Temporal changes in cause-specific death in men with localised prostate cancer treated with radical prostatectomy: a population-based, nationwide study.

BACKGROUND AND OBJECTIVE: Changes in diagnostic work-up, histopathological assessment, and treatment of men with prostate cancer during the last 20 years have affected the prognosis. The objective was to investigate the risk of prostate cancer death in men with clinically localised prostate cancer treated with radical prostatectomy in Sweden in 2000-2010. METHODS: Population-based, nationwide, study on men with clinically localised prostate cancer treated with radical prostatectomy in the period 2000-2010. Cox regression analyses were used to assess differences in risk of prostate cancer death according to calendar period for diagnosis and stratified on risk category. RESULTS: The study included 19 330 men with a median follow-up of 12.4 years. Men diagnosed in 2007-2008 and 2009-2010 had a significantly lower risk of prostate cancer death compared to men diagnosed in 2000-2002. The reduced risk of prostate cancer death was restricted to men with intermediate-risk prostate cancer with no differences observed in men with low- or high-risk prostate cancer. CONCLUSION: During the study period, the risk of prostate cancer death decreased in the total population of men with localised prostate cancer treated with radical prostatectomy. The decrease was restricted to men with intermediate-risk prostate cancer.

Comparison of venous thromboembolic complications following urological surgery between patients with or without cancer.

OBJECTIVE: Guidelines recommend 4 weeks of thromboembolic prophylaxis in patients who undergo major surgery for solid malignancies. However, there are limited head-to-head comparisons of risk of venous thromboembolic complications in patients with and without cancer undergoing similar surgical procedures. The purpose of this study was to compare risk of venous thromboembolic complications following major renal surgery and cystectomy between patients with and without cancer at the time of surgery. MATERIAL AND METHODS: In the nationwide Danish National Patient Registry, which captures all hospital contacts, including surgical procedures, we identified 8,645 patients who underwent major renal surgery (4,273 without cancer and 4,372 with cancer) and 2,164 patients who underwent cystectomy (359 without cancer and 1,805 with cancer) in 2000-2009. The rate of venous thromboembolic events within 6 months from surgery was compared for patients with and without cancer after stratification on organ using Chi-squared test. RESULTS: There was no difference in the rate of venous thromboembolic complications within the first 6 months after major renal surgery (0.4% and 0.3% [p=0.91]) or cystectomy (1.3% and 0.8% [p=0.44]) for patients with and without cancer. The cost for 28 days of Tinzaparin 4.500 IE administered by the patient was €112, whereas the cost if administered by a community nurse was €1.988. CONCLUSIONS: Our study questions the different recommendations in thromboembolic prophylaxis between patients with and without cancer after major renal surgery and cystectomy.

Prediction of metastatic prostate cancer by prostate-specific antigen in combination with T stage and Gleason Grade: Nationwide, population-based register study.

The objective was to investigate the proportion of men with metastatic prostate cancer in groups defined by T stage, Gleason Grade Group (GGG) and serum levels of prostate-specific antigen (PSA) and if PSA can be used to rule in metastatic prostate cancer when combined with T stage and GGG. We identified 102,076 men in Prostate Cancer data Base Sweden 4.0 who were diagnosed with prostate cancer in 2006-2016. Risk of metastases was assessed for PSA stratified on T stage and five-tiered GGG. For men who had not undergone bone imaging, we used multiple imputation to classify metastatic prostate cancer. Advanced T stage, high GGG and high PSA were related to bone metastases. For example: only 79/38 190 (0.2%) of men with T1-2 and GGG 1 had PSA above 500 ng/mL, and 29/79 (44%) of these men had metastases; whereas 1 154/7 018 (16%) of men with T3-4 and GGG 5 had PSA above 500 ng/ml and 1 088/1 154 (94%) of these men had metastases. However, no PSA cut-off could accurately identify the majority of men with metastatic prostate cancer (i.e. high sensitivity) while also correctly classifying most men without metastasis (i.e. high specificity). In conclusion, these results support the use of imaging to confirm bone metastases in men with advanced prostate cancer as no PSA level in combination with T stage and GGG could accurately rule in metastatic prostate cancer and thereby safely omit bone imaging.

Survival Outcomes From a Cumulative Analysis of Worldwide Observational Studies on Sequential Use of New Agents in Metastatic Castration-Resistant Prostate Cancer.

INTRODUCTION: The sequential use of a number of new agents (NAs) have improved the overall survival (OS) of patients with metastatic castration-resistant prostate cancer whose disease progresses after docetaxel (DOC) treatment. The aim of this study was to assess the cumulative survival outcomes of different sequencing strategies by evaluating the individual data from published studies of patients treated with a post-DOC treatment sequence of 2 NAs. PATIENTS AND METHODS: The patients' individual data were analyzed to investigate whether different sequencing strategies lead to differences in OS. RESULTS: We analyzed the data of 1099 evaluable patients. Among the patients treated with a second-line new hormone agent (NHA), median OS from the start of third-line treatment was significantly longer in the patients treated with cabazitaxel (CABA) than in those treated with abiraterone acetate or enzalutamide. Median cumulative OS (cumOS) from the start of second-line treatment was 21.1 months in the patients who received NHA then NHA, 22.1 months in those who received NHA then CABA, and 21.0 months in those who received CABA then NHA. Among the patients with a second-line progression-free survival of ≥6 months, median cumOS was significantly longer in patients who received CABA-including sequences than in those treated with NHA then NHA sequences (29.5 vs. 24.8 months; P = .03). CONCLUSION: Our findings suggest that the sequential use of NAs with different mechanisms of action improves cumOS regardless of the order in which they are administered, thus supporting the hypothesis of cross-resistance between the 2 NHAs.

Active Surveillance Versus Radical Prostatectomy in Favorable-risk Localized Prostate Cancer.

BACKGROUND: Active surveillance (AS) and radical prostatectomy (RP) are both accepted treatments for men with favorable-risk localized prostate cancer (PCa) (ie, clinical tumor category 1-2b, Gleason Grade Group 1-2, and prostate-specific antigen < 20 ng/mL). However, head-to-head studies comparing oncologic outcomes and survival between these 2 treatment strategies are warranted. The objective of this study was to compare the use of prostate cancer treatments and PCa death in men managed on AS and men who underwent immediate RP. PATIENTS AND METHODS: This was an observational study including 647 men on AS and 647 men treated with RP propensity score matched. We examined the 10-year cumulative incidence of salvage radiotherapy, hormonal therapy, castration-resistant PCa, and PCa death. RESULTS: The 10-year curative treatment-free survival for men on AS was 61% (95% confidence interval [CI], 57%-65%). No differences in use of salvage radiotherapy (AS, 2.7%; 95% CI, 1.4%-4.1% vs. RP 5.4%; 95% CI, 3.4%-7.3%), hormonal therapy (AS, 6.9%; 95% CI, 4.4%-9.4% vs. RP, 4.1%; 95% CI, 2.5%-5.6%), developing castration-resistant PCa (AS, 1.7%; 95% CI, 0.5%-2.9% vs. RP, 2.0%; 95% CI, 0.7%-3.4%), or cumulative PCa mortality (AS, 0.4%; 95% CI, 0%-1.0% vs. RP, 0.5%; 95% CI, 0%-1.5%) were observed between the treatment strategies. The main limitation was the non-random allocation to treatment strategy. CONCLUSION: In this observational study on men with favorable-risk localized PCa, we found similar PCa mortality at 10 years between men on AS and men who underwent immediate RP. Moreover, there were no differences in the use of PCa therapies between the groups. Our study supports active surveillance as a treatment strategy for men with favorable-risk localized PCa.

Venous thromboembolic complications following surgical treatment for degenerative spinal disease.

INTRODUCTION: A venous thromboembolism (VTE), i.e. deep vein thrombosis (DVT) or pulmonary embolism (PE), is a potentially lethal complication to surgical procedures. The aim of this study was to evaluate the incidence of symptomatic VTEs in a large consecutive Danish cohort treated surgically for degenerative spinal disease. METHODS: This was a retrospective, consecutive, one-centre cohort study of patients treated surgically for either cervical or lumbar degenerative disease. According to the local treatment protocol, patients with an increased risk of VTE received rivaroxaban as thrombosis prophylaxis. VTE events within six months from the surgical procedure were identified via the Danish National Patient Register and confirmed by patient chart review. RESULTS: A total of 6,145 surgical procedures were included - 808 cervical and 5,337 lumbar procedures. Twelve patients (0.2%) were examined on suspicion of symptomatic VTE, ten for DVT and two for PE. VTE was confirmed in eight patients (0.1%), seven DVT and one PE. One patient died within six months, producing a mortality rate of 0.01%. CONCLUSIONS: VTEs are an uncommon but potentially lethal complication in patients who undergo surgery for a degenerative spinal disease. Incidence and mortality were low in a consecutive cohort where rivaroxaban was used as thrombosis prophylaxis in patients with an increased preoperative risk of VTE. FUNDING: none. TRIAL REGISTRATION: not relevant.

A predictive model based on biparametric magnetic resonance imaging and clinical parameters for improved risk assessment and selection of biopsy-naïve men for prostate biopsies.

BACKGROUND: Prostate cancer risk prediction models and multiparametric magnetic resonance imaging (mpMRI) are used for individualised pre-biopsy risk assessment. However, biparametric MRI (bpMRI) has emerged as a simpler, more rapid MRI approach (fewer scan sequences, no intravenous contrast-media) to reduce costs and facilitate a more widespread clinical implementation. It is unknown how bpMRI and risk models perform conjointly. Therefore, the objective was to develop a predictive model for significant prostate cancer (sPCa) in biopsy-naive men based on bpMRI findings and clinical parameters. METHODS: Eight hundred and seventy-six biopsy-naive men with clinical suspicion of prostate cancer (prostate-specific antigen, <50 ng/mL; tumour stage,

Active Surveillance for Localized Prostate Cancer: Nationwide Observational Study.

PURPOSE: The objective of this study was to investigate nationwide survival outcomes in men with localized prostate cancer managed on active surveillance. MATERIALS AND METHODS: A total of 936 men with localized prostate cancer were initiated on active surveillance in Denmark in 2002 to 2012. Kaplan-Meier estimated curative treatment-free, hormonal therapy-free, castration resistant prostate cancer-free and cause specific survival was calculated. RESULTS: Prostate cancer was classified as very low risk in 223 men, low risk in 436, intermediate risk in 259 (87% were at favorable intermediate risk) and high risk in 18. Median followup was 7.5 years (IQR 6.1-9.1). Kaplan-Meier estimated 10-year curative treatment-free survival was 62.8% (95% CI 59.1-66.3), 10-year hormonal therapy-free survival was 92.2% (95% CI 89.2-94.4), 10-year castration resistant prostate cancer-free survival was 97.2% (95% CI 95.3-98.4) and 10-year cause specific survival was 99.6% (95% CI 98.6-99.9). Compared to men with low risk prostate cancer, those with intermediate risk prostate cancer had higher curative treatment-free survival (69% vs 56%, p = 0.008), lower hormonal therapy-free survival (88% vs 95%, p = 0.005) and similar castration resistant prostate cancer-free survival (95% vs 99%, p = 0.17). CONCLUSIONS: In this nationwide cohort 10-year cause specific survival was similar to that in prospective active surveillance cohorts. Our study supports the use of active surveillance in men with localized prostate cancer, including men with favorable intermediate risk characteristics.

Results of 14 years of brachytherapy for localized prostate cancer in Denmark: the Herlev cohort.

OBJECTIVE: Brachytherapy is one of several curative treatments for localized prostate cancer (PCa). The objective of this study was to report biochemical recurrence-free survival (BRFS), metastatic-free survival (MFS) and PCa-specific mortality after low-dose brachytherapy, stratified according to the D'Amico risk classification in a large Danish cohort. MATERIALS AND METHODS: The study population comprised 502 men treated with brachytherapy in 1998-2012. BRFS was defined by the Phoenix criteria. Kaplan-Meier survival analysis was used to estimate BRFS and MFS. The cumulative PCa mortality was analysed using competing risk analyses. Multivariable Cox regression analysis was used to estimate risk of biochemical recurrence. RESULTS: In total, 206 men were classified with low-risk PCa, 265 men with intermediate-risk PCa and 33 men with high-risk PCa. Median follow-up was 6.6 years [95% confidence interval (CI) 6.2-7.0]. The 10 year BRFS was 90% (95% CI 83-97), 75% (95% CI 65-87) and 75% (95% CI 59-92) in men with low-, intermediate- and high-risk PCa, respectively. The 10 year MFS was 95% (95% CI 89-100), 93% (95% CI 88-98) and 78% (95% CI 57-99) in men with low-, intermediate- and high-risk PCa, respectively. The 10 year cumulative incidence of PCa mortality was 1% (95% CI 0-3), 5% (95% CI 0-12) and 11% (95% CI 0-25) for men with low-, intermediate- and high-risk PCa, respectively. CONCLUSIONS: Low-dose brachytherapy offers good short- to intermediate-term cancer control in selected men with localized PCa. Further studies are needed for safety analyses and for comparison with other treatment modalities.

Active surveillance for localized prostate cancer: update of a prospective single-center cohort.

OBJECTIVE: The purpose of active surveillance (AS) is to reduce overtreatment of men with localized prostate cancer (PCa) without compromising survival. The objective of this study was to update a large Scandinavian single-center AS cohort. Furthermore, the use of curative treatment and subsequent risk of biochemical recurrence were investigated and compared in men with very low-risk, low-risk and intermediate-risk PCa in the cohort. MATERIALS AND METHODS: In total, 451 men were followed on AS and monitored with prostate-specific antigen (PSA) tests, digital rectal examinations and rebiopsies. Recommendation of curative treatment was based on protocolled and predefined risk of progression criteria. Biochemical recurrence was defined as PSA ≥0.2 ng/ml after radical prostatectomy and PSA nadir +2 ng/ml after radiotherapy. RESULTS: Altogether, 34% were defined with very low-risk PCa, 40% with low-risk PCa and 24% with intermediate-risk PCa. The median follow-up was 5.1 years. The estimated 5 year curatively intended treatment-free survival was 60.5% [95% confidence interval (CI) 54.8-66.2%], with no statistically significant difference between men with very low-risk, low-risk or intermediate-risk PCa. The 5 year biochemical recurrence-free survival was 92.3% (95% CI 87.4-97.2), again with no difference between men with very low-risk, low-risk and intermediate-risk PCa. CONCLUSION: AS for very low- to low-risk localized PCa is feasible and safe within the short to intermediate time frame. Men with intermediate-risk PCa had the same risk of undergoing curative treatment as men with low-risk PCa, without compromising biochemical recurrence-free survival.

Prognostic implications of 2005 Gleason grade modification. Population-based study of biochemical recurrence following radical prostatectomy.

OBJECTIVE: To assess the impact of the 2005 modification of the Gleason classification on risk of biochemical recurrence (BCR) after radical prostatectomy (RP). PATIENTS AND METHODS: In the Prostate Cancer data Base Sweden (PCBaSe), 2,574 men assessed with the original Gleason classification and 1,890 men assessed with the modified Gleason classification, diagnosed between 2003 and 2007, underwent primary RP. Histopathology was reported according to the Gleason Grading Groups (GGG): GGG1 = Gleason score (GS) 6, GGG2 = GS 7(3 + 4), GGG3 = GS 7(4 + 3), GGG4 = GS 8 and GGG5 = GS 9-10. Cumulative incidence and multivariable Cox proportional hazards regression models were used to assess difference in BCR. RESULTS: The cumulative incidence of BCR was lower using the modified compared to the original classification: GGG2 (16% vs. 23%), GGG3 (21% vs. 35%) and GGG4 (18% vs. 34%), respectively. Risk of BCR was lower for modified versus original classification, GGG2 Hazard ratio (HR) 0.66, (95%CI 0.49-0.88), GGG3 HR 0.57 (95%CI 0.38-0.88) and GGG4 HR 0.53 (95%CI 0.29-0.94). CONCLUSION: Due to grade migration following the 2005 Gleason modification, outcome after RP are more favourable. Consequently, outcomes from historical studies cannot directly be applied to a contemporary setting. J. Surg. Oncol. 2016;114:664-670. © 2016 Wiley Periodicals, Inc.

Clinical characteristics and primary management of patients diagnosed with prostate cancer between 2007 and 2013: status from a Danish primary referral center.

BACKGROUND: The Danish Cancer Registry holds information on all prostate cancers (PCa) cases, including diagnostic TNM. However, stratification according to contemporary risk classification is not possible because histopathological grading and prostate-specific antigen (PSA) level are not registered. The objective of the study was to report clinical characteristics and primary management of men diagnosed with PCa from a primary referral center in Denmark. MATERIAL AND METHODS: Records on all men diagnosed with PCa at the Department of Urology, Frederiksberg Hospital, 1 January 2007 - 31 December 2013, were reviewed. Clinical characteristics and primary treatment were recorded. The National Comprehensive Cancer Network risk group classification was used. RESULTS: A total of 1934 men with a median age of 69 years (interquartile range 65-75) were diagnosed with PCa in the study period resulting in an incidence rate (World Standard Population) of 84/100 000. Overall, 18% were classified as low-risk, 34% as intermediate-risk, 23% as high-risk, 8% as very high-risk and 17% had metastatic disease at diagnosis. Among men age <65 years 70% had low- or intermediate-risk disease, while this was the case for 58% of men aged 65-75 and 22% of men aged >75. Metastatic disease was found in 11% of men <65 years, 17% of men 65-75 years and 23% of men >75 years. In total 73% of men with low-risk PCa were managed on watchful waiting or active surveillance. Curatively intended treatment was performed in 56% of men with intermediate-risk and 61% of men with high-risk PCa, while hormonal therapy was used in 90% of men with very high-risk and 98% of men with metastatic PCa. CONCLUSION: In a population without systematic PSA testing we found a large proportion of patients presenting with advanced PCa at diagnosis. Elderly patients presented with more advanced disease. Curative treatment was primarily used in younger men with clinically localized PCa.

The impact of the 2005 International Society of Urological Pathology consensus guidelines on Gleason grading - a matched-pair analysis.

OBJECTIVES: To investigate whether the International Society of Urological Pathology (ISUP) 2005 revision of the Gleason grading system has influenced the risk of biochemical recurrence (BCR) after radical prostatectomy (RP), as the new guideline implies that some prostate cancers previously graded as Gleason score 6 (3 + 3) are now considered as 7 (3 + 4). PATIENTS AND METHODS: A matched-pair analysis was conducted. In all, 215 patients with Gleason score 6 or 7 (3 + 4) prostate cancer on biopsy who underwent RP before 31 December 2005 (pre-ISUP group), were matched 1:1 by biopsy Gleason score, clinical tumour category, PSA level, and margin status to patients undergoing RP between 1 January 2008 and 31 December 2011 (post-ISUP group). Patients were followed until BCR defined as a PSA level of ≥0.2 ng/mL. Risk of BCR was analysed in a competing-risk model. RESULTS: The median follow-up was 9.5 years in the pre-ISUP group and 4.8 years in the post-ISUP group. The 5-year cumulative incidences of BCR were 34.0% and 13.9% in the pre-ISUP and post-ISUP groups, respectively (P < 0.001). The difference in cumulative incidence applied to both patients with Gleason score 6 (P < 0.001) and 7 (3 + 4) (P = 0.004). There was no difference in the 5-year cumulative incidence of BCR between patients with pre-ISUP Gleason score 6 and post-ISUP Gleason score 7 (3 + 4) (P = 0.34). In a multiple Cox-proportional hazard regression model, ISUP 2005 grading was a strong prognostic factor for BCR within 5 years of RP (hazard ratio 0.34; 95% confidence interval 0.22-0.54; P < 0.001). CONCLUSION: The revision of the Gleason grading system has reduced the risk of BCR after RP in patients with biopsy Gleason score 6 and 7 (3 + 4). This may have consequences when comparing outcomes across studies and historical periods and may affect future treatment recommendations.

The Movember campaign: Impact on referral patterns and diagnosis of prostate cancer.

AIMS: The aims of the present study were to investigate referral patterns and the diagnosis of prostate cancer (PCa) before and after the Movember campaign was initiated in Denmark. METHODS: All men (n=2817) referred to the Department of Urology at Frederiksberg Hospital with suspicion of having PCa in the period 1 January 2007-31 January 2014 were identified. Based on the referral date, patients were categorised as pre-Movember (1 January 2007-31 January 2011) and Movember (1 February 2011-31 January 2014), respectively. Annual referral-rates/100.000 inhabitants were calculated and compared with rate-ratio (RR) tests. RESULTS: The median prostate-specific antigen (PSA) at referral dropped significantly from 9.8 ng/mL in 2007-2011 to 7.9 ng/mL in 2011-2014,p< 0.001. The incidence rate of men referred with suspicion of PCa increased from 134/100.000 in the pre-Movember period to 168/100.000 in the Movember period (RR 1.25 [95% CI 1.16-1.35]). In contrast to what we anticipated, there was no increase in referral in the months following the campaign. The incidence rates of men diagnosed with PCa and low-risk PCa were similar in the Movember period and the pre-Movember period (PCa: RR 1.08 [0.97-1.21]; low-risk PCa: RR 1.29 [0.98-1.73]). CONCLUSIONS: After the initiation of the Movember campaign a significant decline in the PSA level at referral and an increase in the number of patients referred under suspicion of PCa was observed; however, only minor differences in referral patterns and PCa diagnosis were detected. The results indicate that the Movember campaign had a limited immediate effect on referral, however, it may have contributed to an increased awareness of PCa.

Risk of malignant melanoma in men with prostate cancer: Nationwide, population-based cohort study.

An increased risk of malignant melanoma has been observed in men with prostate cancer. To assess potential shared risk factors and confounding factors, we analysed risk of melanoma in men with prostate cancer including information on tumor characteristics and demographics including socioeconomic status. In The Prostate Cancer data Base Sweden, risk of melanoma was assessed in a cohort of men with prostate cancer and in a comparison cohort of prostate-cancer free men. Data on prostate cancer risk category, melanoma stage, basal cell carcinoma, location of residency, and socioeconomic status were obtained from nationwide registers. Melanoma was diagnosed in 830/108,145 (0.78%) men with prostate cancer and in 3,699/556,792 (0.66%) prostate cancer-free men. In multivariable Cox regression models, men with prostate cancer had a significantly increased risk of melanoma (HR 1.18, 95% CI 1.09-1.27), and so had married men, men with high education and income, and men residing in southern Sweden. The strongest associations were observed for stage 0 melanoma in men with low-risk prostate cancer (HR 1.45, 1.14-1.86), high education (HR 1.87, 1.60-2.18) and top income (HR 1.61, 1.34-1.93), respectively, whereas there was no association between these factors and late-stage melanoma. Men with prostate cancer also had an increased risk of basal cell carcinoma (HR 1.18, 1.15-1.22). In conclusion, men with low-risk prostate cancer, high education, high income and residency in southern Sweden had an increased risk of early-stage melanoma.

The predictive value of ERG protein expression for development of castration-resistant prostate cancer in hormone-naïve advanced prostate cancer treated with primary androgen deprivation therapy.

BACKGROUND: Biomarkers predicting response to primary androgen deprivation therapy (ADT) and risk of castration-resistant prostate cancer (CRPC) is lacking. We aimed to analyse the predictive value of ERG expression for development of CRPC. METHODS: In total, 194 patients with advanced and/or metastatic prostate cancer (PCa) treated with first-line castration-based ADT were included. ERG protein expression was analysed in diagnostic specimens using immunohistochemistry (anti-ERG, EPR3864). Time to CRPC was compared between ERG subgroups using multiple cause-specific Cox regression stratified on ERG-status. Risk reclassification and time-dependent area under the ROC curves were used to assess the discriminative ability of ERG-status. Time to PSA-nadir, proportion achieving PSA-nadir ≤0.2 ng/ml, and risk of PCa-specific death were secondary endpoints. RESULTS: Median follow-up was 6.8 years (IQR: 4.9-7.3). In total, 105 patients (54.1%) were ERG-positive and 89 (45.9%) were ERG-negative. No difference in risk of CRPC was observed between ERG subgroups (P = 0.51). Median time to CRPC was 3.9 years (95%CI: 3.2-5.1) and 4.5 years (95%CI: 2.3-not reached) in the ERG-positive and ERG-negative group, respectively. Compared to a model omitting ERG-status, the ERG-stratified model showed comparable AUC values 1 year (77.6% vs. 78.0%, P = 0.82), 2 years (71.7% vs. 71.8%, P = 0.85), 5 years (68.5% vs. 69.9%, P = 0.32), and 8 years (67.9% vs. 71.4%, P = 0.21) from ADT initiation. No differences in secondary endpoints were observed. CONCLUSIONS: ERG expression was not associated with risk of CRPC suggesting that ERG is not a candidate biomarker for predicting response to primary ADT in patients diagnosed with advanced and/or metastatic PCa.

Survival benefit of early androgen receptor inhibitor therapy in locally advanced prostate cancer: long-term follow-up of the SPCG-6 study.

BACKGROUND: The optimal timing of endocrine therapy in non-metastatic prostate cancer (PCa) is still an issue of debate. METHODS: A randomised, double-blind, parallel-group trial comparing bicalutamide 150mg once daily with placebo in addition to standard care in patients with hormone-naïve, non-metastatic PCa. Kaplan-Meier analysis was used to estimate overall survival (OS) and multivariate Cox proportional hazard model was performed to analyse time-to-event (death). FINDINGS: A total of 1218 patients were included into the Scandinavian Prostate Cancer Group (SPCG)-6 study of which 607 were randomised to receive bicalutamide in addition to their standard care and 611 to receive placebo. Median follow-up was 14.6years. Overall, 866 (71.1%) patients died, 428 (70.5%) in the bicalutamide arm and 438 (71.7%) in the placebo arm, p=0.87. Bicalutamide significantly improved OS in patient with locally advanced disease (hazard ratios (HR)=0.77 (95% confidence interval (CI): 0.63-0.94, p=0.01), regardless of baseline prostate-specific antigen (PSA), with a survival benefit which was apparent throughout the study period. In contrast, survival favoured randomisation to the placebo arm in patients with localised disease (HR=1.19 (95% CI: 1.00-1.43), p=0.056). However, a survival gain from bicalutamide therapy was present in patients with localised disease and a baseline PSA greater than 28ng/mL at randomisation. In multivariate Cox proportional hazard model, only including patients managed on watchful waiting as their standard of care (n=991) OS depended on age, World Health Organisation (WHO) grade, baseline PSA, clinical stage and randomised treatment. INTERPRETATION: Throughout the 14.6year follow-up period the addition of early bicalutamide to standard of care resulted in a significant OS benefit in patients with locally advanced PCa. In contrast, patients with localised PCa and low PSA derived no survival benefit from early bicalutamide. The optimal timing for initiating bicalutamide in non-metastatic PCa patients is dependent on disease stage and baseline PSA.

Repeated biopsies in patients with prostate cancer on active surveillance: clinical implications of interobserver variation in histopathological assessment.

OBJECTIVE: To investigate the clinical implications of interobserver variation in the assessment of re-biopsies obtained during active surveillance (AS) of prostate cancer. PATIENTS AND METHODS: In all, 107 patients with low-risk prostate cancer with 93 diagnostic biopsy sets and 109 re-biopsy sets were included. The International Society of Urological Pathology 2005 Gleason scoring system was used for the histopathological assessment of all biopsies. Three different definitions of histopathological progression were applied. Unweighted and linear weighted Kappa (κ) statistics were used to compare the interobserver agreement. RESULTS: The overall Gleason score agreement was 68.8% with a weighted κ of 0.670. The interobserver agreement was 79.6% for meeting the AS selection criteria. According to the three progression definitions applied, overall agreement was between 80.7% and 89.0% with weighted κ values of 0.746-0.791. Treatment recommendations would have changed in up to 10.1% (95% confidence interval 5.4-17.7%) of the 109 re-biopsy sets. CONCLUSION: Kappa statistics showed strong agreement between the histological evaluations. However, up to 10% of patients on AS would receive a different treatment recommendation depending upon which histopathological evaluation of re-biopsies was used for treatment planning.

Enzalutamide Antitumour Activity Against Metastatic Castration-resistant Prostate Cancer Previously Treated with Docetaxel and Abiraterone: A Multicentre Analysis.

BACKGROUND: The degree of antitumour activity of enzalutamide following disease progression on docetaxel and abiraterone remains controversial. OBJECTIVE: To examine the effect of enzalutamide in patients progressing following taxane-based chemotherapy and abiraterone. DESIGN, SETTING, AND PARTICIPANTS: Metastatic castration-resistant prostate cancer patients entering one of four European compassionate use programmes of enzalutamide. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary end point was overall survival (OS). Secondary end points were association between OS and posttreatment prostate-specific antigen (PSA) kinetics, patient characteristics, and progression-free survival, respectively. Kaplan-Meier survival analysis and Cox proportional hazard analysis were performed. RESULTS AND LIMITATIONS: We identified 137 patients who prior to enzalutamide had progressed following a median of eight cycles of docetaxel and seven courses of abiraterone. The median time on enzalutamide was 3.2 mo; median OS from the time patients started enzalutamide was 8.3 mo (95% confidence interval, 6.8-9.8). Only 45 (38%) and 22 (18%) patients had PSA declines (unconfirmed) >30% and 50%, respectively. Patients who had more than 30% or 50% falls in PSA had improved survival compared with patients who had no such PSA fall (11.4 mo vs 7.1 mo; p=0.001 and 12.6 vs 7.4 mo; p=0.007, respectively). Poor performance status and low haemoglobin was negatively associated with OS. CONCLUSIONS: Median OS on enzalutamide following disease progression on taxane-based chemotherapy and abiraterone was modest, but patients who experience a PSA decline >30% or 50%, respectively, with enzalutamide in this setting had longer survival. PATIENT SUMMARY: Enzalutamide produces modest prostate-specific antigen (PSA) responses in patients progressing following chemotherapy and abiraterone. Despite a modest PSA response, survival may still be improved.

Active surveillance for localized prostate cancer: an analysis of patient contacts and utilization of healthcare resources.

OBJECTIVE: Evidence supports active surveillance (AS) as a means to reduce overtreatment of low-risk prostate cancer (PCa). The consequences of close and long-standing follow-up with regard to outpatient visits, tests and repeated biopsies are widely unknown. This study investigated the trajectory and costs of AS in patients with localized PCa. MATERIALS AND METHODS: In total, 317 PCa patients were followed in a prospective, single-arm AS cohort. The primary outcomes were number of patient contacts, prostate-specific antigen (PSA) tests, biopsies, hospital admissions due to biopsy complications and patients eventually undergoing curative treatment. The secondary outcome was cost. RESULTS: The 5 year cumulative incidence of discontinued AS in a competing-risk model was 40%. During the first 5 years of AS patients underwent a median of two biopsy sets, and patients were seen in an outpatient clinic including PSA testing three to four times annually. In total, 38 of the 406 biopsy sessions led to hospital admission and 87 of the 317 patients required treatment for bladder outlet obstruction (BOO). With a median of 3.7 years' follow-up, the total cost of AS was euro (€) 1,240,286. Assuming all patients had otherwise undergone primary radical prostatectomy, the cost difference favoured AS with a net benefit of €662,661 (35% reduction). CONCLUSIONS: AS entails a close clinical follow-up with a considerable risk of rebiopsy complication, treatment of BOO and subsequent delayed definitive therapy. This risk should be weighed against a potential economic benefit and reduction in the risk of overtreatment compared to immediate radical treatment.