Multi-Institutional Analysis of Metastasis Directed Therapy with or without Androgen Deprivation Therapy in Oligometastatic Castration Sensitive Prostate Cancer

PURPOSE/OBJECTIVE(S)

Several prospective trials in oligometastatic castration sensitive prostate cancer (omCSPC) have shown metastasis-directed therapy (MDT) can delay time to progression and initiation of androgen deprivation therapy (ADT) compared to observation. However, the optimal integration of ADT with MDT remains unclear. Here we report a multi-national, multi-institutional retrospective cohort of omCSPC treated with MDT to characterize the long-term outcomes of patients treated with MDT alone or in combination with ADT.

MATERIALS/METHODS

Patients with a controlled primary site and omCSPC (defined as ≤ 5 lesions on conventional imaging) treated with MDT with or without concurrent ADT and with at least 36 months follow-up were retrospectively screened across 13 institutions. The primary endpoints included biochemical progression free survival (bPFS) and radiographic progression free survival (rPFS) calculated using Kaplan-Meier method and stratified by treatment group (MDT alone vs MDT + ADT). Multivariable Cox regression was performed adjusted for variables found to be prognostic on univariate analysis.

RESULTS

Among 414 patients screened, a total of 263 patients treated between 2003 and 2018 met inclusion criteria and included. Of these, 105 received MDT alone and 158 received MDT+ADT, with median follow-up of 49.5 and 54.5 months, respectively. The majority were metachronous (90%) and had bone lesions (60%). Median ADT duration was 21.3 months (IQR 12.0- 31.9). Patients who received ADT vs. no ADT had poorer prognostic features including 23% vs. 1% synchronous (p<0.001), and 55% vs 40% Gleason 8-10 (p = 0.012). ADT use was associated with a better 5-year bPFS 24% vs 11% (p<0.0001) and rPFS 41% vs 29% (p<0.001). On multivariable Cox regression adjusting for post-MDT PSA nadir and salvage therapy, ADT use maintained significance for both bPFS (HR 0.51 (0.36, 0.71), p<0.001) and rPFS (HR 0.67, 95% CI 0.46-0.96, p = 0.03).

CONCLUSION

Long-term outcomes with MDT alone suggest a small proportion of patients experience sustained disease control. The addition of ADT appears to improve rPFS, however prospective studies are needed in order to allow for personalization of care in patients with omCSPC.

Role of induced negative and positive emotions in sensitivity to itch and pain in women

BACKGROUND

Itch and pain are common symptoms in skin disease. It has been suggested that negative emotions may play a role in itch and pain. To date, however, the role of emotions has only been studied for pain in experimental studies, not yet for itch.

OBJECTIVES

To investigate the effects of negative and positive emotions on the sensitivity to itch and pain.

METHODS

Film fragments were used to induce a negative or positive emotional state in healthy women. Itch and pain were induced using the following somatosensory stimuli: electrical stimulation, histamine iontophoresis and the cold pressor test.

RESULTS

Results showed that the scores for itch and pain evoked by histamine and the cold pressor test, respectively, were significantly higher in the negative than in the positive emotion condition, whereas tolerance thresholds to electrical stimulation and the cold pressor test, and stimulus unpleasantness scores did not differ between the two conditions.

CONCLUSIONS

These findings for the first time indicate in an experimental design that emotions play a role in sensitivity to somatosensory sensations of both itch and pain.

Selective attention for hyperventilatory sensations in panic disorder

According to cognitive theories, panic patients are assumed to display selective attention for feared bodily sensations. To date there has only been indirect evidence for this based on performance on reaction time tasks such as the modified Stroop task and the dot probe detection task. In the present study a more direct attempt was made to investigate whether panic patients show selective attention for feared sensations, in particular hyperventilatory sensations. A group of patients with panic disorder and a group of normal controls were compared on their performance on a reaction time task in which tones of different length had to be discriminated. During the task subjects were asked either to hyperventilate, to overbreathe under isocapnic conditions, or to make a neutral movement. No evidence for selective attention for hyperventilatory sensations was found. The article also discusses whether lack of finding interference during hyperventilation might be due to methodological issues.

Selective attention for cardiac information in panic patients

With various reaction time paradigms, panic patients have been shown to have selective attention for threatening sensations. However, almost all of these paradigms use words describing sensations and not the threatening sensations themselves. To increase the ecological validity, in the current study selective attention for heartbeat information was measured with a paradigm derived from the dot probe detection task but using 'real' heartbeat information instead of words. The results indeed showed selective attention for ECG information in panic patients. However, an accelerated ECG did not attract the attention of panic patients more than a slower ECG. Against expectation, both panic patients and normal controls shifted their attention away from an accelerated ECG. Possible explanations are explored.

No superior perception of hyperventilatory sensations in panic disorder

It has been argued that panic disorder patients may be more skilled at detecting changes in actual physiology than others. The present study investigated if panic patients are better than controls in perceiving sensations produced by light hyperventilation. Twelve panic patients and 28 control subjects underwent a procedure in which they were exposed 12 times to 1 min of light hyperventilation or 1 min of 'placebo' hyperventilation (isocapnia). Differences in sensations reported during real hyperventilation were compared to sensations reported during 'placebo' hyperventilation. Results demonstrated an absence of superior perception of hyperventilatory sensations in panic patients.

Symptom reporting and interoceptive attention in panic patients

The present study investigated whether bodily sensations reported by panic-disorder patients can be due to interoceptive attention. The attention of two groups, one of 16 panic patients and one of 17 normal control subjects was manipulated towards and away from bodily sensations. After each manipulation they had to report the sensations experienced. As expected, panic patients did report more sensations than controls in a baseline condition but against the hypothesis that a ceiling effect would occur in the panic group, both panic patients and controls reported more sensations after being instructed to attend to them. However, when their attention was diverted, panic patients showed a decrease in sensations greater than control subjects showed. The findings suggest that interoceptive attention may partly account for the sensations reported by panic patients.

Hypochondriasis and symptom reporting--the effect of attention versus distraction

BACKGROUND

This study examined symptom perception in hypochondriacal patients without physical stimulation.

METHODS

Seventeen outpatients with DSM-III-R hypochondriasis and 16 healthy control subjects were compared. All subjects were asked to report perceived sensations in three conditions: attention, distraction and control.

RESULTS

It was found that hypochondriacal subjects showed remarkably higher levels of symptom reporting than healthy subjects in all three conditions. In spite of excessive attention to bodily sensations in a control condition, attention instructions still added significantly to symptom reporting in hypochondriacal patients. The effect of distraction was not significant in either of the groups. Furthermore, group differences in symptom reporting appeared to be related to preoccupation with bodily symptoms rather than to general anxiety level as measured by the STAI.

CONCLUSIONS

Hypochondriacal patients report more bodily sensations than healthy controls when no instructions are given. In addition, focussing on bodily sensations seems to cause a significant overall increase of perceived symptoms in hypochondriacal patients, whereas in healthy subjects there is a trend towards an increase in symptom reporting.

An untenable rationale for treating insomnia

In 1995 Cholitz tested a breathing technique to treat insomniacs. The results were incomparably much better than typically reported. It is argued that Cholitz' explanation of his findings is untenable and that independent replications are needed.