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Kulasegaran T, Oliveira N. Metastatic Castration-Resistant Prostate Cancer: Advances in Treatment and Symptom Management. Curr Treat Options Oncol 2024; 25:914-931. [PMID: 38913213 PMCID: PMC11236885 DOI: 10.1007/s11864-024-01215-2] [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] [Accepted: 05/06/2024] [Indexed: 06/25/2024]
Abstract
OPINION STATEMENT The management of metastatic castrate-resistant prostate cancer (mCRPC) has evolved in the past decade due to substantial advances in understanding the genomic landscape and biology underpinning this form of prostate cancer. The implementation of various therapeutic agents has improved overall survival but despite the promising advances in therapeutic options, mCRPC remains incurable. The focus of treatment should be not only to improve survival but also to preserve the patient's quality of life (QoL) and ameliorate cancer-related symptoms such as pain. The choice and sequence of therapy for mCRPC patients are complex and influenced by various factors, such as side effects, disease burden, treatment history, comorbidities, patient preference and, more recently, the presence of actionable genomic alterations or biomarkers. Docetaxel is the first-line treatment for chemo-naïve patients with good performance status and those who have yet to progress on docetaxel in the castration-sensitive setting. Novel androgen agents (NHAs), such as abiraterone and enzalutamide, are effective treatment options that are utilized as second-line options. These medications can be considered upfront in frail patients or patients who are NHA naïve. Current guidelines recommend genetic testing in mCRPC for mutations in DNA repair deficiency genes to inform treatment decisions, as for example in breast cancer gene mutation testing. Other potential biomarkers being investigated include phosphatase and tensin homologues and homologous recombination repair genes. Despite a growing number of studies incorporating biomarkers in their trial designs, to date, only olaparib in the PROFOUND study and lutetium-177 in the VISION trial have improved survival. This is an unmet need, and future trials should focus on biomarker-guided treatment strategies. The advent of novel noncytotoxic agents has enhanced targeted drug delivery and improved treatment responses with favourable toxicity profiling. Trials should continue to incorporate and report health-related QoL scores and functional assessments into their trial designs.
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Affiliation(s)
- Tivya Kulasegaran
- Mater Hospital Brisbane, Cancer Centre, Raymond Terrace, South Brisbane, QLD, 4104, Australia.
- School of Clinical Medicine, Mater Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia, Raymond Terrace, South Brisbane, QLD, 4101, Australia.
| | - Niara Oliveira
- Mater Hospital Brisbane, Cancer Centre, Raymond Terrace, South Brisbane, QLD, 4104, Australia
- School of Clinical Medicine, Mater Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia, Raymond Terrace, South Brisbane, QLD, 4101, Australia
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De Lazzari G, Opattova A, Arena S. Novel frontiers in urogenital cancers: from molecular bases to preclinical models to tailor personalized treatments in ovarian and prostate cancer patients. J Exp Clin Cancer Res 2024; 43:146. [PMID: 38750579 PMCID: PMC11094891 DOI: 10.1186/s13046-024-03065-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024] Open
Abstract
Over the last few decades, the incidence of urogenital cancers has exhibited diverse trends influenced by screening programs and geographical variations. Among women, there has been a consistent or even increased occurrence of endometrial and ovarian cancers; conversely, prostate cancer remains one of the most diagnosed malignancies, with a rise in reported cases, partly due to enhanced and improved screening efforts.Simultaneously, the landscape of cancer therapeutics has undergone a remarkable evolution, encompassing the introduction of targeted therapies and significant advancements in traditional chemotherapy. Modern targeted treatments aim to selectively address the molecular aberrations driving cancer, minimizing adverse effects on normal cells. However, traditional chemotherapy retains its crucial role, offering a broad-spectrum approach that, despite its wider range of side effects, remains indispensable in the treatment of various cancers, often working synergistically with targeted therapies to enhance overall efficacy.For urogenital cancers, especially ovarian and prostate cancers, DNA damage response inhibitors, such as PARP inhibitors, have emerged as promising therapeutic avenues. In BRCA-mutated ovarian cancer, PARP inhibitors like olaparib and niraparib have demonstrated efficacy, leading to their approval for specific indications. Similarly, patients with DNA damage response mutations have shown sensitivity to these agents in prostate cancer, heralding a new frontier in disease management. Furthermore, the progression of ovarian and prostate cancer is intricately linked to hormonal regulation. Ovarian cancer development has also been associated with prolonged exposure to estrogen, while testosterone and its metabolite dihydrotestosterone, can fuel the growth of prostate cancer cells. Thus, understanding the interplay between hormones, DNA damage and repair mechanisms can hold promise for exploring novel targeted therapies for ovarian and prostate tumors.In addition, it is of primary importance the use of preclinical models that mirror as close as possible the biological and genetic features of patients' tumors in order to effectively translate novel therapeutic findings "from the bench to the bedside".In summary, the complex landscape of urogenital cancers underscores the need for innovative approaches. Targeted therapy tailored to DNA repair mechanisms and hormone regulation might offer promising avenues for improving the management and outcomes for patients affected by ovarian and prostate cancers.
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Affiliation(s)
- Giada De Lazzari
- Candiolo Cancer Institute, FPO - IRCCS, Laboratory of Translational Cancer Genetics, Strada Provinciale 142, Km 3.95, Candiolo, TO, ZIP 10060, Italy
| | - Alena Opattova
- Candiolo Cancer Institute, FPO - IRCCS, Laboratory of Translational Cancer Genetics, Strada Provinciale 142, Km 3.95, Candiolo, TO, ZIP 10060, Italy
| | - Sabrina Arena
- Candiolo Cancer Institute, FPO - IRCCS, Laboratory of Translational Cancer Genetics, Strada Provinciale 142, Km 3.95, Candiolo, TO, ZIP 10060, Italy.
- Department of Oncology, University of Torino, Strada Provinciale 142, Km 3.95, Candiolo, TO, ZIP 10060, Italy.
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Tsai AK, Kagalwalla S, Langer J, Le-Kumar T, Le-Kumar V, Antonarakis ES. Pembrolizumab for metastatic castration-resistant prostate cancer: trials and tribulations. Expert Opin Biol Ther 2024; 24:51-62. [PMID: 38284349 DOI: 10.1080/14712598.2024.2311750] [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: 12/04/2023] [Accepted: 01/25/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Immunotherapies have revolutionized the management of various malignancies but have only recently been evaluated systematically in prostate cancer. Pembrolizumab, a programmed-death 1 (PD-1) blocking antibody, has been utilized in a small subset of prostate cancer patients with mismatch repair deficiency/microsatellite instability, but has now been assessed in broader populations of metastatic prostate cancer patients. AREAS COVERED The results of four pembrolizumab-based phase III clinical trials for metastatic castration-resistant prostate cancer (mCRPC) and metastatic hormone-sensitive prostate cancer (mHSPC) patients, including KEYNOTE-641, KEYNOTE-921, KEYNOTE-991, and KEYLYNK-010 are summarized. Programmed death-ligand 1 (PD-L1) expression, the efficacy of pembrolizumab in prostate cancer patients with certain molecular defects, and emerging pembrolizumab-based therapeutic combinations are also reviewed. EXPERT OPINION Pembrolizumab has not benefitted unselected metastatic prostate cancer patients when combined with chemotherapy, next-generation hormonal agents (NHA), or poly(ADP-ribose) polymerase inhibitors (PARPi). PD-L1 positivity does not predict the response to pembrolizumab in this disease. A small number of responding patients can likely be explained by rare genetic and molecular defects, and more innovative combination strategies are needed to improve outcomes in prostate cancer patients who are not sensitive to pembrolizumab. Emphasis should be placed on developing additional or alternative immuno-oncology approaches beyond classical immune checkpoint inhibition.
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Affiliation(s)
- Alexander K Tsai
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Masonic Cancer Center, Minneapolis, MN, USA
- Department of Microbiology & Immunology, University of Minnesota, Minneapolis, MN, USA
| | - Sana Kagalwalla
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Masonic Cancer Center, Minneapolis, MN, USA
| | - Jenna Langer
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Masonic Cancer Center, Minneapolis, MN, USA
| | - Thuy Le-Kumar
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Masonic Cancer Center, Minneapolis, MN, USA
| | - Vikas Le-Kumar
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Masonic Cancer Center, Minneapolis, MN, USA
| | - Emmanuel S Antonarakis
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Masonic Cancer Center, Minneapolis, MN, USA
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Meagher MF, Salmasi A, Stewart TF. Treatment Landscape for Metastatic Castrate-Sensitive Prostate Cancer: A Review. Res Rep Urol 2023; 15:509-517. [PMID: 38025805 PMCID: PMC10655601 DOI: 10.2147/rru.s398129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023] Open
Abstract
With the advent of new therapeutic modalities, management of metastatic castrate-sensitive prostate cancer (mCSPC) has been in flux. From androgen-deprivation therapy to docetaxel to androgen receptor-signaling inhibitors, each agent has heralded a new treatment paradigm. As such, the optimal first-line therapy for mCSPC remains incompletely defined. This review provides a narrative of recent advances to systemic therapy within the mCSPC treatment space, particularly with regard to expansion to triplet therapy.
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Affiliation(s)
- Margaret F Meagher
- Department of Urology, University of California San Diego, La Jolla, CA, USA
| | - Amirali Salmasi
- Department of Urology, University of California San Diego, La Jolla, CA, USA
| | - Tyler F Stewart
- Division of Hematology-Oncology and BMT, University of California San Diego, La Jolla, CA, USA
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Piombino C, Oltrecolli M, Tonni E, Pirola M, Matranga R, Baldessari C, Pipitone S, Dominici M, Sabbatini R, Vitale MG. De Novo Metastatic Prostate Cancer: Are We Moving toward a Personalized Treatment? Cancers (Basel) 2023; 15:4945. [PMID: 37894312 PMCID: PMC10605467 DOI: 10.3390/cancers15204945] [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: 09/07/2023] [Revised: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
De novo metastatic hormone-sensitive PC (mHSPC) accounts for 5-10% of all prostate cancer (PC) diagnoses but it is responsible for nearly 50% of PC-related deaths. Since 2015, the prognosis of mHSPC has slightly improved thanks to the introduction of new hormonal agents and chemotherapy combined with androgen deprivation therapy from the first-line setting. This review describes the current therapeutic opportunities for de novo mHSPC, focusing on potential molecular biomarkers identified in the main clinical trials that have modified the standard of care, the genomic features of de novo mHSPC, and the principal ongoing trials that are investigating new therapeutic approaches and the efficacy of a biomarker-guided treatment in this setting. The road toward personalized treatment for de novo mHSPC is still long, considering that the randomized clinical trials, which have furnished the basis of the current therapeutic options, stratified patients according to clinical criteria that did not necessarily reflect the biological rationale of the chosen therapy. The role of transcriptomic profiling of mHSPC as a predictive biomarker requires further validation, and it remains to be ascertained how the genomic variants detected in mHSPC, which are regarded as predictive in the castration-resistant disease, can be exploited in the mHSPC setting.
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Affiliation(s)
- Claudia Piombino
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
| | - Marco Oltrecolli
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
| | - Elena Tonni
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
| | - Marta Pirola
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
| | - Rossana Matranga
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
| | - Cinza Baldessari
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
| | - Stefania Pipitone
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
| | - Massimo Dominici
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
- Laboratory of Cellular Therapy, Division of Oncology, Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Roberto Sabbatini
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
| | - Maria Giuseppa Vitale
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
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Grypari IM, Tzelepi V, Gyftopoulos K. DNA Damage Repair Pathways in Prostate Cancer: A Narrative Review of Molecular Mechanisms, Emerging Biomarkers and Therapeutic Targets in Precision Oncology. Int J Mol Sci 2023; 24:11418. [PMID: 37511177 PMCID: PMC10380086 DOI: 10.3390/ijms241411418] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/09/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Prostate cancer (PCa) has a distinct molecular signature, including characteristic chromosomal translocations, gene deletions and defective DNA damage repair mechanisms. One crucial pathway involved is homologous recombination deficiency (HRD) and it is found in almost 20% of metastatic castrate-resistant PCa (mCRPC). Inherited/germline mutations are associated with a hereditary predisposition to early PCa development and aggressive behavior. BRCA2, ATM and CHECK2 are the most frequently HRD-mutated genes. BRCA2-mutated tumors have unfavorable clinical and pathological characteristics, such as intraductal carcinoma. PARP inhibitors, due to the induction of synthetic lethality, have been therapeutically approved for mCRPC with HRD alterations. Mutations are detected in metastatic tissue, while a liquid biopsy is utilized during follow-up, recognizing acquired resistance mechanisms. The mismatch repair (MMR) pathway is another DNA repair mechanism implicated in carcinogenesis, although only 5% of metastatic PCa is affected. It is associated with aggressive disease. PD-1 inhibitors have been used in MMR-deficient tumors; thus, the MMR status should be tested in all metastatic PCa cases. A surrogate marker of defective DNA repair mechanisms is the tumor mutational burden. PDL-1 expression and intratumoral lymphocytes have ambivalent predictive value. Few experimental molecules have been so far proposed as potential biomarkers. Future research may further elucidate the role of DNA damage pathways in PCa, revealing new therapeutic targets and predictive biomarkers.
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Affiliation(s)
- Ioanna-Maria Grypari
- Cytology Department, Aretaieion University Hospital, National Kapodistrian University of Athens, 11528 Athens, Greece
| | - Vasiliki Tzelepi
- Department of Pathology, School of Medicine, University of Patras, 26504 Patras, Greece
| | - Kostis Gyftopoulos
- Department of Anatomy, School of Medicine, University of Patras, 26504 Patras, Greece
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