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1.  Trends of risk classification and primary therapy for Japanese patients with prostate cancer in Nara Uro-Oncological Research Group (NUORG)–a comparison between 2004-2006 and 2007-2009 
BMC Cancer  2013;13:588.
To assess the trends of risk classification and primary therapy in Japanese patients who were diagnosed with prostate cancer between 2004-2006 and 2007-2009.
A total of 4752 patients who were newly diagnosed with prostate cancer at Nara Medical University and its 23 affiliated hospitals between 2004 and 2009 were enrolled. The differences in risk classification and primary therapy were compared in patients who were newly diagnosed between 2004-2006 (prior period) and 2007-2009 (latter period).
The proportion of patients with a high or greater risk significantly decreased in the latter period compared to the prior period (p < 0.001). The proportion of primary androgen deprivation therapy (PADT) was 50% in the prior period, and 40% in the latter period. On the other hand, the proportion of radiation therapy was 14% in the prior period, but 24% in the latter period. The proportion of radical prostatectomy was the same in the two periods (30%). The primary therapy was significantly different between the two periods (p < 0.001).
Higher risk patients significantly decreased in the latter period compared to the prior period. The use of PADT also significantly decreased in the latter period. However, there were still higher risk patients in Japan, and the use of PADT was still common in patients with localized prostate cancer or locally advanced prostate cancer in Japan.
PMCID: PMC4028809  PMID: 24325407
Primary therapy; Primary androgen deprivation therapy; Radical prostatectomy; Radiation therapy; Risk classification; Active surveillance
2.  The Role of Primary Androgen Deprivation Therapy in Localized Prostate Cancer 
European urology  2009;56(4):609-616.
Primary androgen deprivation therapy (PADT) is frequently used as a sole modality of treatment in men with localized prostate cancer, despite a lack of clinical trial data supporting its use.
To measure the impact of treatment with PADT compared to observation on overall survival in men with organ-confined prostate cancer.
Design, setting, and participants
The design was for an observational cohort from Surveillance, Epidemiology, and End Results (SEER) Medicare data. The cohort consisted of 16 535 men aged 65–80 yr at diagnosis with organ-confined well-differentiated or moderately differentiated prostate cancer who survived >1 yr past diagnosis and did not undergo treatment with prostatectomy or radiation therapy within 6 mo of diagnosis. They were diagnosed between 1991 and 1999 and followed until death or until the end of the study period (December 31, 2002).
Study subjects were selected to receive PADT alone if they received luteinizing hormone-releasing hormone agonists or bilateral orchiectomy in the first 6 mo after diagnosis, and they were selected to be observed if they did not have claims for PADT during the same interval.
Overall survival.
Results and limitations
After adjusting for potential confounders (ie, tumor characteristics, comorbidities, and demographics), patients who received ADT had a worse overall survival rate than patients who were observed (hazard ratio: 1.20; 95% confidence interval: 1.13–1.27).
In observational studies there may be unmeasured differences between the treated and untreated groups. The SEER database does not provide information on prostate-specific antigen levels.
This large, population-based study suggests that PADT did not improve survival in men with localized prostate cancer, but it suggests that PADT may instead result in worse outcomes compared with observation. Patients and physicians should be cognizant of the potential long-term side effects of ADT in a patient population for which expectant observation is an acceptable treatment strategy.
PMCID: PMC2791191  PMID: 19368995
3.  Nadir PSA level and time to nadir PSA are prognostic factors in patients with metastatic prostate cancer 
BMC Urology  2014;14:33.
Primary androgen deprivation therapy (PADT) is the most effective systemic therapy for patients with metastatic prostate cancer. Nevertheless, once PSA progression develops, the prognosis is serious and mortal. We sought to identify factors that predicted the prognosis in a series of patients with metastatic prostate cancer.
Two-hundred eighty-six metastatic prostate cancer patients who received PADT from 1998 to 2005 in Nara Uro-Oncology Research Group were enrolled. The log-rank test and Cox’s proportional hazards model were used to determine the predictive factors for prognosis; rate of castration-resistant prostate cancer (CRPC) and overall survival.
The median age, follow-up period and PSA level at diagnosis were 73 years, 47 months and 174 ng/mL, respectively. The 5-year overall survival rate was 63.0%. The multivariable analysis showed that Gleason score (Hazard ratio [HR]:1.362; 95% confidence interval [C.I.], 1.023-1.813), nadir PSA (HR:6.332; 95% C.I., 4.006-9.861) and time from PADT to nadir (HR:4.408; 95% C.I., 3.099-6.271) were independent prognostic factors of the incidence of CRPC. The independent parameters in the multivariate analysis that predicted overall survival were nadir PSA (HR:5.221; 95% C.I., 2.757-9.889) and time from PADT to nadir (HR:4.008; 95% C.I., 2.137-7.517).
Nadir PSA and time from PADT to nadir were factors that affect both CRPC and overall survival in a cohort of patients with metastatic prostate cancer. Lower nadir PSA level and longer time from PADT to nadir were good for survival and progression.
PMCID: PMC4018264  PMID: 24773608
Prostate cancer; Metastasis; Risk factors
4.  Risk Assessment Among Prostate Cancer Patients Receiving Primary Androgen Deprivation Therapy 
Journal of Clinical Oncology  2009;27(26):4306-4313.
Prostate cancer epidemiology has been marked overall by a downward risk migration over time. However, in some populations, both in the United States and abroad, many men are still diagnosed with high-risk and/or advanced disease. Primary androgen deprivation therapy (PADT) is frequently offered to these patients, and disease risk prediction is not well-established in this context. We compared risk features between large disease registries from the United States and Japan, and aimed to build and validate a risk prediction model applicable to PADT patients.
Data were analyzed from 13,740 men in the United States community-based Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry and 19,265 men in the Japan Study Group of Prostate Cancer (J-CaP) database, a national Japanese registry of men receiving androgen deprivation therapy. Risk distribution was compared between the two datasets using three well-described multivariable instruments. A novel instrument (Japan Cancer of the Prostate Risk Assessment [J-CAPRA]) was designed and validated to be specifically applicable to PADT patients, and more relevant to high-risk patients than existing instruments.
J-CaP patients are more likely than CaPSURE patients to be diagnosed with high-risk features; 43% of J-CaP versus 5% of CaPSURE patients had locally advanced or metastatic disease that could not be stratified with the standard risk assessment tools. J-CAPRA—scored 0 to 12 based on Gleason score, prostate-specific antigen level, and clinical stage—predicts progression-free survival among PADT patients in J-CaP with a c-index of 0.71, and cancer-specific survival among PADT patients in CaPSURE with a c-index of 0.84.
The novel J-CAPRA is the first risk instrument developed and validated for patients undergoing PADT. It is applicable to those with both localized and advanced disease, and performs well in diverse populations.
PMCID: PMC2744272  PMID: 19667269
5.  Risk factors of PSA progression and overall survival in patients with localized and locally advanced prostate cancer treated with primary androgen deprivation therapy 
BMC Cancer  2015;15:420.
Primary androgen deprivation therapy (PADT) has played an important role in the treatment of prostate cancer. We sought to identify factors of PSA progression in our series of patients with localized and locally advanced prostate cancer treated with PADT.
Six-hundred forty-nine patients with localized and locally advanced prostate cancer who received PADT from 1998 to 2005 by Nara Uro-Oncology Research Group were enrolled. Age, T classification, stage, PSA level at diagnosis, Gleason score, laterality of cancer detected by biopsy and seminal vesicle involvement (SVI) were adopted as parameters of PSA progression. Cox’s proportional hazards model was used to determine the predictive factors for PSA progression.
The median follow-up period and the median PSA level at diagnosis were 49 months and 15 ng/mL. The 5-year disease specific survival rate, overall survival rate and PSA progression-free survival (PFS) rate were 97.9 %, 91.9 % and 71.2 %, respectively. The univariate analysis showed that the PSA level at diagnosis, Gleason score, laterality of cancer detected by biopsy and SVI were independent predictive parameters of PSA-PFS. However, by multivariate analysis, only laterality of cancer detected by biopsy (unilateral vs. bilateral) was an independent predictive parameter of PSA-PFS (p = 0.034). The patients were classified into new risk groups base on three factors: PSA level at diagnosis, Gleason score, and laterality of cancer detected by biopsy. The PSA-PFS rates at 5-years in the low- (none or one factor), intermediate- (two factors) and high-risk (three factors) groups were 78.2 %, 62.5 % and 46.9 % (p < 0.001), respectively.
In localized or locally advanced prostate cancer patients who received PADT, laterality of cancer detected by biopsy was a significant predictor associated with a longer PSA-PFS. Our new risk grouping indicates the usefulness of PSA-PFS.
PMCID: PMC4446859  PMID: 25990314
Localized and locally advanced prostate cancer; Primary androgen deprivation therapy; Risk factors
6.  Effectiveness of Primary Androgen-Deprivation Therapy for Clinically Localized Prostate Cancer 
Journal of Clinical Oncology  2014;32(13):1324-1330.
Primary androgen-deprivation therapy (PADT) is often used to treat clinically localized prostate cancer, but its effects on cause-specific and overall mortality have not been established. Given the widespread use of PADT and the potential risks of serious adverse effects, accurate mortality data are needed to inform treatment decisions.
We conducted a retrospective cohort study using comprehensive utilization and cancer registry data from three integrated health plans. All men were newly diagnosed with clinically localized prostate cancer. Men who were diagnosed between 1995 and 2008, were not treated with curative intent therapy, and received follow-up through December 2010 were included in the study (n = 15,170). We examined all-cause and prostate cancer-specific mortality as our main outcomes. We used Cox proportional hazards models with and without propensity score analysis.
Overall, PADT was associated with neither a risk of all-cause mortality (hazard ratio [HR], 1.04; 95% CI, 0.97 to 1.11) nor prostate-cancer–specific mortality (HR, 1.03; 95% CI, 0.89 to 1.19) after adjusting for all sociodemographic and clinical characteristics. PADT was associated with decreased risk of all-cause mortality but not prostate-cancer–specific mortality. PADT was associated with decreased risk of all-cause mortality only among the subgroup of men with a high risk of cancer progression (HR, 0.88; 95% CI, 0.78 to 0.97).
We found no mortality benefit from PADT compared with no PADT for most men with clinically localized prostate cancer who did not receive curative intent therapy. Men with higher-risk disease may derive a small clinical benefit from PADT. Our study provides the best available contemporary evidence on the lack of survival benefit from PADT for most men with clinically localized prostate cancer.
PMCID: PMC3992722  PMID: 24638009
7.  Survival Following Primary Androgen Deprivation Therapy among Men with Localized Prostate Cancer 
Despite a lack of data, increasing numbers of patients are receiving primary androgen deprivation therapy (PADT) as an alternative to surgery, radiation or conservative management for the treatment of localized prostate cancer.
Evaluate the association between PADT and survival in elderly men with localized prostate cancer.
Main Outcome Measures
Cancer-specific and overall survival.
Population-based cohort study of 19,271 men who did not receive definitive local therapy for T1-T2 prostate cancer. Instrumental variable analysis was used to address potential biases associated with unmeasured confounding variables.
Medicare patients aged ≥66 years diagnosed in 1992-2002 within predefined US geographical areas.
Even though 41% of the population (median age 77) received PADT, PADT was associated with somewhat worse 10-year prostate cancer-specific survival (80.1% vs. 82.6%, hazard ratio [HR] 1.17; 95% CI 1.03–1.33) and no improvement in 10-year overall survival (30.2% vs. 30.3%,, HR 1.00; 95% CI 0.96–1.05) compared to conservative management. However, in a pre-specified subset analysis, PADT use in men with poorly-differentiated cancer was associated with marginally improved prostate cancer-specific survival (HR 0.84; 95% CI 0.70–1.00, P =0.05) but not overall survival (HR 0.92; 95% CI 0.84 – 1.01).
Primary androgen deprivation therapy is not associated with improved survival among the majority of elderly men with localized prostate cancer when compared with conservative management.
PMCID: PMC2645653  PMID: 18612114
prostatic neoplasm; Medicare; SEER program; antineoplastic agents; hormonal
8.  Does Primary Androgen-Deprivation Therapy Delay the Receipt of Secondary Cancer Therapy for Localized Prostate Cancer? 
European urology  2012;62(6):966-972.
Despite evidence that shows no survival advantage, many older patients receive primary androgen-deprivation therapy (PADT) shortly after the diagnosis of localized prostate cancer (PCa).
This study evaluates whether the early use of PADT affects the subsequent receipt of additional palliative cancer treatments such as chemotherapy, palliative radiation therapy, or intervention for spinal cord compression or bladder outlet obstruction.
Design, setting, and participants
This longitudinal population-based cohort study consists of Medicare patients aged ≥66 yr diagnosed with localized PCa from 1992 to 2006 in areas covered by the Surveillance Epidemiology and End Results (SEER) program. SEER-Medicare linked data through 2009 were used to identify the use of PADT and palliative cancer therapy.
Outcome measurements and statistical analysis
Instrumental variable analysis methods were used to minimize confounding effects. Confidence intervals were derived from the bootstrap estimates.
Results and limitations
This study includes 29 775 men who did not receive local therapy for T1–T2 PCa within the first year of cancer diagnosis. Among low-risk patients (Gleason score 2–7 in 1992–2002 and Gleason score 2–6 in 2003–2006) with a median age of 78 yr and a median follow-up of 10.3 yr, PADT was associated with a 25% higher use of chemotherapy (hazard ratio [HR]: 1.25; 95% confidence interval [CI], 1.08–1.44) and a borderline higher use of any palliative cancer surgery (HR: 1.07; 95% CI, 0.97– 1.19) within 10 yr of diagnosis in regions with high PADT use compared with regions with low PADT use. Because this study was limited to men >65 yr, the results may not be applicable to younger patients.
Early treatment of low-risk, localized PCa with PADT does not delay the receipt of subsequent palliative therapies and is associated with an increased use of chemotherapy.
PMCID: PMC3472155  PMID: 22608160
Prostatic neoplasm; Medicare; SEER program; Antineoplastic agents–hormonal
9.  Androgen-deprivation therapy versus radical prostatectomy as monotherapy among clinically localized prostate cancer patients 
OncoTargets and therapy  2013;6:725-732.
The most recent randomized controlled trial in a predominantly prostate-specific antigen-detected prostate cancer (PC) population found a nonsignificant reduction in mortality from radical prostatectomy (RP) compared to conservative management. The optimal treatment for clinically localized prostate cancer is anything but clear. The PC-specific mortality and all-cause mortality were compared between primary androgen-deprivation treatment (PADT) and RP, both as monotherapy, among clinically localized PC patients.
A retrospective cohort study among PC patients in Surveillance, Epidemiology and End Results-Medicare data with a median follow up of 2.87 years in the PADT cohort and 2.95 years in the RP cohort. Propensity score-matching was employed to adjust for the observed selection bias. PC-specific mortality and all-cause mortality were modeled using the Fine and Gray competing risk model and Cox proportional hazards model, respectively. The independent variables in these models included age, race, Gleason score risk groups, T-score, prostate-specific antigen, Charlson comorbidity, and index year of treatment initiation.
After propensity score-matching, there were 1624 in the PADT cohort and 1624 in the RP cohort. All baseline values were comparable (all P-values >0.35). There were a total of 266 deaths (16.38%) and 60 (3.69%) PC-specific deaths among PADT recipients, while there were 56 (3.45%) deaths and four (0.25%) PC-specific deaths among RP recipients. According to the Kaplan–Meier estimation, the 8-year survival rate was 43.39% in the PADT cohort and 79.62% in the RP cohort. PADT was associated with increased risk of overall mortality (hazard ratio = 2.98, 95% confidence interval 2.35–3.79; P < 0.001) and increased risk of PC-specific mortality (hazard ratio = 12.47, 95% confidence interval 4.48–34.70; P < 0.001).
With adjustment for the observed selection bias, PADT was associated with increased all-cause mortality and PC-specific mortality when compared to RP.
PMCID: PMC3699299  PMID: 23836984
prostate cancer; primary androgen-deprivation treatment; radical prostatectomy; survival
10.  National Practice Patterns and Time Trends in Androgen Ablation for Localized Prostate Cancer 
Recent reports have suggested that growing numbers of patients with localized prostate cancer are receiving androgen deprivation therapy as primary or neoadjuvant treatment, yet sparse clinical evidence supports the use of such treatment in some contexts. We describe national trends in the use of androgen deprivation therapy for localized disease and identify sociodemographic variables that are associated with its use.
CaPSURE™ is an observational database of 7195 patients with prostate cancer. For this study, 3439 of these patients were included who were diagnosed since 1989, had clinical staging information available, and were treated with radical prostatectomy, radiation therapy, or primary androgen deprivation therapy (PADT). High-, intermediate-, or low-risk groups were defined by serum prostate-specific antigen level, Gleason sum, and clinical tumor stage. Time trends in use of PADT and neoadjuvant androgen deprivation therapy (NADT) were analyzed, and a multivariable logistic regression model was used to identify sociodemographic factors associated with various treatments. All statistical tests were two-sided.
Rates of PADT use have risen sharply from 4.6% to 14.2%, 8.9% to 19.7%, and 32.8% to 48.2% (all P<.001) in low-, intermediate-, and high-risk groups, respectively. NADT use likewise has increased in association with radical prostatectomy (2.9% to 7.8% of patients, P = .003) and external-beam radiotherapy (9.8% to 74.6%, P<.001) across all risk levels combined. Rates among patients treated with brachytherapy also have risen but the rise was not statistically significant. (7.4% to 24.6%, P = .100).
Rates of both PADT and NADT are increasing across risk groups and treatment types. Additional clinical trials must define more clearly the appropriate role of hormonal therapy in localized prostate cancer, and future results should shape updated practice guidelines.
PMCID: PMC2994265  PMID: 12837834
11.  Primary Androgen Deprivation Therapy for Prostate Cancer in Koreans: A Retrospective Multicenter Study 
The World Journal of Men's Health  2014;32(3):159-166.
To evaluate the characteristics of patients who received primary androgen deprivation therapy (PADT) for prostate cancer and the clinical efficacy of this treatment.
Materials and Methods
Two hundred forty patients treated by PADT were reviewed. These patients could not receive definitive therapy owing to old age, patient need, and medical comorbidity. The patients were divided into three groups according to the extent of prostate cancer: localized, locally advanced, and metastatic. Then, prostate-specific antigen (PSA) progression in these groups was analyzed.
The median age of the patients was 73.0 years, and the median pretreatment PSA level was 47.0 ng/mL. Of the patients, 91.7% were treated with combined androgen blockade, and 8.3% were treated with monotherapy. Clinical factors for PSA progression were a PSA nadir and a high clinical stage. Estimated PSA recurrence-free median survival time in each group was 57, 24, and 12 months, respectively. A PSA nadir of >0.2 ng/mL and metastatic stage were independent factors for expecting a poor response to PADT (hazard ratio 4.26, p<0.001; and 2.60, p<0.001).
Patients with localized or locally advanced prostate cancer who did not receive definitive therapy had lower PSA progression rates than those at metastatic stage during PADT. Further, a PSA nadir of ≤0.2 ng/mL showed better progression-free survival. Therefore, PADT can be another therapeutic option in well-selected patients with localized or locally advanced prostate cancer and PSA change should be checked carefully.
PMCID: PMC4298819  PMID: 25606565
Androgen antagonists; Prostate; Prostate neoplasms
12.  Evaluation of primary androgen deprivation therapy in prostate cancer patients using the J-CAPRA risk score 
Prostate International  2013;1(2):81-88.
To determine the influence of maximal androgen blockade (MAB) and non-MAB hormonal therapy with an luteinizing hormone releasing hormone (LHRH) analog on overall survival of prostate cancer patients in the Japan Study Group of Prostate Cancer (J-CaP) registry according to risk, as assessed using the novel J-CAPRA risk instrument. To undertake a multivariate analysis combining J-CAPRA risk score, type of hormonal therapy and comorbidities, in order to assess their impact on overall survival.
The J-CaP database includes men in Japan diagnosed with any stage of prostate cancer between 2001 and 2003 and treated with primary androgen deprivation therapy (PADT), as monotherapy or in combination. A total of 26,272 men were enrolled and of these 19,265 were treated with PADT. This analysis was undertaken using the latest data set (30 April, 2010) including a total of 15,727 patients who received PADT and had follow-up data for periods ranging from 0 to 9.2 years.
MAB for prostate cancer patients with intermediate- or high-risk disease has a significant benefit in terms of overall survival compared with LHRH analog monotherapy or surgical castration alone. Better results may be achieved in older (≥75 years) patients. Patient comorbidities are an important factor in determining overall survival, notably in older patients, and should be considered when selecting therapy.
Based on large-scale registry data, this report is the first to analyze the outcomes of MAB therapy in patients with prostate cancer at a wide range of disease stages. MAB therapy may provide significant survival benefits in intermediate- and high-risk patients.
PMCID: PMC3814111  PMID: 24223407
Prostate neoplasms; Maximal androgen blockade; Overall survival; Primary androgen deprivation therapy; Risk scoring
13.  Multi-transcript profiling in archival diagnostic prostate cancer needle biopsies to evaluate biomarkers in non-surgically treated men 
BMC Cancer  2014;14:673.
Most biomarkers in prostate cancer have only been evaluated in surgical cohorts. The value of these biomarkers in a different therapy context remains unclear. Our objective was to test a panel of surgical biomarkers for prognostic value in men treated by external beam radiotherapy (EBRT) and primary androgen deprivation therapy (PADT).
The Fluidigm® PCR array was used for multi-transcript profiling of laser microdissected tumours from archival formalin-fixed diagnostic biopsies of patients treated by EBRT or PADT. Cases were matched for disease characteristics and had known 5 year biochemical relapse outcomes (n = 60). Results were validated by immunohistochemistry in a custom needle biopsy tissue microarray. Six biomarkers previously tested only in surgical cohorts were analysed (PTEN, E-Cadherin, EGFR, EZH2, PSMA, MSMB). Transcript and protein expression was correlated with clinical outcome analysed using Kruskal Wallis, Fisher’s test and Cox proportional hazard model.
Altered expression of E-Cadherin (p = 0.008) was associated with early relapse after EBRT. In PADT treated men however only altered MSMB transcript was prognostic for early relapse (p = 0.001). The remaining biomarkers however did not demonstrate prognostic ability in either cohort. In a separate tissue array we validated altered E-Cadherin protein as a predictor of early relapse after EBRT (n = 47) (HR 0.34, CI p = 0.02) but not in PADT treated men (n = 63).
We demonstrate proof of principle of multiple transcript profiling in archival diagnostic biopsies of non-surgically treated men for biomarker discovery. We identify a role for E-Cadherin as a novel biomarker of early relapse following EBRT.
PMCID: PMC4174634  PMID: 25227682
14.  Oncological results, functional outcomes and health-related quality-of-life in men who received a radical prostatectomy or external beam radiation therapy for localized prostate cancer: a study on long-term patient outcome with risk stratification 
Asian Journal of Andrology  2009;11(3):283-290.
Health-related quality-of-life (HRQOL) after a radical prostatectomy (RP) or external beam radiation therapy (EBRT) has not been studied in conjunction with oncological outcomes in relation to disease risk stratification. Moreover, the long-term outcomes of these treatment approaches have not been studied. We retrospectively analyzed oncological outcomes between consecutive patients receiving RP (n = 86) and EBRT (n = 76) for localized prostate cancer. HRQOL and functional outcomes could be assessed in 62 RP (79%) and 54 EBRT (79%) patients over a 3-year follow-up period (median: 41 months) using the Medical Outcomes Study Short Form-36 (SF-36) and the University of California Los Angeles Prostate Cancer Index (UCLA PCI). The 5-year biochemical progression-free survival did not differ between the RP and EBRT groups for low-risk (74.6% vs. 75.0%, P = 0.931) and intermediate-risk (61.3% vs. 71.1%, P = 0.691) patients. For high-risk patients, progression-free survival was lower in the RP group (45.1%) than in the EBRT group (79.7%) (P = 0.002). The general HRQOL was comparable between the two groups. Regarding functional outcomes, the RP group reported lower scores on urinary function and less urinary bother and sexual bother than the EBRT group (P < 0.001, P < 0.05 and P < 0.001, respectively). With risk stratification, the low- and intermediate-risk patients in the RP group reported poorer urinary function than patients in the EBRT group (P < 0.001 for each). The sexual function of the high-risk patients in the EBRT group was better than that of the same risk RP patients (P < 0.001). Biochemical recurrence was not associated with the UCLA PCI score in either group. In conclusion, low- to intermediate-risk patients treated with an RP may report relatively decreased urinary function during long-term follow-up. The patient's HRQOL after treatment did not depend on biochemical recurrence.
PMCID: PMC3735298  PMID: 19349948
long-term observation; quality-of-life; radiation therapy; radical prostatectomy; risk stratification
15.  Variation in Adherence to External Beam Radiotherapy Quality Measures Among Elderly Men with Localized Prostate Cancer 
We characterized variation in adherence to quality measures of external beam radiotherapy (EBRT) for localized prostate cancer and its relation to patient and provider characteristics in a population-based, representative sample of US men.
Methods and Materials
We evaluated EBRT quality measures proposed by a RAND expert panel of physicians among men age 65 or older diagnosed from 2000 to 2002 with localized prostate cancer and treated with primary EBRT using data from the linked Surveillance, Epidemiology, and End Results (SEER) Medicare program. We assessed adherence to five EBRT quality measures that were amenable to analysis using SEER-Medicare data: 1) use of conformal radiotherapy treatment planning; 2) use of high-energy (>10MV) photons; 3) use of custom immobilization; 4) completion of two follow-up visits with a radiation oncologist in the year following therapy; and 5) radiation oncologist board certification.
Of the 11,674 patients, 85% received conformal radiotherapy treatment planning, 75% received high-energy photons, and 97% received custom immobilization. One-third of patients completed two follow-up visits with a radiation oncologist, though 91% had at least one visit with a urologist or a radiation oncologist. The majority of patients (85%) were treated by a board certified radiation oncologist.
Overall high adherence to EBRT quality measures masked substantial variation by geography, socioeconomic status in area of residence, and teaching affiliation of the radiotherapy facility. Future research should examine reasons for variation in these measures and whether variation is associated with important clinical outcomes.
PMCID: PMC2267435  PMID: 17689880
Prostate cancer; quality of care; external beam radiotherapy; SEER-Medicare; health services research
16.  Increasing Use of Dose-escalated External Beam Radiation Therapy for Men with Non-Metastatic Prostate Cancer 
Dose-escalated external beam radiotherapy (EBRT) is associated with improved tumor control rates for men with prostate cancer. In this study, we examine recent practice patterns using a large national cancer registry to understand the extent to which dose-escalated EBRT has been incorporated into routine clinical practice.
We conducted a retrospective observational cohort study using the National Cancer Database (NCDB), a nationwide oncology outcomes database in the United States. We identified 98,755 men diagnosed with non-metastatic prostate cancer between 2006 and 2011 who received definitive EBRT and classified patients into NCCN risk groups. We defined dose-escalated EBRT as total prescribed dose of ≥ 75.6 Gy. Using multivariable logistic regression, we examined the association of patient, clinical, and demographic characteristics with the use of dose-escalated EBRT.
Overall, 81.6% of men received dose-escalated EBRT during the study period. The use of dose-escalated EBRT did not vary substantially by NCCN risk group. Use of dose-escalated EBRT increased from 70.7% of patients receiving treatment in 2006 to 89.8% of patients receiving treatment in 2011. On multivariable analysis, year of diagnosis and use of intensity modulated radiation therapy (IMRT) were significantly associated with receipt of dose-escalated EBRT.
Our study results indicate that dose-escalated EBRT has been widely adopted by radiation oncologists treating prostate cancer in the United States. The proportion of patients receiving dose-escalated EBRT increased nearly 20% between 2006 and 2011. We observed high utilization rates of dose-escalated EBRT within all disease risk groups. Adoption of IMRT was strongly associated with use of dose-escalated treatment.
PMCID: PMC4049263  PMID: 24725694
17.  Prognostic utility of CCP score in men with prostate cancer after primary external beam radiation therapy 
The cell cycle progression (CCP) score, a prognostic RNA signature based on the average expression level of 31 CCP genes, has been shown to predict biochemical recurrence (BCR) after prostatectomy and prostate cancer specific mortality in men undergoing observation. However, the value of the CCP score in men who received primary external beam radiation therapy (EBRT) is untested.
Methods and Materials
The CCP score was derived retrospectively from diagnostic biopsy specimens of men diagnosed with prostate cancer from 1991 to 2006 (n=141). All patients were treated with definitive EBRT; approximately half of the cohort was African-American. Outcome was time from EBRT to BCR using the Phoenix definition. Median follow-up for patients without BCR was 4.8 years. Association with outcome was evaluated by CoxPH survival analysis and likelihood ratio tests.
Of 141 patients, 19 (13%) had BCR. The median CCP score for patient samples was 0.12. In univariable analysis, CCP score significantly predicted BCR (p-value = 0.0017). The hazard ratio (HR) for BCR was 2.55 for a one-unit increase in CCP score (equivalent to a doubling of gene expression). In a multivariable analysis with Gleason score, PSA, percent positive cores, and androgen deprivation therapy, the HR for CCP remained significant (p-value = 0.034), indicating that CCP provides prognostic information that is not provided by standard clinical parameters. With 10-year censoring, the CCP score was associated with prostate cancer specific mortality (p-value = 0.013). There was no evidence for interaction between CCP and any clinical variable, including ethnicity.
Among men treated with EBRT, the CCP score significantly predicated outcome and provided greater prognostic information than was available with clinical parameters. If validated in a larger cohort, CCP score could identify high-risk men undergoing EBRT who may need more aggressive therapy.
PMCID: PMC3710548  PMID: 23755923
CCP; radiation; biomarkers
18.  Salvage radiotherapy after high-intensity focused ultrasound treatment for localized prostate cancer: feasibility, tolerance and efficacy 
The objective of this study is to evaluate the feasibility, tolerance and efficacy of salvage external beam radiotherapy (EBRT) in persistent or recurrent prostate cancer after failed high intensity focused ultrasound (HIFU) therapy.
We reviewed data on tolerance and oncologic outcomes for all patients with biopsy-proven locally recurrent or persistent prostate cancer who underwent salvage EBRT in our department between April 2004 and June 2008. Minimum follow-up for inclusion was 2 years. Failure with EBRT was defined as biochemical relapse (Phoenix definition) or introduction of androgen deprivation therapy (ADT). Gastrointestinal and urinary toxicity and urinary stress incontinence were scored at 12 and 24 months (Radiation Therapy Oncology Group and Ingelman Sundberg rating, respectively).
The mean age of the patients was 68.8 years (range: 60–79). Mean prostate-specific antigen (PSA) before EBRT was 5.57 ng/mL (range: 2.5–14.8). Median follow-up was 36.5 ± 10.9 months (range: 24–54). No patient received adjunctive ADT. The EBRT course was well-tolerated and completed by all patients. The mean PSA nadir was 0.62 ng/mL (range: 0.03–2.4) and occurred after a median of 22 months (range: 12–36). One patient experienced biochemical failure and was prescribed ADT 30 months after EBRT. The disease-free survival rate was 83.3% at 36.5 months. There was no major EBRT-related toxicity at 12 or 24 months.
Our early clinical results confirm the feasibility and good tolerance of salvage radiotherapy after HIFU failure. Oncological outcomes were promising. A prospective study with longer follow-up is needed to identify factors predictive of success for salvage EBRT therapy after HIFU failure.
PMCID: PMC3478387  PMID: 21539766
19.  Long-Term Survival After Radical Prostatectomy Versus External Beam Radiotherapy for Patients with High-Risk Prostate Cancer 
Cancer  2011;117(13):2883-2891.
We compared the long-term survival of patients with high-risk prostate cancer following radical prostatectomy (RRP) and external beam radiation therapy (EBRT) with and without adjuvant androgen deprivation treatment (ADT).
We identified 1,238 patients who underwent RRP and 609 patients treated with EBRT (344 with EBRT + ADT and 265 with EBRT alone) between 1988–2004 who had a pretreatment prostate-specific antigen level (PSA) ≥ 20 ng/mL, biopsy Gleason score 8–10, or clinical stage ≥ T3. Median follow-up was 10.2, 6.0, and 7.2 years after RRP, EBRT + ADT, and EBRT alone, respectively. The impact of treatment modality on systemic progression, cancer-specific, and overall survival was evaluated using multivariable Cox proportional hazard regression analysis and a competing risk-regression model.
Ten-year cancer-specific survival was 92%, 92%, and 88% following RRP, EBRT + ADT, and EBRT alone (p=0.06). After adjustment for case mix, no significant differences in the risks of systemic progression (hazard ratio, 0.78; 95% CI, 0.51 to 1.18; p=0.23) or prostate cancer death (hazard ratio 1.14; 95% CI, 0.68 to 1.91; p=0.61) were seen between patients treated with EBRT + ADT and patients who underwent RRP. The risk of all-cause mortality was, however, greater after EBRT + ADT than RRP (hazard ratio, 1.60; 95% CI, 1.25 to 2.05; p=0.0002).
RRP and EBRT + ADT provide similar long-term cancer control for patients with high-risk disease. Continued investigation into the differing impact of treatments on quality-of-life and non-cancer mortality are necessary to determine the optimal management approach for these patients.
PMCID: PMC3139725  PMID: 21692049
prostate cancer; radical prostatectomy; radiation therapy; androgen-deprivation therapy; prostate-specific antigen
Cancer  2011;117(19):4557-4565.
Hip fracture is associated with high morbidity and mortality. Pelvic external beam radiotherapy (EBRT) is known to increase the risk of hip fractures in women but the effect in men is unknown.
45,662 men aged ≥66 years, diagnosed with prostate cancer in 1992–2004 were identified from the SEER-Medicare database. Using Kaplan-Meier methods and Cox proportional hazards models, the primary outcome of hip fracture risk was compared among men who received radical prostatectomy (RP), EBRT, EBRT+androgen suppression therapy (AST) or AST alone, controlling for age, osteoporosis, race and other comorbidities. A secondary outcome was distal forearm fractures as an indicator of fragility fracture risk outside the radiation field.
After controlling for covariates, EBRT increased the risk of hip fractures by 76% (HR 1.76, 95% CI 1.38–2.40) without increasing the risk of distal forearm fractures (HR 0.80, 95% CI 0.56–1.14). Combination therapy with EBRT+AST increased the risk of hip fracture 145% relative to RP (HR 2.45, 95% CI 1.88–3.19) and by 40% relative to EBRT (HR 1.40, 95% CI 1.17–1.68). EBRT+AST increased the risk of distal forearm fracture by 43% relative to RP (HR 1.43, 95% CI 0.97–2.10). The number needed to treat to result in 1 hip fracture through 10 years was 51 (95% CI 31–103).
In men with prostate cancer, pelvic 3-D conformal EBRT is associated with a 76% increased risk of hip fracture. This risk is slightly increased further by the addition of short-course AST to EBRT. This risk associated with EBRT is site-specific as there is no increase in the risk of fall-related fractures outside the radiation field.
PMCID: PMC3135749  PMID: 21412999
21.  Timing of High-Dose Rate Brachytherapy With External Beam Radiotherapy in Intermediate and High-Risk Localized Prostate CAncer (THEPCA) Patients and Its Effects on Toxicity and Quality of Life: Protocol of a Randomized Feasibility Trial 
JMIR Research Protocols  2015;4(2):e49.
Prostate cancer is the most common cancer in males in the UK and affects around 105 men for every 100,000. The role of radiotherapy in the management of prostate cancer significantly changed over the last few decades with developments in brachytherapy, external beam radiotherapy (EBRT), intensity-modulated radiotherapy (IMRT), and image-guided radiotherapy (IGRT). One of the challenging factors of radiotherapy treatment of localized prostate cancer is the development of acute and late genitourinary and gastrointestinal toxicities. The recent European guidelines suggest that there is no consensus regarding the timing of high-dose rate (HDR) brachytherapy and EBRT. The schedules vary in different institutions where an HDR boost can be given either before or after EBRT. Few centers deliver HDR in between the fractions of EBRT.
Assessment of acute genitourinary and gastrointestinal toxicities at various time points to better understand if the order in which treatment modality is delivered (ie, HDR brachytherapy or EBRT first) has an effect on the toxicity profile.
Timing of HDR brachytherapy with EBRT in Prostate CAncer (THEPCA) is a single-center, open, randomized controlled feasibility trial in patients with intermediate and high-risk localized prostate cancer. A group of 50 patients aged 18 years old and over with histological diagnosis of prostate cancer (stages T1b-T3BNOMO), will be randomized to one of two treatment arms (ratio 1:1), following explanation of the study and informed consent. Patients in both arms of the study will be treated with HDR brachytherapy and EBRT, however, the order in which they receive the treatments will vary. In Arm A, patients will receive HDR brachytherapy before EBRT. In Arm B (control arm), patients will receive EBRT before HDR brachytherapy. Study outcomes will look at prospective assessment of genitourinary and gastrointestinal toxicities. The primary endpoint will be grade 3 genitourinary toxicity and the secondary endpoints will be all other grades of genitourinary toxicities (grades 1 and 2), gastrointestinal toxicities (grades 1 to 4), prostate-specific antigen (PSA) recurrence-free survival, overall survival, and quality of life.
Results from this feasibility trial will be available in mid-2016.
If the results from this feasibility trial show evidence that the sequence of treatment modality does affect the patients’ toxicity profiles, then funding would be sought to conduct a large, multicenter, randomized controlled trial.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 15835424; (Archived by WebCite at
PMCID: PMC4430680  PMID: 25926023
prostate cancer; radiotherapy; brachytherapy; external beam radiotherapy; EBRT; randomized controlled trial; RCT; Southend Hospital
22.  Hypofractionated SBRT versus conventionally fractionated EBRT for prostate cancer: comparison of PSA slope and nadir 
Patients with early stage prostate cancer have a variety of curative radiotherapy options, including conventionally-fractionated external beam radiotherapy (CF-EBRT) and hypofractionated stereotactic body radiotherapy (SBRT). Although results of CF-EBRT are well known, the use of SBRT for prostate cancer is a more recent development, and long-term follow-up is not yet available. However, rapid post-treatment PSA decline and low PSA nadir have been linked to improved clinical outcomes. The purpose of this study was to compare the PSA kinetics between CF-EBRT and SBRT in newly diagnosed localized prostate cancer.
75 patients with low to low-intermediate risk prostate cancer (T1-T2; GS 3 + 3, PSA < 20 or 3 + 4, PSA < 15) treated without hormones with CF-EBRT (>70.2 Gy, <76 Gy) to the prostate only, were identified from a prospectively collected cohort of patients treated at the University of California, San Francisco (1997–2012). Patients were excluded if they failed therapy by the Phoenix definition or had less than 1 year of follow-up or <3 PSAs. 43 patients who were treated with SBRT to the prostate to 38 Gy in 4 daily fractions also met the same criteria. PSA nadir and rate of change in PSA over time (slope) were calculated from the completion of RT to 1, 2 and 3 years post-RT.
The median PSA nadir and slope for CF-EBRT was 1.00, 0.72 and 0.60 ng/ml and -0.09, -0.04, -0.02 ng/ml/month, respectively, for durations of 1, 2 and 3 years post RT. Similarly, for SBRT, the median PSA nadirs and slopes were 0.70, 0.40, 0.24 ng and -0.09, -0.06, -0.05 ng/ml/month, respectively. The PSA slope for SBRT was greater than CF-EBRT (p < 0.05) at 2 and 3 years following RT, although similar during the first year. Similarly, PSA nadir was significantly lower for SBRT when compared to EBRT for years 2 and 3 (p < 0.005).
Patients treated with SBRT experienced a lower PSA nadir and greater rate of decline in PSA 2 and 3 years following completion of RT than with CF-EBRT, consistent with delivery of a higher bioequivalent dose. Although follow-up for SBRT is limited, the improved PSA kinetics over CF-EBRT are promising for improved biochemical control.
PMCID: PMC3923240  PMID: 24484652
SBRT; Stereotactic body radiotherapy; Prostate; External beam; Conventionally fractionated; Nadir; Kinetics; Slope
23.  Treatment Decisions for Localized Prostate Cancer 
To identify what factors men consider important when choosing treatment for prostate cancer, and to assess why men reject watchful waiting as a treatment option.
One hundred two consecutive men with newly diagnosed localized prostate cancer identified from hospital and community-based urology practice groups.
Patients were asked open-ended questions about likes and dislikes of all treatments considered, how they chose their treatment, and reasons for rejecting watchful waiting. The interviews were conducted in person, after the men had made a treatment decision but before they received the treatment.
The most common reasons for liking a treatment were removal of tumor for radical prostatectomy (RP) (n = 15), evidence for external beam radiation (EBRT) (n = 6), and short duration of therapy for brachytherapy (seeds) (n = 25). The most frequently cited dislikes were high risk of incontinence for RP (n = 46), long duration of therapy for EBRT (n = 29), and lack of evidence for seeds (n = 16). Only 12 men chose watchful waiting. Fear of future consequences, cited by 64% (n = 90) of men, was the most common reason to reject watchful waiting.
In discussing treatment options for localized prostate cancer, clinicians, including primary care providers, should recognize that patients' decisions are often based on specific beliefs regarding each therapy's intrinsic characteristics, supporting evidence, or pattern of complications. Even if patients do not recall a physician recommendation against watchful waiting, this option may not be chosen because of fear of future consequences.
PMCID: PMC1495597  PMID: 11089712
localized prostate cancer; treatment; decision making
24.  Urethroplasty After Radiation Therapy for Prostate Cancer 
Urology  2012;79(6):1402-1405.
To report urethroplasty outcomes in men who developed urethral stricture after undergoing radiation therapy for prostate cancer.
Our urethroplasty database was reviewed for cases of urethral stricture after radiation therapy for prostate cancer between June 2004 and May 2010. Patient demographics, prostate cancer therapy type, stricture length and location, and type of urethroplasty were obtained. All patients received clinical evaluation, including imaging studies post procedure. Treatment success was defined as no need for repeat surgical intervention.
Twenty-nine patients underwent urethroplasty for radiation-induced stricture. Previous radiation therapy included external beam radiotherapy (EBRT), radical prostatectomy (RP)/EBRT, EBRT/brachytherapy (BT) and BT alone in 11 (38%), 7 (24%), 7 (24%), and 4 (14%) patients, respectively. Mean age was 69 (±6.9) years. Mean stricture length was 2.6 (±1.6) cm. Anastomotic urethroplasty was performed in 76% patients, buccal mucosal graft in 17%, and perineal flap repair in 7%. Stricture was localized to bulbar urethra in 12 (41%), membranous in 12 (41%), vesicourethra in 3 (10%), and pan-urethral in 2 (7%) patients. Overall success rate was 90%. Median follow-up was 40 months (range 12-83). Time to recurrence ranged from 6-16 months.
Multiple forms of urethroplasty appear to be viable options in treating radiation-induced urethral stricture. Future studies are needed to examine the durability of repairs.
PMCID: PMC3565607  PMID: 22521189
25.  Mortality After Prostate Cancer Treatment with Radical Prostatectomy, External-Beam Radiation Therapy, or Brachytherapy in Men Without Comorbidity 
European urology  2013;64(3):372-378.
Medical comorbidity is a confounding factor in prostate cancer (PCa) treatment selection and mortality. Large-scale comparative evaluation of PCa mortality (PCM) and overall mortality (OM) restricted to men without comorbidity at the time of treatment has not been performed.
To evaluate PCM and OM in men with no recorded comorbidity treated with radical prostatectomy (RP), external-beam radiation therapy (EBRT), or brachytherapy (BT).
Design, setting, and participants
Data from 10 361 men with localized PCa treated from 1995 to 2007 at two academic centers in the United States were prospectively obtained at diagnosis and retrospectively reviewed. We identified 6692 men with no recorded comorbidity on a validated comorbidity index. Median follow-up after treatment was 7.2 yr.
Treatment with RP in 4459 men, EBRT in 1261 men, or BT in 972 men.
Outcome measurements and statistical analysis
Univariate and multivariate Cox proportional hazards regression analysis, including propensity score adjustment, compared PCM and OM for EBRT and BT relative to RP as reference treatment category. PCM was also evaluated by competing risks analysis.
Results and limitations
Using Cox analysis, EBRT was associated with an increase in PCM compared with RP (hazard ratio [HR]: 1.66; 95% confidence interval [CI], 1.05–2.63), while there was no statistically significant increase with BT (HR: 1.83; 95% CI, 0.88–3.82). Using competing risks analysis, the benefit of RP remained but was no longer statistically significant for EBRT (HR: 1.55; 95% CI, 0.92–2.60) or BT (HR: 1.66; 95% CI, 0.79–3.46). In comparison with RP, both EBRT (HR: 1.71; 95% CI, 1.40–2.08) and BT (HR: 1.78; 95% CI, 1.37–2.31) were associated with increased OM.
In a large multicenter series of men without recorded comorbidity, both forms of radiation therapy were associated with an increase in OM compared with surgery, but there were no differences in PCM when evaluated by competing risks analysis. These findings may result from an imbalance of confounders or differences in mortality related to primary or salvage therapy.
PMCID: PMC3930076  PMID: 23506834
Prostatic neoplasms; Prostatectomy; Radiation therapy; Comorbidity; Comparative effectiveness research

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