Prostate Cancer

Prostate-specific antigen testing, the most widely used screening tool in prostate cancer, has long had both critics and supporters. Two studies published in the New England Journal of Medicine continue to generate debate over the value of PSA screening. The papers have two major points in common: They are large-scale studies, and they leave more questions than answers.

DENVER—Designer T cells that attack tumors with a vengeance could be the future of prostate cancer treatment. Although the results are very preliminary, the incorporation of designer T cells into prostate cancer treatment led to a significant reduction in PSA levels, according to researchers from Boston University School of Medicine in Providence, R.I.

SAN FRANCISCO-Studies show improved outcomes when androgen deprivation therapy (ADT) is part of the care for men with intermediate-risk prostate cancer, said Mack Roach III, MD, taking the “pro” side of a debate on the issue. But “con” speaker Arul Mahadevan, MD, argued that the studies in question included mostly high-risk patients, and that monotherapy is effective in intermediate-risk patients.

Osteoporosis, the most common late effect of cancer treatment in the US, occurs with greater frequency among cancer survivors than the general population. Survivors of breast cancer, prostate cancer, and childhood leukemia are at particularly high risk for changes in bone mineral density (BMD) / osteoporosis that can lead to fractures.[1] In breast and prostate cancer patients, bone effects are often the result of endocrine therapy–induced alterations in bone microarchitecture. They also can be caused by other types of cancer therapy, vitamin D deficiency, and other physiological changes that may or may not be related to cancer or its treatment. In childhood leukemia patients, bone effects can be caused by a variety of factors, including corticosteroid therapy, radiation therapy to the brain, and the disease itself.

Ferring Pharmaceuticals received approval from the US Food and Drug Administration (FDA) for degarelix, a new injectable gonadotropin-releasing hormone (GnRH) receptor antagonist indicated for patients with advanced prostate cancer.

CHICAGO-Prostate-specific antigen measurements are considered a useful organ-specific marker, but they are not necessarily an adequate tumor marker. PET/CT in combination with PSA levels can play a significant role in detecting and staging prostate cancer, according to two presentations at RSNA 2008 (abstracts SSA18-02 and SSA18-09).

Omer Kucuk, MD, has joined Emory University’s Winship Cancer Institute in Atlanta as professor of hematology and medical oncology. Dr. Kucuk conducted the earliest clinical trials on soy and lycopene supplements in prostate cancer treatment. He was previously at the Karmanos Cancer Center at Wayne State University in Detroit.

When the U.S. Preventive Services Task Force reported that routine prostate cancer screening for older men appears to result in little benefit, the announcement raised more than a few eyebrows in the urologic medical community.

For men with locally advanced prostate cancer, the addition of radiation treatment to antiandrogen hormone therapy reduces the risk of dying of prostate cancer by 50% compared to those who have antiandrogen hormone treatment alone, according to a randomized study presented September 22, 2008, during the plenary session of the American Society for Therapeutic Radiology and Oncology’s 50th Annual Meeting in Boston.

Men over 70 years of age with early-stage prostate cancer have a 20% higher mortality if they are treated first with hormone therapy before being treated with radiation seed implants (brachytherapy), compared to men who are treated with brachytherapy alone, according to the largest cohort study of its kind presented September 23, 2008, at the 50th Annual Meeting of the American Society for Therapeutic Radiology and Oncology in Boston.

During this election year, approximately 1.4 million U.S. residents will be diagnosed with cancer. For U.S. presidential hopefuls Sen. Barack Obama and Sen. John McCain, cancer has hit close to home. Sen. McCain, 72, has been treated several times for squamous cell carcinoma and malignant melanoma. Sen. Obama lost his grandfather to prostate cancer and his mother to ovarian cancer.

SOUTH SAN FRANCISCO-Cell Genesys terminated VITAL-2, the second of two phase III clinical trials of Gvax immunotherapy for prostate cancer.

In the article entitled "Interstitial Brachytherapy Should Be Standard of Care for Treatment of High-Risk Prostate Cancer," Merrick, Wallner, and Butler once again make the case for interstitial brachytherapy as a primary treatment for prostate cancer (see their earlier article, "Permanent Prostate Brachytherapy: Is Supplemental External-Beam Radiation Therapy Necessary?" in ONCOLOGY, April 2006).[1] This time Nathan Bittner has joined as the lead author.

In this issue of ONCOLOGY, Bittner et al provide a thoughtful review of the literature to advocate for the viewpoint that interstitial brachytherapy should be standard of care for the treatment of high-risk prostate cancer.

In the realm of general oncology, patients who present with aggressive, poorly differentiated malignancies are usually at high risk for disseminated disease, and systemic therapy often supersedes local therapy in importance. It is not surprising, then, that a similar systemic approach to therapy is often considered for patients who present with high-risk prostate cancer. This recommendation is often supported by much of the surgical literature that cites discouraging outcomes in these patients when treated by radical prostatectomy alone.

The magnitude of the role surgical exploration and extirpation play in the contemporary management of patients with advanced ovarian cancer is hard to overstate. Beyond diagnostic confirmation, the aggressive posture taken to remove bulk disease provides-among other benefits-symptomatic relief, theoretically enhanced immunologic integrity, chemosensitivity, and improved survival characteristics.

Given the poor outcomes observed with radical prostatectomy (RP) and external-beam radiation therapy (EBRT), some in the urologic community contend that high-risk disease is not curable with currently available treatment strategies.[1,2] In fact, there is a growing contingent of clinicians who advocate the use of chemotherapy in conjunction with RP. With the established efficacy of brachytherapy, these efforts are likely excessive.

The standard management for advanced-stage ovarian cancer was established in the mid-1970s. At a 1974 National Cancer Institute Consensus Conference on Ovarian Cancer, Griffiths presented data supporting the role for aggressive cytoreductive surgery as the first step in the management of this disease, followed by cytotoxic chemotherapy.

A combination of two antiangiogenic agents-bevacizumab (Avastin) and thalidomide (Thalomid)-with docetaxel (Taxotere) is associated with a median progression-free survival of about a year and a half among men with metastatic, hormone-refractory prostate cancer, finds a phase II trial presented at ASCO 2008 (abstract 5000).

Treatment inside a 2-year window and a PSA doubling time of less than 6 months may be the key factors for optimizing salvage radiotherapy results for recurrent prostate cancer, according to investigators from the Brady Urological Institute at Johns Hopkins School of Medicine in Baltimore.

Mice that are prone to develop prostate tumors because they lack the PTEN tumor-suppressor protein remained cancer free when researchers disabled the growth-stimulating p110-beta protein, suggesting that this protein could be a promising prostate cancer drug target (Nature doi:10.1038/nature07091).

This is an expertly written summary of the experience with cryotherapy as primary treatment of prostate cancer and the rationale for proceeding toward more limited, organ-sparing approaches with this procedure as focal treatment for low-risk cancers. Growing evidence of overdetection and overtreatment in many men with low-risk tumors has resulted in the recognition that alternatives to conventional treatment strategies are needed. Observation, a laudable and appropriate approach, appeals to relatively few patients.

The article by Polascik and coauthors provides a timely synopsis of modern technologic advances in prostate cryoablation and a review of the rationale for and experience with targeted prostate treatments. Prostate cryoablation has a storied past, which can be briefly summarized as high excitement followed by near-complete abandonment. Fortunately, a few practitioners improved the technique and incorporated new technologies allowing for its resurrection.

Recently, third-generation cryosurgery has been widely introduced into clinical practice using argon-driven, ultrathin 17-gauge cryoprobes in accordance with the Joule-Thompson principle.[1-3] Contemporary cryosurgery includes these technologic advances along with the routine utilization of ultrathin needles incorporating a thermal monitoring system (TMS) for temperature surveillance, transrectal ultrasound (TRUS) imaging, and a urethral warming catheter to minimize morbidity associated with the procedure.[4-7]

CHICAGO-The combination of custir-sen sodium (OGX-011, OncoGenex Technologies Inc), an investigational agent, with docetaxel (Taxotere) or mitoxantrone has acceptable toxicity in patients with hormone-refractory prostate cancer who have experienced a failure of first-line docetaxel-based chemotherapy, investigators reported at ASCO 2008 (abstract 5002). Efficacy outcomes were somewhat better with the custirsen/docetaxel combination.

High-intensity focused ultrasonic (HIFU) ablation is used to manage localized prostate cancer after external beam radiation therapy. But post-treatment alterations to prostate zonal anatomy hamper the assessment of local tumor progression in order to make decisions about second-line treatment. An interdisciplinary group from South Korea tested two MRI techniques for predicting local tumor progression.

External-beam radiation is a highly effective curative treatment option for men with localized prostate cancer.[1,2] Over the past several decades, efforts have been made to improve the “therapeutic ratio” of radiation by increasing dose to improve cure rates without causing a substantial increase in side effects. Due to its potential to create superior dose distributions, proton therapy is considered by many to be the best available form of external radiation therapy. Here we will critically examine the evidence supporting the use of protons in the treatment of prostate cancer.

Financial pressures from Medicare reimbursement changes may have caused physicians to switch from providing hormonal-induced castration to providing surgical castration for men with prostate cancer. That is the finding of a new study published in the May 15 issue of CANCER. The study suggests that factors other than evidence-based medicine may have a significant influence on treatment decisions.

A drug proven effective in a large randomized prostate cancer prevention trial is rarely used for that indication. ONI explores the economic and clinical reasons underlying the agent's lack of use.

Medical castration has lost some ground as the preferred androgen deprivation treatment for prostate cancer, while use of surgical castration has increased slightly, according to researchers from the Cleveland Clinic.