Androgen Blockade and Salvage ­Radiation Therapy in Prostate Cancer: Cautious Optimism Amid Unanswered Questions

Excerpt:

“The recent report of results of RTOG 9601 by Shipley et al in The New England Journal of Medicine—reviewed in this issue of The ASCO Post—strongly supports the variably used practice of adding ‘androgen blockade’ to salvage radiation therapy in men with a rising prostate-specific antigen (PSA) after radical prostatectomy. The findings show a clear reduction in prostate cancer–specific and overall mortality with the addition of 2 years of bicalutamide to salvage radiation therapy. Another likely (although not demonstrated) benefit is the reduction in the need to treat patients with subsequent life-long continuous or intermittent androgen blockade at the expense of treating all men with 2 years of bicalutamide.”

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Expert Highlights Clinical Benefits of Prostatectomy

Excerpt:

“For patients with prostate cancer, prostatectomy—whether laparoscopic or robotic—can provide a significant clinical benefit, according to Gregory Zagaja, MD. Between the 2 prostatectomy techniques, he adds, the results have been fairly comparable.

“In an interview with Targeted Oncology, Zagaja, professor of Surgery, director of the Prostate Cancer Center at the University of Chicago Medicine, discussed the benefits of radical prostatectomy and other ongoing developments with surgery in prostate cancer.”

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'End of Controversy': Robotic Prostatectomy Is Winner

Excerpt:

“The long-running debate about which surgical method is best for removing a cancerous prostate is over, a urologic surgeon declares in an editorial published in the July issue of the Journal of Urology.

” ‘Robotic prostatectomy has superior or at least equal oncologic efficacy and complication rates compared to open prostatectomy,’ writes Michael O. Koch, MD, from the Indiana University School of Medicine in Indianapolis. ‘I believe the most current literature supports that view and this debate should finally be put to rest.’

“Dr Koch presents himself as an impartial judge, saying that he has ‘substantial surgical experience with both techniques.’

“Dr Koch’s editorial, partially entitled the ‘End of the Controversy,’ accompanies a study that prompted his declaration and compares the rival procedures.”

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ASCO: Combo Tx Fails in Local High-Risk Prostate Ca

Excerpt:

“Neoadjuvant enzalutamide (ENZA) and abiraterone acetate (AA) plus 5 mg prednisone daily can be given safely for 6 months in men with localized high-risk prostate cancer prior to prostatectomy, a neoadjuvant study showed.

“However, the findings did not favor adding ENZA to augment AA plus leuprolide acetate (LHRHa) efficacy in localized high-risk prostate cancer, Eleni Efstathiou, MD, PhD, of the University of Texas MD Anderson Cancer Center, in Houston, said during a presentation at the American Society of Clinical Oncology.

“Pathologic downstaging (≤ pT2N0) occurred in 30% of patients treated with the combination therapy (AA+ENZA+ LHRHa) versus 52% of patients who received AA plus LHRHa alone (P=0.07), the study showed. Despite universal PSA depletion (≤ 0.1), a wide range of viable tumor was observed (volume 0-8.64 cc, cellularity 0-90%, and a tumor epithelial volume [TEV] 0-5.58 cc). TEV and stage were aligned.”

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Surgery Improves Survival Rates for Men With Prostate Cancer If Radiation Treatments Fail

“Approximately 14 percent of men will be diagnosed with prostate cancer at some point in their lifetimes, according to the National Institutes of Health. Radiation therapy traditionally has been a primary treatment for the cancer, but one-fourth of men have a recurrence of prostate cancer within five years after the therapy. Now, a University of Missouri School of Medicine researcher has found that a complex procedure to remove the prostate achieves excellent long-term survival for men after radiation therapy has failed.

” ‘Prostate cancer, unfortunately, is a common cancer, and more than 27,000 men are estimated to have died from the disease in 2015,’ said Naveen Pokala, M.D., an assistant professor in the Division of Urology at the MU School of Medicine and lead author of the study. ‘By studying a national database of prostate cancer cases, we found that a procedure known as salvage radical prostatectomy can greatly increase a man’s chance of survival when traditional radiation therapy has failed to eradicate the cancer.’ ”


Postprostatectomy Radiation Therapy Yields Low Toxicity and Favorable Patient-Reported Quality of Life

“A prospective study of guideline-based, postoperative, image-guided intensity-modulated radiation therapy in patients with prostate cancer found low toxicity profiles and favorable patient-reported quality of life following treatment, with researchers concluding that toxicity and health-related quality of life should not impact the recommendation of radiation therapy following prostatectomy. The research was published by Berlin et al in Practical Radiation Oncology.

“Postprostatectomy radiation therapy has been reported as underutilized, with randomized trials showing the benefit of adjuvant radiation therapy, but only about 10% of patients receiving the treatment. One potential reason for underutilization could be concern over side effects or a negative impact on health-related quality of life.”


Adding ADT to RT Improved PFS After Radical Prostatectomy

“Assigning men in biological relapse after radical prostatectomy to combined salvage treatment with hormone therapy and radiation therapy significantly delayed disease progression compared with radiation therapy alone, according to the results of the GETUG-AFU 16 phase III trial (abstract 5006).

“ ‘Salvage radiotherapy combined with limited androgen deprivation therapy improves the 5-year progression-free survival rate compared to radiotherapy alone,’ said study presenter Christian Carrie, MD, of the department of radiation oncology at the University of Lyon-Centre Leon Berard. ‘There is no significant difference in overall survival, but the follow-up is still too short.’

“Between October 2006 and March 2010, 743 patients were enrolled in GETUG-AFU 16 and randomly assigned to radiation therapy alone (n = 374) or radiation plus hormone therapy with goserelin 10.8 mg for 6 months (n = 369). The primary endpoint of the trial was progression-free survival.”


Robotic Prostatectomy: Volume, Complications, Disincentives (CME/CE)

“As robot-assisted radical prostatectomy (RARP) migrated into the community setting, institutional volume decreased leading to a twofold difference in complication rates between low- and high-volume centers, according to a study reported here.

“From 2009 through 2011, the number of hospitals offering RARP remained stable, but median procedural volume decreased from 137 cases to 85. Hospitals that performed the fewest RARP procedures had a 14.7% complication rate, whereas complications occurred in 5.7% of procedures at high-volume hospitals.

“The findings suggest that market and reimbursement forces created a ‘perverse disincentive’ that discouraged low-volume hospitals from referring patients to high-volume centers, Jesse Sammon, DO, of the Henry Ford Health System in Detroit, said at the American Urological Association meeting.’

” ‘As more institutions acquire a robot, in the U.S., the fee-for-service model tends to disincentivize referral to high-volume institutions,’ said Sammon. ‘Once you’ve invested in a robotic platform, you’re incentivized to promote its use, even if you’re only doing 20, 25, or 30 cases a year.

” ‘The question is: Does this jeopardize patient care? I would say it’s hard to argue against that.’ “


Recurrence of Prostate Cancer Detected Earlier with Innovative PSMA-Ligand PET/CT

“A recent study reported in The Journal of Nuclear Medicine compared use of the novel Ga-68-PSMA-ligand PET/CT with other imaging methods and found that it had substantially higher detection rates of prostate-specific membrane antigen (PSMA) in patients with biochemical recurrence after radical prostatectomy. Discovering a recurrence early can strongly influence further clinical management, so it is especially noteworthy that this hybrid PSMA-ligand identified a large number of positive findings in the clinically important range of low PSA-values (<0.5ng/mL).

“According to the CDC, prostate cancer is the most common cancer among men in the United States, after non-melanoma skin cancer. While many men with prostate cancer die from other causes, prostate cancer remains one of the leading causes of cancer death among men of all races. Treatment and survival after recurrence depend on many factors, but early detection of the recurrence is certainly key.

“Matthias Eiber, MD, corresponding author of the study, noted, ‘The study is the first to examine this highly promising PET tracer in the use of a homogeneous patient collective consisting of only those with biochemical recurrence after radical prostatectomy. It found superb detection rates compared to other tracers, like choline, or imaging modalities, like MRI. For patients, this means that the referring urologist can receive earlier and more precise information about the site and extent of metastatic disease. Physicians will also be better able estimate whether a PSMA-PET scan might be useful in a specific setting.’ “