Prostate cancer news update: Tuesday, December 22, 2009

There are three fairly significant news reports today dealing with the following issues:

  • The relationship between a family history of prostate cancer and age at diagnosis
  • The impact of RALP on selection of surgery as a first-line treatment option
  • The management of ADT-related hot flashes

It is well known that a family history of prostate cancer is associated with an increased risk for diagnosis. However, quantification of this risk is less well documented. Brandt et al. have analyzed data from the national Swedish Family-Cancer Database, which classifies patients according to the number and type of affected first-degree relatives (father or brother) and according to the relative’s age at diagnosis. Using data from this source, they showed that the cumulative incidence of prostate cancer was highest for men with multiple affected first-degree relatives, and it was higher for brothers than for sons of prostate cancer patients. They also showed that the age to reach the same cumulative incidence as the general population at age 55 years varied slightly, decreasing with decreasing age at diagnosis of the relative, and ranged from 48.7 years (when the patient’s father was diagnosed at younger than 60 years of age) to 53.7 years (when the patient’s father was diagnosed at more than 82 years of age). Apparently, in this population, prostate cancer-specific mortality was also related to the number and type of affected relatives — but there was no clear evidence for a dependency on the age at diagnosis of the relative.

Secondly, Barlow et al. used their institutional database in an attempt to determine whether the lower short-term morbidity associated with robot-assisted radical prostatectomy (RALP) compared to open surgery has resulted in any alteration in the disease-specific risk profile of radical prostatectomy (RP) patients. They identified 1,751 patients who underwent  RP between 2000 and 2007 at their institution. These patients were then divided into two groups: patients who received surgery either before or after the initiation of RALP at their institution (from 2003 onward). They found that between 2000 and 2002 (the “pre-RALP” era) a total of 663 patients underwent an open RP and from 2003 to 2007 a total of 1,088 patients had an RP, of whom 519 had a RALP and 569 had an open RP. There was no significant difference between the two eras regarding patient age, Kattan nomogram score, or tumor stage. There was a significant difference between the patients’ preoperative PSA levels and Gleason scores. Overall, however, the authors conclude that the advent of RALP for prostate cancer at their institution did not significantly affect the characteristics of patients undergoing prostatectomy, and that the advent of RALP had no consequential effect on the risk stratification of patients choosing surgery for prostate cancer at this institution. This study is interesting primarily because the advent of minimally invasive forms of surgery for other elective procedure (e.g., cholecystectomy for the treatment of gall bladder inflammation) has historically been associated with an expansion in the numbers of patients willing to undergo surgery.

The third report, by Irani et al., deals with a randomized, double-blind, controlled trial of a drug called venlaxafine (Effexor) compared to older drugs (medroxyprogesterone acetate and cyproterone acetate) in the management of hot flashes. Each of these three drugs has shown effectiveness in management of hot flashes in the past. However, there has been no prior randomized trial comparing their effectiveness. The study initially enrolled 919 patients at 106 French urology centers between April 2004 and April 2007. All patients were treated for 6 months with an LHRH agonist alone. At month 6, patients who spontaneously asked for treatment, or those who presented with 14 hot flashes or more during the week before the visit, were randomly assigned to either venlafaxine 75 mg daily, medroxyprogesterone acetate 20 mg daily, or cyproterone acetate 100 mg daily. Of the 919 men initially enrolled, 311 were randomly assigned to one of the study treatments at 6 months: 102 to venlafaxine, 101 to cyproterone, and 108 to medroxyprogesterone. 309/311 patients were included in the efficacy analysis, since two were excluded for protocol deviations. The changes in median daily hot-flash score between randomization and 1 month post-randomization were: -47.2 percent in the venlafaxine group, -94.5 percent in the cyproterone group, and -83.7% percent in the medroxyprogesterone group. The decreases in hot-flash score were significantly larger in the cyproterone and medroxyprogesterone groups than in the venlafaxine group, but here was no significant difference between the cyproterone and medroxyprogesterone groups. Serious side effects occurred in four, seven, and five patients in the venlafaxine, cyproterone, and medroxyprogesterone groups, respectively, but only two of these side effects were considered related to the drug. The authors conclude that venlafaxine, cyproterone, and medroxyprogesterone were all effective in reducing hot flushes, but that cyproterone and medroxyprogesterone acetate were both significantly more effective than venlafaxine. They further state that since (in Europe) cyproterone acetate is a recognized treatment for prostate cancer, and its use could interfere with hormonal therapy, medroxyprogesterone “could be considered to be the standard treatment” for hot flashes in men undergoing androgen suppression for prostate cancer. The “New” Prostate Cancer InfoLink notes that cyproterone acetate has never been approved for use in the USA, so it’s use is not an option in this country.

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