likely results in an increase in injection site pain compared to standard androgen suppression therapy. Maximum follow-up of included studies was 14 months, which is short. There is a need for methodologically better designed and executed studies with long-term follow-up evaluating men with metastatic prostate cancer.
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Affiliation(s)
- Friedemann Zengerling
- Department of Urology and Paediatric Urology, University Hospital Ulm, Ulm, Germany
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
| | - Joachim J Jakob
- Department of Urology and Paediatric Urology, University Hospital Ulm, Ulm, Germany
| | | | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Anette Blümle
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christine Schmucker
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Frank Kunath
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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26
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Saad F, Shore ND. Relugolix: a novel androgen deprivation therapy for management of patients with advanced prostate cancer. Ther Adv Med Oncol 2021; 13:1758835921998586. [PMID: 34408793 PMCID: PMC8366106 DOI: 10.1177/1758835921998586] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/05/2021] [Indexed: 12/11/2022] Open
Abstract
Androgen deprivation therapy (ADT) is the foundation of treatment for patients with locally advanced, recurrent and metastatic prostate cancer, most commonly using luteinizing releasing hormone (LHRH) agonists. More recently, a new approach to ADT has emerged with the development of gonadotropin-releasing hormone (GnRH) antagonists, which aim to overcome some of the potential adverse physiologic effects of LHRH agonists. This article focuses on the newest GnRH antagonist, relugolix - a once-daily treatment and the only oral GnRH antagonist that has now been approved for the treatment of advanced prostate cancer. In phase II and III studies, relugolix achieved rapid and sustained castration without the testosterone surge associated with LHRH agonists, thus avoiding the potential clinical consequences of tumor flare and the necessity for concomitant anti-androgen therapy. Relugolix also achieved rapid testosterone recovery, which may potentially reduce ADT-related adverse events and offer opportunities for combination and intermittent therapy strategies. Cardiovascular safety is a particular concern in men with prostate cancer and ADT further increases cardiovascular risk: indeed, LHRH agonists are required to have a drug label warning about an increased risk of cardiovascular disease. Data from the phase III HERO study demonstrate an improved cardiac safety profile for the GnRH antagonist relugolix compared with the LHRH agonist leuprolide, including a significantly reduced risk for a major adverse cardiovascular event. Taken together, the data indicate that relugolix may mitigate some of the cardiovascular concerns surrounding ADT and has the potential to become a new standard of care for men with prostate cancer. In summary, relugolix represents a novel and recently available prostate cancer management strategy, incorporating the mechanistic advantages of GnRH antagonists and the potential benefits of oral administration.
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Affiliation(s)
- Fred Saad
- University of Montreal Hospital Centre, Pavillon R 900, Rue St-Denis, Montreal, Quebec H2X 0A9, Canada
| | - Neal D. Shore
- Carolina Urologic Research Center, Myrtle Beach, SC, USA
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Challa AA, Calaway AC, Cullen J, Garcia J, Desai N, Weintraub NL, Deswal A, Kutty S, Vallakati A, Addison D, Baliga R, Campbell CM, Guha A. Cardiovascular Toxicities of Androgen Deprivation Therapy. Curr Treat Options Oncol 2021; 22:47. [PMID: 33866442 PMCID: PMC8053026 DOI: 10.1007/s11864-021-00846-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 02/02/2023]
Abstract
OPINION STATEMENT Prostate cancer is the second leading cause of cancer death in men, and cardiovascular disease is the number one cause of death in patients with prostate cancer. Androgen deprivation therapy, the cornerstone of prostate cancer treatment, has been associated with adverse cardiovascular events. Emerging data supports decreased cardiovascular risk of gonadotropin releasing hormone (GnRH) antagonists compared to agonists. Ongoing clinical trials are assessing the relative safety of different modalities of androgen deprivation therapy. Racial disparities in cardiovascular outcomes in prostate cancer patients are starting to be explored. An intriguing inquiry connects androgen deprivation therapy with reduced risk of COVID-19 infection susceptibility and severity. Recognition of the cardiotoxicity of androgen deprivation therapy and aggressive risk factor modification are crucial for optimal patient care.
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Affiliation(s)
- Azariyas A. Challa
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Adam Christopher Calaway
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Jennifer Cullen
- Department of Population and Quantitative Health Sciences, Case Comprehensive Cancer Center, Cleveland, OH USA
| | - Jorge Garcia
- Division of Solid Tumor Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Nihar Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT USA ,Center for Outcomes Research and Evaluation, New Haven, CT USA
| | - Neal L. Weintraub
- Vascular Biology Center, Augusta University, August, GA USA ,Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA USA
| | - Anita Deswal
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Shelby Kutty
- The Helen B. Taussig Heart Center, The Johns Hopkins Hospital and Johns Hopkins University, Baltimore, MD USA
| | - Ajay Vallakati
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Ragavendra Baliga
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Courtney M. Campbell
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Avirup Guha
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA ,Harrington Heart and Vascular Institute, UH Cleveland Medical Center, Cleveland, OH USA
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Sciarra A, Busetto GM, Salciccia S, Del Giudice F, Maggi M, Crocetto F, Ferro M, De Berardinis E, Scarpa RM, Porpiglia F, Carmignani L, Damiano R, Artibani W, Carrieri G. Does Exist a Differential Impact of Degarelix Versus LHRH Agonists on Cardiovascular Safety? Evidences From Randomized and Real-World Studies. Front Endocrinol (Lausanne) 2021; 12:695170. [PMID: 34194398 PMCID: PMC8237856 DOI: 10.3389/fendo.2021.695170] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/24/2021] [Indexed: 11/16/2022] Open
Abstract
The main systemic therapy for the management of hormone-sensitive prostate cancer (PC) is androgen deprivation therapy (ADT), with the use of long-acting luteinizing hormone releasing-hormone (LHRH) agonists considered the main form of ADT used in clinical practice to obtain castration in PC. The concomitant administration of antiandrogens for the first weeks could reduce the incidence of clinical effects related to the testosterone flare-up in the first injection of LHRH. On the contrary, Gonadotropin Rh (GnRH) antagonists produce a rapid decrease of testosterone levels without the initial flare-up, with degarelix commonly used in clinical practice to induce castration in PC patients. Even if no long-term data are reported in terms of survival to define a superiority of GnRH or LHRH, for oncological efficacy and PC control, data from randomized clinical trials and from real-life experiences, suggest a difference in cardiovascular risk of patients starting ADT. The age-related decline in testosterone levels may represent a factor connected to the increase of cardiovascular disease risk, however, the role of ADT in increasing CV events remains controversial. For these reasons, the aim of the paper is to synthesize the difference in cardiovascular risk between LHRH and degarelix in patients undergoing ADT. A difference in cardiovascular risk could be indeed an important parameter in the evaluation of these two forms of castration therapy. The Randomized trials analyzed in this paper sustain a possible protective role for degarelix versus LHRH agonists in reducing the rate of new CV events and interventions in the short-term period. On the contrary, real-word data are contradictory in different national experiences and are strongly conditioned by huge differences between the LHRH agonists group and the degarelix group.
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Affiliation(s)
- Alessandro Sciarra
- Department of Urology, Sapienza Rome University Policlinico Umberto I, Rome, Italy
| | - Gian Maria Busetto
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti, Foggia, Italy
| | - Stefano Salciccia
- Department of Urology, Sapienza Rome University Policlinico Umberto I, Rome, Italy
| | | | - Martina Maggi
- Department of Urology, Sapienza Rome University Policlinico Umberto I, Rome, Italy
| | - Felice Crocetto
- Department of Neurosciences, Human Reproduction and Odontostomatology, University of Naples Federico II, Naples, Italy
- *Correspondence: Felice Crocetto,
| | - Matteo Ferro
- Department of Urology, IRCCS European Institute of Oncology (IEO), Milan, Italy
| | - Ettore De Berardinis
- Department of Urology, Sapienza Rome University Policlinico Umberto I, Rome, Italy
| | | | - Francesco Porpiglia
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Turin, Italy
| | - Luca Carmignani
- Department of Urology, San Donato Policlinic Hospital, Milan, Italy
| | - Rocco Damiano
- Department of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Walter Artibani
- Department of Urology, Abano Terme Policlinic, Abano Terme, Italy
| | - Giuseppe Carrieri
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti, Foggia, Italy
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Gonadotropin-Releasing Hormone Receptors in Prostate Cancer: Molecular Aspects and Biological Functions. Int J Mol Sci 2020; 21:ijms21249511. [PMID: 33327545 PMCID: PMC7765031 DOI: 10.3390/ijms21249511] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/02/2020] [Accepted: 12/09/2020] [Indexed: 02/07/2023] Open
Abstract
Pituitary Gonadotropin-Releasing Hormone receptors (GnRH-R) mediate the activity of the hypothalamic decapeptide GnRH, thus playing a key role in the regulation of the reproductive axis. Early-stage prostate cancer (PCa) is dependent on serum androgen levels, and androgen-deprivation therapy (ADT), based on GnRH agonists and antagonists, represents the standard therapeutic approach for PCa patients. Unfortunately, the tumor often progresses towards the more aggressive castration-resistant prostate cancer (CRPC) stage. GnRH receptors are also expressed in CRPC tissues, where their binding to both GnRH agonists and antagonists is associated with significant antiproliferative/proapoptotic, antimetastatic and antiangiogenic effects, mediated by the Gαi/cAMP signaling cascade. GnRH agonists and antagonists are now considered as an effective therapeutic strategy for CRPC patients with many clinical trials demonstrating that the combined use of these drugs with standard therapies (i.e., docetaxel, enzalutamide, abiraterone) significantly improves disease-free survival. In this context, GnRH-based bioconjugates (cytotoxic drugs covalently linked to a GnRH-based decapeptide) have been recently developed. The rationale of this treatment is that the GnRH peptide selectively binds to its receptors, delivering the cytotoxic drug to CRPC cells while sparing nontumor cells. Some of these compounds have already entered clinical trials.
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31
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Cardiovascular risk profiles of GnRH agonists and antagonists: real-world analysis from UK general practice. World J Urol 2020; 39:307-315. [PMID: 32979057 PMCID: PMC7910366 DOI: 10.1007/s00345-020-03433-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/30/2020] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Androgen deprivation therapy (ADT) is the mainstay for the management of metastatic prostate cancer. Available pharmaceutical ADTs include gonadotropin-releasing hormone (GnRH) agonists and antagonists. Here, real-world data are presented from the UK general practitioner Optimum Patient Care Research Database. The study investigated the hypothesis that GnRH antagonists have lower cardiac event rates than GnRH agonists. METHODS The incidence of cardiac events following initiation of GnRH antagonist or agonist therapy was investigated in a population-based cohort study conducted in UK primary care between 2010 and 2017. RESULTS Analysis of real-world data from the UK primary care setting showed that relative risk of experiencing cardiac events was significantly lower with degarelix, a GnRH antagonist, compared with GnRH agonists (risk ratio: 0.39 [95% confidence interval 0.191, 0.799]; p = 0.01). Patients that received degarelix as first-line treatment switched treatment more frequently (33.7%), often to a GnRH agonist, than those who initiated treatment with a GnRH agonist (6.7-18.6%). CONCLUSION Screening for known or underlying vascular disease and identifying those at high risk of a cardiac event is important for risk mitigation in patients with prostate cancer receiving hormone therapy. The GnRH antagonist degarelix conferred a significantly lower risk of cardiac events than GnRH agonists. Prior to treatment, patients should be stratified based on level of cardiovascular (CV) risk, and appropriate lifestyle, and pharmacological interventions to mitigate CV risk should be recommended. CV risk factors and patient response to the intervention should be monitored at regular intervals.
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