Saturday, February 2, 2019

#ProstateCancerNews for February, 2019

Contents


Next IPCSG Meeting Speaker

February 16, 2019       Member Panel 

Last IPCSG Meeting Summary

JANUARY 19, 2019         Radiation Therapy and Prostate Cancer – 2019 Update & Perspectives

Summary by Bill Lewis
Dr. Arno J. Mundt, Professor & Chair of the Dept. of Radiation Oncology, and Sr. Deputy Director, Moores Cancer Center at the University of California San Diego.
There is a long history of the use of radiation therapy for prostate cancer, both as a definitive treatment (without surgery) and as an adjuvant treatment following surgery.  Two main types of radiation are used:  External beam radiation therapy (EBRT) using photons (X-rays) or protons (particles), normally delivered over several weeks; and Brachytherapy.  The latter is internal radiation therapy, in which radioactive pellets are introduced into the prostate, either permanently (low dose rate) or temporarily (high dose rate).  Deciding which approach to use depends on multiple factors, of which the most important is the risk group the patient is in.  The risk group may be low, medium or high and depends on the PSA enzyme blood level (whether <10 moderate="" or="">20), the Gleason score (6, 7, or ≥ 8), and the “T Stage” (originally based on rectal exam results as to whether nodules are present, and now also whether the seminal vesicles are involved, or whether other organs have been invaded).  The intermediate risk group is subdivided into “favorable” and “unfavorable” groups, mainly depending on how much higher-Gleason-grade disease is present.
Low risk disease is now usually monitored with “Active Surveillance,” with close attention to the PSA levels, rectal exams and symptoms.  PSA tests are usually performed every three months, with a repeat biopsy every 1-2 years.  These patients used to be commonly treated with Brachytherapy, but not often any more.  No treatment is given until test results change significantly, or MRI shows definite growth within the prostate. 
Favorable intermediate risk disease is not usually given Active Surveillance, but is treated with surgery or radiation, as discussed below.  The “good news” is that ADT (hormone suppression with Lupron or the like, with many side effects commonly experienced) is usually not considered to be needed.
Which treatment is best?  Both surgery and radiation have improved tremendously over the past 30 years.  Both have equal cure rates, but toxicity risks (side effects) are very different.  No one treatment is best.  One treatment may be good for one patient and bad for another.  It’s a very personal decision – it’s your body.  Be open-minded and become involved in the decision.  Don’t make snap decisions based on incomplete information or emotion.
Photons vs. Protons:  Intensity Modulated Radiation Therapy (IMRT) uses sophisticated computers to “shrink wrap” the X-ray dose around the prostate, reducing the dose to normal tissue and thus the risk of toxicity.  Protons, unlike X-rays, stop at a predetermined point in the body, so are even better at sparing surrounding tissue, and can deliver very focused treatment.  UCSD is affiliated with the California Proton Center. (Refer to our DVD 2018 09 Dr. Rossi available to purchase for more proton information)
External beam vs. Brachytherapy:  Both are equally effective.  There is a different time commitment for the patient:  EBRT requires 4-5 weeks (though this is getting shortened).  Brachytherapy requires 1-4 treatments, depending on the dose rate.  EBRT has less bladder toxicity, but can have more rectal bleeding.  Brachytherapy may have less sexual dysfunction.
Unfavorable intermediate risk disease is usually treated EBRT with or without Brachytherapy, along with 6 months of ADT.  Clinical trials suggest that adding a Brachytherapy “boost” leads to better outcomes, and allows a shorter course of EBRT.  This is becoming common at UCSD.  Surgery is considered less desirable, given the high likelihood of needing radiation therapy following surgery.
High risk disease (PSA >20, Gleason 8 or more, and T3 or T4 stage) may be treated with EBRT (X-ray or protons) + Brachytherapy (as above, increasingly common) + 18 months of ADT.  Brachytherapy is not likely to be used if the patient already has poor urinary function, has had a prior TURP (reaming out of the urethra), a large prostate, or disease spread beyond the prostate.  Dr. Mundt does not recommend surgery for high risk patients, because they will almost certainly need radiation as well, and then would have the negative side effects of both procedures.
Postoperative radiation therapy is commonly, but not always, needed following prostatectomy (i.e., surgery to remove the prostate).  The radiation (either protons or X-rays) can be given soon after surgery, or can be delayed until the PSA rises.  Prompt administration of radiation is called for in men who have regained urinary continence (i.e., have healed from the surgery) and who have positive margins (tumor left behind by the surgery), seminal vesicle invasion, or disease found outside the prostate.  If the PSA rises from zero after surgery, radiation should be considered.  It is most effective if the disease is only in the prostate “bed,” which may include margins and seminal vesicles.  Imaging studies can be critical in determining where the disease is, so that the radiation can be effectively targeted.  Brachytherapy is not used after surgery.  If the PSA is greater than 0.2, 6 months of ADT is usually added.
Another traditional use of radiation therapy is in preventing or reducing painful gynecomastia (breast growth) in men on prolonged ADT.  It only requires 3 treatments to each breast.  It’s not routinely used, but may be requested.
A new indication for radiation therapy is for oligo-metastatic disease.  It is traditionally used in patients with painful metastases, such as in the bones or spine, and is very helpful to avoid the need for narcotics.  It also can help prevent fractures, which could require surgery and prolonged bed rest (which is actually very unhealthy in old patients!). 
If there are only a few metastases, instead of being considered incurable and only being treated with ADT, now it is considered appropriate to treat such patients for cure with a combination of ADT and/or chemotherapy plus very focused radiation therapy.  The advent of new imaging techniques such as C-11 and Axumin has made possible the numbering and localization of these oligo-metastases.  It often takes only 1 – 5 radiation sessions to “zap” the spot or spots, which means a very low risk of side effects.
Two recently-published clinical trials (SABR-COMET trial in Europe/Canada and STOMP trial in Europe) strongly support the use of SBRT (stereotactic body radiation therapy, which is super-focused radiation) in patients with oligo-metastatic disease.  In the SABR-COMET trial, remission time and lifespan after treatment were both doubled.  In the STOMP trial, the need for ADT was delayed almost two years, with no significant side effects.  At UCSD, this approach for oligo-metastatic disease is now standard.
New Imaging Research – presentation by Tyler Seibert, MD, PhD, of the UCSD faculty.
Standard imaging (bone, CT) scans miss some tumors and have false positives or ambiguous results.  Newer PET/CT scans such as C-11 or PSMA are much better, but are not widely available, are usually not reimbursed by insurance, and the PSMA scans are not yet FDA approved.
MRI may become an attractive option.  It is available at every modern hospital in the U.S.  It is very good at detecting cancer in the prostate, and studies in the U.S. and Europe have shown promise for metastases too. Scientists at UCSD have developed an advanced MRI technique called Restriction Spectrum Imaging (RSI) that is now the clinical standard at UCSD for targeting biopsies, and for looking for cancer spread outside the prostate.
An ongoing clinical trial at UCSD is studying the use of whole-body RSI for a) Men with metastatic prostate cancer and b) Men at high risk of metastases (newly diagnosed with high- or very-high-risk prostate cancer, newly diagnosed with disease in lymph nodes, or men with a rising PSA after treatment by radiation or surgery).  There is no cost to the patient or to his insurance company!
The imaging takes about an hour, and includes standard MRI and RSI from head to knees.  Results will be compared to other imaging the patient gets.  At least one such scan needs to be within 3 months of the MRI-RSI scan.  The study will also look at treatment response after radiation, ADT, chemotherapy or other treatment (Keytruda, Xofigo, etc.). 
Whole-body MRI-RSI could become a widely available way to look at bone metastases.  Currently, there is not very good imaging for evaluating bone lesions for response to therapy.  MRI-RSI could be used for precision radiation therapy (SBRT / Cyberknife), could make it easier for doctors to decide if their treatment is working or not, and would facilitate clinical trials of new therapies for metastatic disease.  Note that there is no ionizing radiation with MRI, and no IV contrast is needed.
Questions: 
If the PSA is rising after surgery, how high does it need to be, to qualify for the whole-body MRI-RSI study?  No lower limit.
Any hope for patients with a pacemaker to have an MRI scan?  Yes, but “down the road.”
Can patients who are Kaiser Permanente clients join the trial?  Yes, since there is no cost to them (or to the patient), but they do need to approve your going to UCSD.
How long will the trial last?  At least another 1 – 2 years.
How does the MRI-RSI compare with PSMA scanning?  Both show similar results.  The study is intended to give a more detailed answer as to “which is better when.”
Can a PET / CT scan (such as a C-11 acetate scan at the Mayo Clinic) be used for radiation treatment planning?  Yes.
Whole body MRI scans were offered a year ago at UCSD as part of a research study, but the results weren’t available to the patient.  Has this changed?  Yes, somewhat, and working through Dr. Mundt or Dr. Seibert would help.
After Cyberknife treatment for a rising PSA, the PSA has been at zero.  What to do?  Be happy, until the PSA rises. It’s not a guarantee that no cancer is growing, but it’s a very good indication.
Can prostate cancer affect markers for other cancers?  Not likely, especially if the PSA is not rising.  Look for another explanation.
How do UCSD radiologists and Kaiser interact?  Good working relationship for 9 years already.  UCSD can make recommendations, and a Kaiser group in L.A. decides which treatment to approve.  Contact any of the UCSD radiologists for an appointment, or go through your Kaiser doctor – they all know each other.

The video of this presentation, including the PowerPoint slides, will be available via the website shortly before the next meeting, or at that meeting, which will be held on February 16th, 2019.

Anyone interested in the RSI trial discussed by Dr. Seibert during our Jan. 19th meeting may contact:
Katie O’Neil, Clinical Research Manager
UC San Diego Health, 1200 Garden View Suite 200, Encinitas, CA 92024-0871
Office: (760) 479-5376  Fax: (858) 246-0501  croneil@ucsd.edu


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Gene Responsible for Spread of Prostate Cancer Identified

Fri, 01/18/2019 - 4:30pm
by Rutgers University
A Rutgers study has found that a specific gene in cancerous prostate tumors indicates when patients are at high-risk for the cancer to spread, suggesting that targeting this gene can help patients live longer.
The study, which was published in the journal Nature Communications, identified the NSD2 gene through a computer algorithm developed to determine which cancer genes that spread in a mouse model were most relevant to humans. The researchers were able to turn off the gene in the mice tumor cells, which significantly decreased the cancer's spread.
Deeper Insights
Exploring DNA Damage/Genotoxicity Using a 7-Plex DNA Damage/Genotoxicity Kit
"Currently, when a patient is diagnosed with prostate cancer, physicians can determine how advanced a tumor is but not whether the patients' cancer will spread," said lead author Antonina Mitrofanova, an assistant professor at Rutgers School of Health Professions and a research member of Rutgers Cancer Institute of New Jersey. "If we can determine whether a patient's cancer is likely to spread at the time of diagnosis, we can start them on a targeted treatment plan as soon as possible to decrease the likelihood of their cancer spreading."
Mitrofanova and collaborators are researching a potential drug to target NSD2, but she encourages doctors to begin incorporating NSD2 screening so they can start high-risk patients on anti-metastatic treatment as soon as possible.
While the algorithm used in the study focused on prostate cancer, Mitrofanova said it can be applied more broadly to study other cancers to better understand what findings can be translated to people.
According to the American Cancer Society, prostate cancer is the second most common cancer in American men and the second leading cause of cancer deaths.
Cancer Research

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Back to basics: two useful articles to pass along

Posted on December 27, 2018
The Prostate Cancer Foundation posted two useful and basic articles on its blog site this December that may be useful resources for men concerned about their risk for or newly diagnosed with prostate cancer or monitoring their PSA over time (for any one of all sorts of possible reasons).
The first, “Make sure your PSA is as accurate as possible” by Janet Farrar Worthington discusses the importance of understanding that PSA levels can vary over time for all sorts of possible reasons. It is therefore rarely a good idea to make critical decisions on the basis of a single PSA test.
Indeed, Prostate Cancer International and The “New” Prostate Cancer InfoLink advises men who need to get their PSA levels checked on a regular basis to get all their tests done (if possible) at the same laboratory, using the same type of PSA test, and to have blood drawn for those PSA tests at the same time of day (probably best first thing in the morning on an empty stomach, which is what is requested when one has blood drawn for things like cholesterol levels too).
The second, derived from interviews with a whole bunch of prostate cancer survivors is headed “Prostate cancer survivors: what advice would you give the newly diagnosed?” by Tim Barley, and is full of good, straightforward guidance and advice, with the basic messages being “Don’t freak out” and “Do your homework”.
This correlates well with the core article on this web site entitled, “For newly diagnosed patients …” with its four-step set of suggestions
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Radical Prostatectomy or Watchful Waiting in Prostate Cancer — 29-Year Follow-up | NEJM:

Original Article from The New England Journal of Medicine —
Abstract
Background
Radical prostatectomy reduces mortality among men with clinically detected localized prostate cancer, but evidence from randomized trials with long-term follow-up is sparse.
Methods
We randomly assigned 695 men with localized prostate cancer to watchful waiting or radical prostatectomy from October 1989 through February 1999 and collected follow-up data through 2017. Cumulative incidence and relative risks with 95% confidence intervals for death from any cause, death from prostate cancer, and metastasis were estimated in intention-to-treat and per-protocol analyses, and numbers of years of life gained were estimated. We evaluated the prognostic value of histopathological measures with a Cox proportional-hazards model.
Results
By December 31, 2017, a total of 261 of the 347 men in the radical-prostatectomy group and 292 of the 348 men in the watchful-waiting group had died; 71 deaths in the radical-prostatectomy group and 110 in the watchful-waiting group were due to prostate cancer (relative risk, 0.55; 95% confidence interval [CI], 0.41 to 0.74; P<0 .001="" 10="" 11.7="" 18.2="" 2.9="" 23="" 2="" 5.2="" 5="" 6="" 7="" 8.4.="" 95="" a="" absolute="" aggressive="" among="" and="" any="" as="" associated="" at="" avert="" cancer="" cause="" ci="" death="" difference="" extension="" extra="" extracapsular="" from="" gained="" gleason="" high="" higher="" in="" indicating="" life="" lower="" mean="" men="" more="" needed="" number="" of="" one="" or="" percentage="" points="" prostate="" prostatectomy.="" prostatectomy="" radical="" range="" risk="" score="" scores="" span="" than="" that="" the="" times="" to="" treat="" underwent="" was="" were="" who="" with="" without="" years="">
Conclusions
Men with clinically detected, localized prostate cancer and a long life expectancy benefited from radical prostatectomy, with a mean of 2.9 years of life gained. A high Gleason score and the presence of extracapsular extension in the radical prostatectomy specimens were highly predictive of death from prostate cancer. (Funded by the Swedish Cancer Society and others.)
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News digest – a cancer breath test, tumour VR, lab culture and 2019 predictions

Category: Science blog January 5, 2019 Gabriella Beer0 comments
A cancer breath test trial launches
The launch of a trial we’re supporting for a potential cancer breath test in people was widely reported. The device uses Breath Biopsy® technology that analyses the presence and quantity of chemicals in breath. Researchers based at a hospital in Cambridge hope to find out if the tech can spot signs of cancer in people’s breath to detect a range of cancers earlier. Read our blog post and press release for the details.

Cancer in virtual reality
The BBC visited our scientists in Cambridge to step inside their immersive 3D models of cancer. The team is developing a new way to look at tumours using virtual reality.
Advanced liver cancer patients to receive life-extending treatment on the NHS
The National Institute for Health and Care excellence (NICE) has said that people with a type of advanced liver cancer should have access to a targeted cancer drug on the NHS. Read PharmaTimes for more.
Further calls to ban nitrates in processed meat
The Evening Standard reports calls from health experts and politicians for nitrates found in processed meats, like bacon, to be banned. Meat that has been processed by adding nitrates, or other ingredients like salt, can increase the risk of developing bowel cancer.
Mixing a new lab cocktail
The Atlantic investigates research showing the liquid used to keep cells alive in the lab, commonly known as cell culture media, may be skewing results. As a result, research groups around the world are now mixing their own culture media cocktails that better mimic conditions inside the body.
Trial to reduce side effects of prostate cancer surgery launches
The Evening Standard reports that a new prostate cancer surgery technique is undergoing trials in hospitals in London. The procedure aims to preserve nerves around the prostate gland when it’s removed to stop a patient developing erectile dysfunction, a side effect that can occur after conventional surgery.
And finally
To mark the New Year, the BBC looked back at the medical discoveries from 2018 that could impact our lives in the future and reviewed the pressures the NHS is facing in the year ahead. We also asked some of our experts for their 2019 research ambitions, which you can read in this post.
Gabi
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www.medscape.com

Finasteride Clears Its Name New Data on Prostate Cancer in NEJM

Nick Mulcahy
January 23, 2019
Long-standing concerns about the consequences of finasteride increasing the risk of high-grade prostate cancer "have not been borne out," report investigators from the landmark Prostate Cancer Prevention Trial (PCPT).
This trial previously indicated that finasteride, a 5-alpha-reductase inhibitor commonly used for benign prostatic hyperplasia and male pattern baldness, is an effective chemopreventive agent for prostate cancer.
However, the drug has never been fully accepted for this use, mainly because earlier results from the trial showed an increased risk of high-grade prostate cancer. 
Now, longer-term results from this trial (median follow-up of 18.6 years) show that there has been no increase in prostate cancer-related deaths with the drug, the researchers point out in correspondence published online today in The New England Journal of Medicine.
Such an increase would be expected if finasteride truly caused more high-grade cancers.
"Finasteride is safe, inexpensive, and effective as a preventive strategy for prostate cancer," summarized Ian Thompson Jr, MD, principal investigator of the PCPT and professor emeritus at the University of Texas Health Science Center at San Antonio.
Thompson hopes that physicians give finasteride, which is the only proven method for preventing prostate cancer, a chance in the clinic.
"Doctors should share these results with men who get regular prostate-specific antigen tests that screen for the presence of prostate cancer. The drug will have its greatest effect in this group of men," he said.
New Long-Term Data Show No Increase in Deaths
The story of the PCPT starts in the 1990s, when Thompson and co-trialists randomized more than 18,000 American men ages 55 and older to receive finasteride (5 mg daily) or placebo for 7 years to prevent prostate cancer.
When initial results were first published in 2003, the trial was both a success and a failure.
On the one hand, the risk of prostate cancer with finasteride was 24.8% lower than with placebo.
But at the same time, there was a significant increase in the number of high-grade cancers with the drug compared with placebo (280 vs 237).
This latter finding torpedoed use of the hormone blocker as a cancer prevention agent.
"There is no question that the reason finasteride is not used for prostate cancer prevention is because of the small but statistically significant increase in high-grade disease. Absolutely no question," Thompson told Medscape Medical News at the 2018 annual meeting of the American Urological Association (AUA), where the newly published data were first presented.
This finding has been paradoxical, say Thompson and his coauthors in their correspondence to the NEJM.
So the team initiated a long-term analysis — to see if the increase in high-grade disease resulted in more prostate-cancer related deaths in the finasteride group of the PCPT, as might be expected.
But that's not how it played out. Instead, in the new analysis, there were fewer prostate cancer deaths in the finasteride group than in the placebo group (42 vs 56).
This translated to a 25% lower risk of death from prostate cancer with finasteride compared to placebo in the trial (hazard ratio 0.75, 95% confidence interval [CI] 0.50 - 1.12), which was sponsored by the Southwest Oncology Group.
"We have no evidence that there's an increase in prostate cancer death in the finasteride arm," Thompson said.
In other words, the initial study findings in 2003 showing an increase in high-grade disease are not consequential 16 years later.
Side Effects Not Mentioned
The newly published letter from the PCPT investigators does not discuss the side effects of finasteride in men. At the AUA meeting, Thompson indicated that more sexual adverse effects have been consistently reported with finasteride than with placebo. However, he described them as "relatively modest."
In affected men, "it's like being maybe 3 years older," he said. The trial also showed, among other side effects, that the risk for gynecomastia was higher with finasteride than with placebo (4.5% vs 2.8%). Notably, the drug has not been shown to improve overall survival.
The chemopreventive agent, which is now generic, is inexpensive, about $48 to $108 a month.
At AUA last year, another urologist endorsed finasteride. "I do use it for some patients, but they tend to have concomitant urinary symptoms," said Scott Eggener, MD, from the University of Chicago.
He said that he discusses finasteride for cancer prevention with some men. "Most guys, when they hear the data, say, 'that sounds good,' " Eggener added.
The sexual adverse effects are concerning, but in his experience and in clinical trials, only a small percentage of men are affected, and problems such as low libido and reduced ejaculate are reversible, Eggener told Medscape Medical News.
The reputation of finasteride — that it increases the risk for high-grade disease — is unfair. "I think it's been completely disproven, given the totality of the research," he said.
The National Cancer Institute and the National Institutes of Health funded the study. Thompson and Eggener have disclosed no relevant financial relationships.
N Engl J Med.  Published online January 23, 2019. Full text
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Medscape Medical News © 2019
Cite this article: Finasteride Clears Its Name - Medscape - Jan 23, 2019.

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www.medscape.com

Does 'Castrate' in Prostate Cancer Need Revision? Pilot Dataset Questions the Current Standard

Nick Mulcahy
January 24, 2019
The level of testosterone (T) in the blood of men with riskier, localized prostate cancers who undergo hormone therapy should be suppressed to a level lower than currently accepted to achieve optimal outcomes, suggests a new retrospective study.
Androgen deprivation therapy (ADT) is a standard treatment for some men with intermediate- and high-risk prostate cancer that has not yet spread outside of the gland, point out the study authors, led by Brent Rose, MD, a radiation oncologist at the University of California, San Diego.
The goal of ADT is to reduce T levels to a "castrate" level, which is historically defined as <50 and="" cancer.="" dl="" hormonal="" ng="" of="" slow="" span="" stimulation="" the="" thereby="">
However, other research has suggested that, in the setting of metastatic disease, patients with "nadir" T levels from 20 - 50 ng/dL have poorer outcomes compared to men who achieve even lower levels of T, namely, <20 be.="" better="" dl.="" in="" level="" lower="" ng="" outcome="" short="" span="" tends="" testosterone="" the="" to="">
So Rose and colleagues decided to study this issue in men with earlier-stage disease and add to the small body of related literature.
Their study was published online December 10, 2018, in the International Journal of Radiation Oncology - Biology - Physics.
Using a Veteran's Administration database, the investigators identified 764 men with intermediate- or high-risk localized prostate cancer who underwent treatment with ADT and definitive radiotherapy from 2000 to 2015.
The men were divided into two groups on the basis of their minimum T level during continuous gonadotropic-releasing hormone agonist therapy: <20 -="" 20="" 49="" and="" dl.="" dl="" ng="" span="">
Rose and colleagues report that for men with T levels from 20 - 49 ng/dL, 10-year biochemical recurrence rates were higher (28.1% vs 18.3%), as were metastasis rates (12.9% vs 7.8%), compared to the patients with T levels <20 dl.="" ng="" span="">
The difference in rates persisted when the investigator performed multivariable analyses.
Also, shorter-term measures favored the group with lower T levels.
Specifically, the T nadir of 20 - 49 ng/dL was associated with higher 3-month postradiotherapy prostate-specific antigen (PSA) levels compared to a T nadir <20 0.12="" 0.16="" 2-year="" and="" dl="" higher="" nadir="" ng="" p=".005).</span" psa="">
Higher PSA levels are undesirable and are a sign of more active disease.
There was also a trend toward inferior prostate cancer–specific mortality for the 20 - 49 ng/dL group.
"Our study suggests that there are clinically significant differences in early PSA response and long-term clinical outcomes among patients who achieve differing levels of testosterone suppression below the historical 50 ng/dL castrate level," summarize the authors.
Inadequate Testosterone Suppression?
The new results raise questions about current practice and castrate levels of serum T, suggested David Wise, MD, PhD, a medical oncologist at New York University (NYU) Langone Health in New York City.
"The NCCN [National Comprehensive Cancer Network] guidelines recommend <50 accepted="" an="" and="" dl="" email.="" he="" in="" is="" medical="" medscape="" news="" ng="" span="" standard="" this="" told="">
"This study provides an intriguing pilot dataset that calls into question the reliance on this standard <50 added.="" dl="" he="" ng="" span="" threshold="">
The new findings need further validation in an independent cohort, Wise advised.
The NYU physician also said that it is standard to check the serum T level after initiation of androgen suppression to ensure appropriate suppression. "Inadequate testosterone suppression can happen and is a preventable cause of poor outcome," he reminded.
Wise said the new findings are consistent with previous studies that suggest a link between the depth of testosterone suppression and clinical outcome.
According to the study authors, the new results also prompt the question, what do you do clinically when T levels cannot be satisfactorily suppressed?
"Newer therapies such as abiraterone [multiple brands] and enzalutamide [Xtandi, Astellas] may suppress serum testosterone more effectively in many patients and thus hold promise as adjunct therapies in patients with insufficient testosterone suppression," they propose.
Again, Wise said use of these agents needed confirmation: "Further prospective studies will be needed to validate this approach for this highly curable disease."
The study was supported by the National Institutes of Health. The authors and Dr Wise have disclosed no relevant financial relationships.
Int J Radiat Oncol Biol Phys. Published online December 10, 2018. Abstract
Follow Medscape journalist Nick Mulcahy on Twitter. For more from Medscape Oncology, follow us on Twitter.
Medscape Medical News © 2019
Cite this article: Does 'Castrate' in Prostate Cancer Need Revision? - Medscape - Jan 24, 2019.

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https://www.onclive.com/web-exclusives/advancements-emerging-in-nonmetastatic-and-mcrpc-paradigms

Advancements Emerging in Nonmetastatic and mCRPC Paradigms

Caroline Seymour
Tanya Dorff, MD
Two critical clinical trials—SPARTAN and PROSPER—served as the basis for the 2018 FDA approvals of apalutamide (Erleada) and enzalutamide (Xtandi), respectively, agents that have drastically changed the standard of care for patients with nonmetastatic castration-resistant prostate cancer (CRPC), said Tanya B. Dorff, MD.
During the 2018 OncLive® State of the Science SummitTM on Genitourinary Cancers, Dorff explained that these approvals have established a foundation for subsequent progress for patients with nonmetastatic CRPC.
In the metastatic castration-resistant prostate cancer (mCRPC) space, more research is moving forward with immunotherapy, PARP inhibitors, and imaging techniques.
“As we define molecular subsets, and we find the drugs that have a big impact, such as PARP inhibitors in patients with DNA repair deficiency, it will likely be amplified in earlier [lines of therapy]. It’s what we’ve seen with docetaxel in CHAARTED and abiraterone acetate (Zytiga) and docetaxel in STAMPEDE and LATITUDE,” said Dorff. “The earlier we use these drugs, the better. The big space to focus on is trying to bring more durable responses to patients, provided we don't do it at the cost of quality of life (QoL).”
In an interview with OncLive® during the meeting, Dorff, associate clinical professor in the Department of Medical Oncology and Therapeutics Research, and head of the genitourinary cancers program at City of Hope, discussed landmark approvals in nonmetastatic CRPC and anticipated developments in metastatic CRPC.
OncLive®: What trials have defined the field of nonmetastatic CRPC?
Dorff: For nonmetastatic CRPC, there were 2 landmark studies that have now changed the way we practice. First and foremost, it's important to image patients whose prostate-specific antigen (PSA) is rising despite castration therapy, so that we can correctly categorize them as metastatic or nonmetastatic––even oligometastatic versus large-volume metastatic disease. When we do find patients who are truly nonmetastatic castration-resistant, but we can't find anything on conventional imaging, we need to check their doubling time to categorize them as high-risk or not. We use a PSA doubling time cutoff of £10 months. That's what was used in both of the trials.
If a patient meets all those criteria, we now have treatment options for them, whereas before we really didn't. We used to do some secondary hormonal manipulations, but there was nothing we knew would improve survival. Both apalutamide and enzalutamide were studied in large randomized trials and showed a positive primary endpoint of metastasis-free survival (MFS). This is a new endpoint for the prostate cancer community, but it led to the FDA approval of these drugs in this context. It’s clinically meaningful and resonates with patients.
We don’t have comparative data between apalutamide and enzalutamide. Either one is a perfectly acceptable option. There are some slight differences between their side effect profiles, but generally speaking there is no major reason to choose one or the other.
Additionally, QoL seems to be maintained on these drugs. The other major thing to emphasize is that fractures were seen on one of the studies. These men have been castrated for quite a while and are going to continue on castration therapy, so we have to pay attention to bone supportive therapy when we're treating men in this earlier-disease setting.
Do payers have a preference with regard to apalutamide and enzalutamide?
It's possible that insurers may have a preference. I did have that situation with one patient. [A payer may opt for one drug] if it is priced more favorably for their group. Falls or seizures are side effects we traditionally associate with enzalutamide. If a patient has had issues with falls or seizures, one might think we should choose apalutamide.
However, the side effect profile overlaps there. There are no patient characteristics that stand out, and there shouldn't be a patient preference, I would think. It would be rare to find a patient who had been exposed to both and could tell you about both of them. It's going to be up to doctors to get a feel for the drugs and see how they work relative to each other in this population.
How important is supplementing treatment with bone-supporting agents?
Bone health is becoming increasingly important as we hear about studies like ERA-223 with increased fractures. As we move into this earlier disease state, in which men are going to be on therapy for a lot longer, we can use bisphosphonates, such as alendronate. We can use 5 mg of zoledronic acid once yearly, or 60 mg of denosumab (Xgeva) every 6 months. All patients should be instructed to take calcium and vitamin D. Weight-bearing exercise is also likely important to help maintain bone strength. It's something that we need to pay attention to. 
Looking to the future, what's coming down the pike?
What is coming in this space is imaging. A lot of people believe that as we get more sensitive PET scans, we will no longer categorize patients as having nonmetastatic CRPC. We know the cancer cells are there, so it's semantics. We know they're metastatic. It's just a question of whether they're micrometastatic or macrometastatic on imaging.
As Gallium-68 prostate-specific membrane antigen (PSMA) and other PSMA agents become available, this population will shrink. Metastatic hormone-sensitive will become the new frontier to try new agents in upfront intensification. Of course, genomic characterization is the other big paradigm shift that should be brought into the mainstream once we have approval of agents that are designed for specific molecular subclasses.
You also spoke on metastatic CRPC. How should clinicians approach sequencing in that space?
When we’re sequencing for metastatic CRPC, we have a whole host of options now, which is great. I remember when I started practicing, I just had standard castration, a couple of androgen receptor drugs, such as bicalutamide (Casodex), and chemotherapy. Now, we have all these choices that have been proven to prolong survival, maintain a good QoL, and reduce skeletal symptomatic events. It becomes an opportunity to individualize treatment in the absence of directly comparative data. There is no one right sequence.
You may have a patient who you might want to give chemotherapy to after they’ve received abiraterone or enzalutamide. However, they might be elderly, or they might be young and working and can't afford to quit their job for the 6 months that you want to give them chemotherapy. We have radium-223 dichloride (Xofigo), which is a nice option for patients who have bone-only or metastatic disease that is limited to the bone. For patients with soft tissue and visceral metastases, that's not an option. On top of chemotherapy, abiraterone, and enzalutamide, there is immunotherapy with sipuleucel-T (Provenge) for select patients. Those patients should be minimally symptomatic, asymptomatic, and have slowly progressing disease.
It's important to look at the patient's characteristics and think through the pace of their progression. Moreover, what is the distribution? Imaging becomes key in this context as well. Sometimes PSA can be going up, even though the patient looks and feels great. We really want to get the most mileage out of treatment. If their scans aren’t changing, it’s probably not appropriate to switch therapy.
What is the future of PARP inhibitors in this space?
PARP inhibitors will be the next drugs approved for prostate cancer, and I think it will happen in 2019. There are phase III trials that have completed showing that these drugs are effective in BRCA-mutated and certain other DNA-repair deficiency populations.
We're going to see comparative studies of olaparib (Lynparza) versus physician's choice of abiraterone, enzalutamide, or docetaxel. Those studies are going to be important in benchmarking. It will be the first sort of directly comparative data we'll have about some of our existing strategies and new strategies. This will make a huge impact. Unfortunately, it's only 20% or 25% of patients who have the right mutation. For those patients, it's going to be a very nice additional tool.
Where would you like to see researched focused moving forward?
[I would like to see it focused] in the metastatic hormone-sensitive or perhaps biochemical recurrence settings. Additionally, a lot of newer studies incorporate patient-reported outcomes. That’s important. Since this is a longer-term disease process, we want men to live well as they're living longer.
The other space that's open for revolution is immunotherapy. It's been disappointing that the immune checkpoint inhibitors haven't been as successful in these patients. Sipuleucel-T (Provenge) has been around a while; we know men live longer when they get it. We're looking for something that will be game-changing. There are many studies that are combining radiation with immunotherapy, immunotherapy plus immunotherapy, and exploring which hormone therapies are most immunogenic. It will take a little bit longer for that to make its way into clinical treatment, but it's definitely on the horizon within the next 5 years.

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Home » Harvard Health Blog » Hormonal therapy for aggressive prostate cancer: How long is enough? - Harvard Health Blog

Hormonal therapy for aggressive prostate cancer: How long is enough?

Posted January 28, 2019, 3:57 pm
Charlie Schmidt
Editor, Harvard Medical School Annual Report on Prostate Diseases
Men weighing treatment options for intermediate- or high-risk cancer that is still localized to the prostate can face a tricky question. A standard approach in these cases is to give radiation to the prostate along with drugs that block testosterone, a hormone that makes the cancer cells grow faster. For how long should this hormone therapy last? That’s not entirely clear. The drugs have side effects, such as fatigue, impotence, and a loss of muscle mass. But radiation doesn’t control prostate cancer effectively without them. Doctors therefore aim to give hormone therapy only for as long as it takes to help their patients, without causing any undue harm.
Now, newly published results from a phase 3 clinical trial are providing some needed guidance.
How the study was performed
During the study, scientists randomized 1,071 men with intermediate- or high-risk localized prostate cancer into four groups. One group received radiation and six months of an anti-testosterone drug called leuporelin, and the second group received radiation plus 18 months of leuporelin therapy. Two other groups were treated with the same regimens of either radiation plus six or 18 months of leuporelin therapy, along with another drug called zoledronic acid, which helps to limit skeletal pain and related complications should cancer spread to the bones. Study enrollment occurred between 2003 and 2007 at 23 treatment centers across New Zealand and Australia.
Here’s what the results showed
After a median follow-up of just over 10 years, 9.7% of men who were treated with radiation and leuporelin for 18 months had died from prostate cancer, compared to 13.3% of the men treated with radiation and leuporelin for six months. Adding zoledronic acid made no difference in either case.
The authors concluded that hormonal therapy is more effective at preventing prostate cancer death when it’s given for 18 months rather than six. And similar benefits were noted for other endpoints as well. For instance, prostate tumors were less likely to metastasize, or spread, among men in the longer duration treatment group, and it took longer for their cancers to become resistant to hormone therapy if it was reinitiated later.
In earlier clinical research, scientists discovered that hormonal therapy given for three years protects against prostate cancer death more effectively than a six-month treatment regimen. But three years of hormone therapy isn’t easily tolerated, and evidence so far shows that 10-year survival rates after either 18 months or three years of hormonal therapy are similar, the authors of the new study claim.
“This study reaffirms what many clinicians have put into practice: longer duration hormonal therapy in appropriately selected patient populations provides a greater benefit,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “Prior studies using three years of hormonal therapy have also shown this, but it is important to recognize that some men may have significantly delayed return of the body’s testosterone upon completion of the therapy — a fact that needs to be discussed when contemplating longer-term treatment programs.”

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MRI grading system helps simplify prostate cancer assessment

January 25, 2019 | Matt O'Connor | Diagnostic Imaging

A team of national researchers has identified a set of multiparametric MRI-based guidelines and clinical features which can help clinicians easier determine a patient’s risk their prostate cancer will spread, according to a Jan. 22 study published in Radiology.
Extraprostatic extension (EPE) occurs when a tumor extends beyond glands in the prostate and is associated with an increased risk of biochemical recurrence, metastatic disease and lower cancer-specific survival after prostatectomy, wrote first author, Sherif Mehralivand, with University Medical Center in Mainz, Germany, and colleagues.
This new grading system, however, may allow for earlier detection and better treatment for these patients.
“The system adds additional diagnostic value to clinical parameters and provides a graded quantifiable risk assessment of pathologic EPE,” the authors wrote. “It is based on only a few imaging features, making it easy to teach, and it should be relatively easy to implement.”
The team retrospectively analyzed 553 men (mean age of 60) who underwent 3T MRI followed by robotic-assisted laparoscopic radical prostatectomy—125 men had pathologically-confirmed EPE.
They determined EPE visible with MRI, curvilinear contact length greater than 1.5 cm and capsular bulge and irregularity were all the main features associated with a higher risk of EPE. These markers made up their four-point grading system. Grade 0 is no suspicion of pathologic EPE; grade 1 included curvilinear contact length or capsular bulge and irregularity, grade 2 included both features and grade 3 meant MRI-verified EPE or tumor expansion past the prostate.
As the grades went up, so did the detection of pathologic EPE. For grades 1,2 and 3 those rates were 24 percent, 38 percent and 66 percent, respectively.
Additionally, combining clinical features with the MRI-based EPE grading system predicted EPE better than MRI alone (AUC of 0.81 compared to 0.77).
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Links to Further Reading:

·         Alternative therapies for cancer - Harvard Health Blog - Harvard Health Publishing: A recent large study found that outcomes were not better for people who chose a complementary treatment along with conventional cancer treatment.
·         Docetaxel or Abiraterone Acetate With ADT in Treating Patients With Metastatic Hormone Sensitive Prostate Cancer - Full Text View - ClinicalTrials.gov: Docetaxel or Abiraterone Acetate With ADT in Treating Patients With Metastatic Hormone Sensitive Prostate Cancer - Full Text View.
·         PCF publishes updated patient handbook | THE "NEW" PROSTATE CANCER INFOLINK: The Prostate Cancer Foundation (PCF) has just published the 2019 update to its Prostate Cancer Patient Guide, which is a very useful (and free) introduction to prostate cancer for patients and their caregivers…
·         The modern tragedy of fake cancer cures - STAT: An underreported story about a half-baked advance caught fire and scorched its way through social media, onto TV, and into the minds of millions. A cure for cancer? Israeli scientists say they think they found one - HEALTH & SCIENCE - Jerusalem Post: “We believe we will offer in a year's time a complete cure for cancer."
·         Apalutamide Improves Survival in Metastatic Castration-Sensitive Prostate Cancer: Apalutamide (Erleada) in combination with androgen deprivation therapy was found to significantly improve radiographic progression-free survival and overall survival versus placebo in patients with metastatic castration-sensitive prostate cancer.
·         Diet, diagnosis, AS, and the management of lower-risk forms of prostate cancer | THE "NEW" PROSTATE CANCER INFOLINK: Over the years there has been a great deal of speculation (and a very small amount of data) suggesting that men who get diagnosed with relatively low-risk forms of prostate cancer may be able to de
·         Adjuvant Docetaxel No Help in High-Risk Prostate Cancer | Medpage Today: Similar rates of progression at 10 years in androgen-dependent disease
·         Evaluating the Clinical Accuracy of Gallium-68 PSMA PET/CT Imaging in Patients With Biochemical Recurrence of Prostate Cancer - Full Text View - ClinicalTrials.gov: Evaluating the Clinical Accuracy of Gallium-68 PSMA PET/CT Imaging in Patients With Biochemical Recurrence of Prostate Cancer - Full Text View.
·         Virtual Prostate Biopsy Protocol for Patients on Active Surveillance and at Risk of Prostate Cancer - Full Text View - ClinicalTrials.gov: Virtual Prostate Biopsy Protocol for Patients on Active Surveillance and at Risk of Prostate Cancer - Full Text View
·         Prostatepedia Weekly 1.30.19
·         A story of treatment failure and end-of-life decisions: As we raise a toast to my father, I look around, breathe in the moment and think: Courage. Lives. Here.
·         Poor Adherence to International Cancer Prevention Recommendations Among Patients With Prostate Cancer: First Results From the MARTINI-Lifestyle Cohort - European Urology Focus: Following a healthy lifestyle practice is recommended for all patients with cancer diagnosis. However, results from the MARTINI-Lifestyle cohort suggest poor adherence to the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) recommendations among patients with prostate cancer. Thus, encouraging patients to improve lifestyle seems to be justified.
·         Economic Support for Your Prostate Cancer Drugs — Cancer ABCs: Reach out to the PAN Foundation to see if you qualify for economic support for your prostate cancer drugs.
·         Prognosis of patient progression and outcomes on active surveillance | THE "NEW" PROSTATE CANCER INFOLINK: The prostate cancer research team led by Dr. Peter Pinto at the National Cancer Institute has just published some interesting new information on risk for disease progression in men on active survei…
·         Howard Wolinsky dodges another MRI and another biopsy | THE "NEW" PROSTATE CANCER INFOLINK: Under the heading “Rats, my PSA went up. Do I need another bleeping biopsy?” Howard Wolinsky provides us with the latest “lowdown” on his 8-year-long prostate cancer journey
·         Home | Active Surveillance Patients Conference | Iceland | Oct 2019: The Active Surveillance Patient Conference will empower men concerned with prostate cancer. ASPs goal is to provide the most current information to help these patients make informed decisions regarding approaches to AS and choosing appropriate care.
·         Hormonal therapy for aggressive prostate cancer: How long is enough? - Harvard Health Blog - Harvard Health Publishing: Men weighing treatment options for intermediate- or high-risk cancer that is still localized to the prostate can face a tricky question. A standard approach in these cases is to give radiation to the prostate along with drugs that block testosterone, a hormone that makes the cancer cells grow faster. For how long should this hormone …
·         MRI grading system helps simplify prostate cancer assessment: A team of national researchers has identified a set of multiparametric MRI-based guidelines and clinical features which can help clinicians easier determine a patient’s risk their prostate cancer will spread, according to a Jan. 22 study published in Radiology.
·         Prostatepedia Weekly 1.23.19
·         Rapid Next-Generation Sequencing Method for Prediction of Prostate Cancer Risks - The Journal of Molecular Diagnostics: Prostate cancer is the most commonly diagnosed male cancer and the second leading cause of cancer deaths among men in the United States, with approximately 220,000 new diagnoses and approximately 27,000 deaths each year. Men with clinical low-risk disease can receive active surveillance to safely preserve quality of life, provided that the risk of an undetected aggressive cancer can be managed. Thus, prediction of a tumor's metastatic potential, ideally using only a biopsy sample, is criticalto choosing appropriate treatment.
·         Utilization of Salvage Radiation Therapy for Biochemical Recurrence after Radical Prostatectomy - ScienceDirect: For men with biochemical recurrence after radical prostatectomy (RP), salvage radiation therapy (SRT), especially “early” SRT(PSA ≤0.5 ng/mL), is a po…
·         Differences in United States insurance payer policies and American Society for Radiation Oncology’s (ASTRO) model policy on stereotactic body radiation therapy (SBRT) - ScienceDirect: Insurance payers in the United States vary in what indications they consider SBRT “medically necessary.” We compared changes in policies after the las…
·         Gene Responsible for Spread of Prostate Cancer Identified: A study has found that a specific gene in cancerous prostate tumors indicates when patients are at high-risk for the cancer to spread, suggesting that targeting this gene can help patients live longer.
·         Radium 223-mediated zonal cytotoxicity of prostate cancer in bone | JNCI: Journal of the National Cancer Institute | Oxford Academic: AbstractBackground. Bone-targeting radiotherapy with Radium-223 (Rad-223), a radioisotope emitting genotoxic alpha-radiation with limited tissue penetrance (1
·         Scientists identify gene responsible for spread of prostate cancer: A Rutgers study has found that a specific gene in cancerous prostate tumors indicates when patients are at high-risk for the cancer to spread, suggesting that targeting this gene can help patients live longer.
·         Prostatepedia Weekly 1.16.18
·         What PSA Test Scores Mean for Prostate Cancer Screening: The new prostate cancer test scoring system that leads to far fewer freak-outs.
·         J&J Raises U.S. Prices on Around Two Dozen Drugs: Johnson & Johnson raised U.S. prices on around two dozen prescription drugs on Thursday, including the psoriasis treatment Stelara (ustekinumab), prostate cancer drug Zytiga (abiraterone) and blood thinner Xarelto (rivaroxaban), all among its top-selling products.
·         Picking the right men for initial management on AS | THE "NEW" PROSTATE CANCER INFOLINK: At the recently completed Canadian Uro-oncology Summit in Toronto, Dr. Laurence Klotz gave a very thorough update on active surveillance (AS) and its application in the management of lower-risk for…
·         Age-related risks of radical prostatectomy | THE "NEW" PROSTATE CANCER INFOLINK: It will hardly come as a surprise to most prostate cancer support group leaders and other prostate cancer advocates that there is a strong association between patient age and risk for side effects …
·         Diagnostic performance of 68Ga-PSMA PET/CT in the detection of prostate cancer prior to initial biopsy: comparison with cancer-predicting nomograms | SpringerLink: Purpose To assess the diagnostic performance of 68Ga-PSMA PET/CT for detecting suspected prostate cancer (PCa) and to compare it with that of two cancer-predicting nomograms.
·         Long-term oncological and functional outcomes support use of low-dose-rate brachytherapy with or without external beam radiation in young men (≤60 years) with localized prostate cancer - Brachytherapy: To evaluate the oncological and functional outcomes of young men treated with low-dose-rate brachytherapy (BT) for prostate cancer (PCa).
·         Palliative radiotherapy to dominant symptomatic lesion in patients with hormone refractory prostate cancer (PRADO) | Radiation Oncology | Full Text: This study was conducted to investigate a new short-course radiotherapy regimen for patients with metastatic hormone refractory prostate cancer (HRPC) presenting with a dominant debilitating symptom. This is an international, multi-center single arm prospective feasibility study that aims to include 34 patients with HRPC and a dominant debilitating symptom. The dominant symptomatic lesion will receive 4×5Gy of high-precision radiotherapy, and the most aggressive part of the lesion 4×7Gy using a simultaneous integrated boost technique. Based on advanced magnetic resonance imaging (MRI), an apparent diffusion coefficient (ADC) map will be calculated for the lesion using diffusion weighted imaging sequences. The dominant symptomatic lesion (GTV1) is drawn manually using the information from T2w-MRI and computed tomography scans. The most aggressive part of the dominant lesion (GTV2) is defined by using the ADC map. An auxiliary volume is created including only voxels in the GTV1 that presents with ADC values below 1200×10− 6mm2/s. The most aggressive part is defined as voxels with an ADC value below the median ADC value. Primary endpoint is feasibility, i.e. proportion of pat
·         Researchers Discover Biological Markers that Could Guide Treatment for Prostate Cancer | Cooking with Kathy Man: Susan Buckles wrote . . . . . . . . . Genetic alterations in low-risk prostate cancer diagnosed by needle biopsy can identify men that harbor higher-risk cancer in their prostate glands, Mayo Clini…
·         A Population-Based Study Of Palliative Radiotherapy For Bone Metastases In Patients Dying Of Prostate Cancer - ScienceDirect: Increasing survival of patients with metastatic prostate cancer (PCa) may impact the demand for palliative radiation to bone (PRTB). Our aim was to ch…
·         How to get a free gallium-68 PSMA-11 PET/CT scan (and yes, there IS a catch) | THE "NEW" PROSTATE CANCER INFOLINK: A research team at the University of California, Los Angeles (UCLA) is seeking participants for a randomized, Phase III, clinical trial of the utility of 68Ga-PSMA-11 PET/CT molecular imaging for p…
·         Questions About Metastasis-Free Survival in Prostate Cancer: Last year, for the first time ever, metastasis-free survival was used as a new endpoint for drug approvals. A pair of critics raise questions about it.

1 comment:

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