Prostate cancer


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  • Prostate cancer–specific mortality rates were unchanged after 15 years of follow-up ( Table 3 ). The prostate cancer mortality rate was 33 per 1000 person-years during the first 15 years (95% CI, 28-38) and 18 per 1000 person-years after 15 years of follow-up (95% CI, 10-29). These rates were not statistically different after adjusting for the more favorable histology profiles among men who survived more than 15 years from diagnosis (rate ratio, 1.1; 95% CI, 0.6-1.9).
  • Figure 1. Cumulative Incidence of Death from Any Cause, Death from Prostate Cancer, and Development of Metastases. The cumulative incidence of death from any cause, death from prostate cancer, and development of metastases in the radical-prostatectomy group and the watchful-waiting group is shown in the total cohort (Panels A, B, and C), in men 65 years of age or older (Panels D, E, and F), and in men younger than 65 years of age (Panels G, H, and I).
  • Figure 1. Cumulative Incidence of Death from Any Cause, Death from Prostate Cancer, and Development of Metastases. The cumulative incidence of death from any cause, death from prostate cancer, and development of metastases in the radical-prostatectomy group and the watchful-waiting group is shown in the total cohort (Panels A, B, and C), in men 65 years of age or older (Panels D, E, and F), and in men younger than 65 years of age (Panels G, H, and I).
  • Background: Men treated for clinically localized prostate cancer with either radical prostatectomy or external beam radiotherapy usually survive many years with the side effects of these treatments. We present treatment-specific quality-of-life outcomes for prostate cancer patients 5 years after initial diagnosis. Methods: The cohort consisted of men aged 55–74 years who were newly diagnosed with clinically localized prostate cancer in 1994–1995 and were treated with radical prostatectomy (n = 901) or external beam radiotherapy (n = 286). We used clinical and quality-of-life data previously collected at the time of diagnosis (i.e., baseline) and at the 2-year follow-up and data newly collected at 5 years after diagnosis to compare urinary, bowel, and sexual function and to examine temporal changes in those functions. Odds ratios (ORs) and adjusted percentages were calculated by logistic regression. All statistical tests were two-sided. Results: At 5 years after diagnosis, overall sexual function declined in both groups to approximately the same level. However, at 5 years after diagnosis, erectile dysfunction was more prevalent in the radical prostatectomy group than in the external beam radiotherapy group (79.3% versus 63.5%; OR = 2.5, 95% confidence interval [CI] = 1.6 to 3.8). Approximately 14%–16% of radical prostatectomy and 4% of external beam radiotherapy patients were incontinent at 5 years (OR = 4.4, 95% CI = 2.2 to 8.6). Bowel urgency and painful hemorrhoids were more common in the external beam radiotherapy group than in the radical prostatectomy group. All of these differences remained statistically significant after adjustment for confounders and for differences between treatment groups in some baseline characteristics. Conclusions: At 5 years after diagnosis, men treated with radical prostatectomy for localized prostate cancer continue to experience worse urinary incontinence than men treated with external beam radiotherapy. However, the two treatment groups were more similar to each other with respect to overall sexual function, mostly because of a continuing decline in erectile function among the external beam radiotherapy patients between years 2 and 5.
  • Of 425 eligible men 211 were randomized to observation and 214 to adjuvant radiation. Of those men under observation 70 ultimately received radiotherapy. Metastasis-free survival was significantly greater with radiotherapy (93 of 214 events on the radiotherapy arm vs 114 of 211 events on observation; HR 0.71; 95% CI 0.54, 0.94; p = 0.016). Survival improved significantly with adjuvant radiation (88 deaths of 214 on the radiotherapy arm vs 110 deaths of 211 on observation; HR 0.72; 95% CI 0.55, 0.96; p = 0.023).
  • Huggins C, Hodges C. Studies on prostatic cancer: The effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. Cancer Res 1941; 1:293-299.
  • Lecture Notes Five-year survival curves for only the trials that used nilutamide or flutamide show a 3% increase for CAB over AS alone. Of patients who received CAB, 27.6% were alive at 5 years versus 24.7% of patients who received AS alone ( P =0.005). However, the lower confidence limit for this 2.9% difference barely exceeds zero, giving it only weak statistical significance. In contrast, 5-year survival among patients who received CAB with cyproterone acetate (not shown) was only 15.4% versus 18.1% for patients in the AS alone group ( P =0.04). The poor result of cyproterone acetate may have been due to a chance adverse effect on nonprostate cancer deaths. 1. Prostate Cancer Trialists’ Collaborative Group. Maximum androgen blockade in advanced prostate cancer: an overview of the randomised trials. Lancet. 2000;355:1491-1498. Slide 73
  • 7 38
  • Figure 1. Kaplan–Meier Estimates of Overall Survival, Time to PSA Progression, and Progression-free Survival According to Radiographic Evidence in the Intention-to-Treat Population.
  • Pre-planned interim analysis positive for OS benefit Grades 3-4 neutropenia in 1.8% radium-223 compared to 0.8% placebo.
  • 11/19/12
  • The median of survival of the patients taking Prostvac have improved about 50%. It was 25.1 month versus 16.6 months or eight and a month improvement and it had a ratio of .56 and the effect was statistically significant at the .006 level. It is a variable statistical measure of how survival was impacted depending on the number of patients. Even more impressive, if you look at the feature of the first 12 months in the curve which is fairly typical for me in the therapy is the patient who dies quickly do not benefit They delay the fact as the metric has a ratio. So, you lose about 30% of the patients in this study initially because it is such an aggressive disease. It progresses and dies before the vaccine can work. But still the remainder of the patients’ benefits has a large effect at the study of variable statistical
  • 11/19/12
  • Tumor growth is a dynamic process and is the result of new cells dividing and other cells dying. The growth rate is the change in size of tumor over time. The intrinsic biology of the tumor as well as extrinsic factors such as therapies, affect the growth rate. However, chemotherapy only affects the growth rate while the chemotherapy is given. Immunotherapy may not cause dramatic changes in the tumor burden in a short period of time, but the continued cumulative pressure on the tumor, especially if started early in the disease course, may lead to substantial improvements in overall survival.
  • Death within 30 days of study drug Cabazitaxel 5% Docetaxel 3% Sip-T 0.5%
  • Prostate cancer

    1. 1. Prostate Cancer: Clinical Update James L. Gulley M.D., Ph.D., F.A.C.P.Director, Clinical Trials Group & Deputy ChiefLaboratory of Tumor Immunology and BiologySenior Investigator, Medical Oncology BranchCenter for Cancer ResearchNational Cancer Institute, NIH 1
    2. 2. Presentation OutlineI. Prostate Cancer detection and prognosisII. Standard Local TherapyIII. Standard Systemic Therapy a. Androgen deprivation therapy (ADT) b. Chemotherapy c. Bone targeted therapy d. ImmunotherapyIV. Future Directions 2
    3. 3. Disease Continuum in Prostate Cancer Death Docetaxel* CastrationTumorvolume Local Cabazitaxel* Therapy 2nd-line Abiraterone* Hormonal Enzalutamide* therapy Sipuleucel-T* Alpharadin? Asymptomatic Symptoms Non-Metastatic Metastatic Castration Sensitive Castration Resistant Death from Prostate Cancer Time 3
    4. 4. Introduction• ~241,740 new cases in 2012• ~28,170 deaths in 2012• 1 in 6 men will develop clinically significant prostate cancer 4
    5. 5. Risk Factors Age (median age 71y/o; <15% younger than 65)Family HistoryGeographic locationRaceFor caucasians 16.6% of the men get prostate cancerand 3.5% die. For african americans 18.1% getprostate cancer and 4.3 % die. 5
    6. 6. DetectionMay be detected due tosymptoms, physical finding orthrough PSA screening.Most patients in the US areasymptomatic at the time ofdiagnosis. 6
    7. 7. Digital Rectal Exam A – Central zone B – Fibromuscular zone C – Transitional zone D – Peripheral zone E – Periurethral zone Seminal Vesicles Prostate 7
    8. 8. Incidence vs. Mortality Prostate Cancer in the U.S. PSA Screening 250New Prostate Cancer Cases and Deaths 200 (per 100,000 men) 150 New cases 100 50 Deaths 0 1975 1980 1985 1990 1995 2000 8 (G. Welch, “Should I Be Tested for Cancer?”, 2004)
    9. 9. Does Screening Save Lives?• PLCO Trial – N=76,693 men (screen vs. no screen) – After 7 years 50 vs. 44 deaths from PC – ?Too early – PSA test too available?• ERSPC Trial – N=182,000 (screen vs. no screen) – At a median of 9 years, a 20% reduction in PC death – Different patient population than US? 9
    10. 10. Histologic Grading• Gleason Grade – most common grading system – Tumors are graded from 1-5 with the – higher number indicates a more aggressive tumor – Two most predominant patterns added together for a score from 2-10 10
    11. 11. Staging Stage I(A) has a T1a and is localized. Stage II (B) has a T1b,T1c, T2a, T2b and T2c and is localized to theprostate. Stage III (C)has a T3a and Teb and is locally advanced. Stage IV(D) has aT4N1M1 and is metastatic. 11
    12. 12. Prognosis• PSA at diagnosis, percent of tumor in a biopsy specimen, number of positive biopsies, Gleason Score and clinical stage are useful prognostic factors• Nomograms are available to predict the likelihood of positive surgical margins, lymph node involvement and disease recurrence after local therapy. 12
    13. 13. Treatment• Patients with a life expectancy of less than 10 years and low grade/ low stage lesions may be candidates for active surveillance 13
    14. 14. ActiveSurveillanceThe chance of dyingof prostate cancerdecreases with:Lower Gleason scoreOlder age (morecompeting causes ofmortality) 14
    15. 15. ADT as Primary Therapy• For patients who are not candidates for local therapy, immediate ADT offers better OS than waiting until symptomatic disease• 985 pts randomized in EORTC trial – HR 1.25 (favoring immediate ADT)• No earlier time to CRPC despite earlier ADT• Disease specific survival reportedly not different in this trial raising some questions 15
    16. 16. Treatment - continued• Eradication of the cancer is the goal of therapy in patients with a life expectancy greater than 10 years – Radical Prostatectomy – External-beam Radiation – Brachytherapy 16
    17. 17. Radical Prostatectomy• Surgical removal of the prostate• May be done with a retropubic, perineal, or laproscopic approach• Most common side effects are impotence and incontinence 17
    18. 18. Randomized Trial ComparingSurgery and Watchful Waiting 18
    19. 19. Randomized Trial ComparingSurgery and Watchful Waiting 19
    20. 20. External-beam Radiation• Radiation to the prostate (and pelvis) from outside the body• Evidence that higher doses are associated with better efficacy• IMRT aims to increase radiation delivery and to decrease toxicity• Most common side effects are impotence and rectal irritation 20
    21. 21. Average multi-item sexual domain summary scores RT RP 21
    22. 22. Prostate anatomy 22
    23. 23. Average multi-item incontinence summary scores RT RP 23
    24. 24. Average multi-item bowel summary scores RT RP 24
    25. 25. Brachytherapy• Radiation implants placed directly into the prostate under ultrasound or CT guidance• Very high dose radiation to the prostate with little radiation outside the prostatic bed• Acute urinary symptoms common, some patients with impotence• Procedure completed in one day 25
    26. 26. Treatment of Locally Advanced Disease• Conservative management• Hormonal therapy plus radiation• Hormonal therapy plus surgery 26
    27. 27. EORTC Trial• Randomized trial of radiotherapy ± ADT• Locally advanced prostate cancer (n=415)• Concurrent + adjuvant ADT continued for 3 years• Improved outcomes for combination: – Local control – metastases free survival – overall survival (62% vs. 78% 5 yr survival p=0.0002) 27
    28. 28. ECOG (Messing et al.)• Randomized trial of immediate hormonal therapy vs. observation in men undergoing radical prostatectomy with evidence of positive lymph nodes• 98 eligible patients enrolled• Deaths by 11.9 years f/u – 17/47 immediate anti-androgen – 28/51 delayed therapy group (HR 1.84; p=0.04)• Criticisms 28
    29. 29. Adjuvant RTRandomized study of adjuvant RT vs. observation forT3N0M0 (n=425) For adjuvant RT of 214 patients53% had Metastasis free survival and 59% hadoverall survival. For observation of 211 patients46% had metastasis free survival and 48% hadoverall survival. 29
    30. 30. Disease Continuum in Prostate CancerTumorvolume Local Therapy Asymptomatic Symptoms Non-Metastatic Metastatic Castration Sensitive Castration Resistant 30
    31. 31. Biochemical Recurrence• May be occult local or metastatic disease• Options include additional local therapy, hormonal treatment or watchful waiting• Virtually impossible to predict the impact of treatment on survival 31
    32. 32. Pound Data• Probably the most important report on this population because of the limited use of radiation and hormonal therapy• Over 15 years 1,997 patients underwent a radical prostatectomy, with 304 (15%) experiencing a PSA relapse.• Of the 304, 103 (34 %) developed metastatic disease. 32
    33. 33. Pound Data (continued)• No patients received hormonal therapy without clinically evident metastatic disease.• Median time from PSA elevation to metastatic disease was 8 years• Median time to death after metastatic disease was 5 years.• Prognostic factors predictive of outcome included the Gleason score in the surgical specimen, and PSA doubling time. 33
    34. 34. Disease Continuum in Prostate CancerTumorvolume Local Therapy Asymptomatic Symptoms Non-Metastatic Metastatic Castration Sensitive Castration Resistant 34
    35. 35. Metastatic PC• Prostate Cancer tends to spread to bone and lymph nodes• However metastatic lesions have been found in virtually every part of the body including brain, liver and lungs.• Many patients do not have measurable lesions thus traditional response criteria (RECIST) are difficult to use. 35
    36. 36. ADT Treatment of metastatic PC• 1941 Charles Huggins showed that advanced PC was inhibited by decreasing Testosterone (castration or estrogen) and activated by adding testosterone.• 1966 Nobel Prize in Medicine 36
    37. 37. Action of Androgens in Prostate Cells. Testosterone is metabolized to DHT
    38. 38. Action of Androgens in Prostate Cells.DHT receptor complex enters nucleus.
    39. 39. Action of Androgens in Prostate Cells. DHT receptor complex alters gene expression
    40. 40. Action of Androgens in Prostate Cells.mRNA is translated in cytosol into protein.
    41. 41. ADT Treatment of metastatic PC• Testosterone lowering therapies – GnRH agonists (e.g., Leuprolide and Goserelin) • Both agents are expensive • May initially result in an increase in testosterone – GnRH antagonist (e.g., Degarelix) • Similar cost issues without an increase in testosterone • Monthly injections – Orchiectomy- outpatient procedure. Cost effective if ADT for 6 months or more. 41
    42. 42. Side Effects of ADT.●Sexual effects include decreased libido anderectile dysfunction. ●Physical effects include hot flashes, fatigue,weight gain, hair changes, breast pain, decreasedmuscle mass, bone mineral density and penis size. ●Metabolic changes include lipidchanges, anemia and diabetes mellitus. ●Mental changes include lack ofinitiative, emotional lability, and decreased memoryand cognitive function. 42
    43. 43. Androgen Receptor Antagonists• bicalutamide, nilutamide, flutamide and enzalutamide• Do not ↓ Testosterone, bind androgen receptor and prevent anabolic (growth related) effects• Different dosing schedules and potency• Different side effect profile• Similar activity and all may show “withdrawal response” 43
    44. 44. Combined Androgen Blockade• Combination of anti-androgen with orchiectomy or GnRH-A• Controversial results• Not significantly more effective, but more expensive and may add toxicity 44
    45. 45. 5-Year Survival in the 20 RandomizedTrials of CAB (AS plus Nilutamide or Flutamide) vs AS Alone 6500 Men in 20 Trials of Nilutamide/Flutamide Androgen Suppression Only Androgen Suppression Antiandrogen Proportion Alive (%) 27.6% Treatment Better by 2.9% (SE 1.3) Logrank P=0.005 24.7% Time Since Randomization (Years) 45
    46. 46. Other Hormonal Agents• Ketoconazole• Abiraterone (recently approved)• Patients may respond to multiple sequential hormonal manipulations 46
    47. 47. Disease Continuum in Prostate CancerTumorvolume Local Therapy Asymptomatic Symptoms Non-Metastatic Metastatic Castration Sensitive Castration Resistant 47
    48. 48. Chemotherapy• Studies prior to 2004 disappointing• Quality of life measurements• Difficulty in evaluating response 48
    49. 49. Mitoxantrone + Glucocorticoids• Improved quality of life when compared to Glucocorticoids alone• No survival advantage• FDA approval for the palliation of painful lesions in 1996 49
    50. 50. TAX327 A Multicenter, Randomized Phase III Study of Intermittent Docetaxel + Prednisone vs. Weekly Docetaxel + Prednisone vs. Mitoxantrone + Prednisone in Patients with Hormone-Refractory Prostate Cancer Docetaxel 75mg/m2 Q3 + RANDOMIZE Prednisone 10mg orally given daily Castration Resistant Docetaxel 30mg/m2 Wkly + Prostate Prednisone 10mg orally given daily Cancer Mitoxantrone 12mg/m2 Q3 + Prednisone 10mg orally given daily1006 Patients Entered 50
    51. 51. TAX 327: Survival Advantage Only Shown for Q3W Docetaxel 1.0 0.9 Docetaxel 3 wkly Docetaxel wkly 0.8Probability of Surviving Mitoxantrone 0.7 0.6 0.5 0.4 Median survival Hazard 0.3 (mos) ratio P-value 0.2 D 3wkly: 18.9 0.76 0.009 D wkly: 17.3 0.91 0.3 0.1 Mitoxantrone 16.4 – – 0.0 0 6 12 18 24 30 Months 51
    52. 52. Cabazitaxel• Novel taxane active in docetaxel resistant cell lines• 755 men with metastatic CRPC who had progressed on or following docetaxel randomized to cabazitaxel vs. mitoxantrone. Patients in both arms received prednisone.• Worse toxicity in Cabazitaxel arm with grade 3/4 neutropenia in 82% vs. 58%. About 5% treatment related deaths in Cabazitaxel arm. 52
    53. 53. Primary Endpoint: Overall Survival (ITT Analysis) MP CBZP Median OS (months) 12.7 15.1 Hazard Ratio 0.70 95% CI 0.59–0.83 P-value <.0001 53
    54. 54. Progression-Free Survival (PFS) Results MP CBZP Median PFS (months) 1.4 2.8 Hazard Ratio 0.74 95% CI 0.64–0.86 P-value <.0001 PFS composite endpoint: PSA progression, pain progression, tumor progression, symptom deterioration, or death. 54
    55. 55. Abiraterone 55
    56. 56. Randomized trial of Prednisone withAbiraterone vs. Placebo 56
    57. 57. Randomized trial of Prednisone with Abiraterone vs. Polaceb 57
    58. 58. Effects of MDV3100 on the Androgen Receptor AreDistinct from Bicalutamide 1. AR Binding Affinity • 1 DHT ~ 5nM HSP 90 LBD Ligand • Bicalutamide ~160 nM HD • MDV3100 ~35 nM DBD 2. Nuclear Import NTD • DHT: ++++ • Bicalutamide: ++++ 2 • MDV3100: ++ 3. DNA Binding • DHT: ++++ • Bicalutamide: ++ • MDV3100: - 4 POL II 4. Coactivator recruitment • DHT: ++++ 3 • Bicalutamide: ++ • MDV3100: - DNA
    59. 59. Waterfall Plot of Percent PSA Changefrom Baseline Chemotherapy-Naïve (N=65) Post-Chemotherapy (N=75) 62% (40/65) 51% (38/75) >50% Decline >50% Decline
    60. 60. Prostate cancer survival curve 60
    61. 61. Alpharadin 61
    62. 62. Survival curve
    63. 63. Therapeutic Vaccines 63
    64. 64. APC Vaccine: Sipuleucel-T (Provenge).On day 1 Leukapheresis is is performed at a Center.On day 2-3 sipuleucel-T is manufactured at acompany.On day 3-4 the patient is infused at the Doctor’soffice.
    65. 65. IMPACT: Randomized Phase 3 Trial(IMmunotherapy Prostate AdenoCarcinoma Treatment).Patients (342) will be treated with Sipuleucel-T (Q 2 weeksx 3). Patients (170) will be treated with Placebo (Q2 weeksx 3). The primary endpoint is overall survival and thesecondary endpoint it time to objective diseaseprogression. 65
    66. 66. Sipuleucel-T: IMPACT Overall Survival: Primary Endpoint Intent-to-Treat Population 100 P = 0.032 (Cox model) 75 HR = 0.775 [95% CI: 0.614, 0.979]Percent Survival Median Survival Benefit = 4.1 Mos. 50 Sipuleucel-T (n = 341) Median Survival: 25.8 Mos. 25 Placebo (n = 171) Median Survival: 21.7 Mos. 0 0 6 12 18 24 30 36 42 48 54 60 66 Survival (Months) 66
    67. 67. Pox Vector Vaccine: PSA TRICOM (PROSTVAC)PSA Developed at NCI CRADA with BN 67
    68. 68. Randomized Controlled DoubleBlind Phase II Study.Patients (84) will be treated with PSA-TRICOM +GM-CSF. Patients (42) will be treated with emptyvector + placebo. The primary endpoint isprogression free survival. The secondary endpointis overall survival. 68
    69. 69. PROSTVAC Significantly Extended Overall Survival by 8.5 months 100 80Overall survival (% patients) 60 40 20 PROSTVAC Control 0 0 12 24 36 48 60 Months
    70. 70. Therapeutic vaccines vs. Conventional therapy.●Conventional therapy targets the tumor or itsmicroenvironment. The action is immediate but islimited by toxicity.●Therapeutic vaccines target the immune system.The action requires a memory response and isdelayed but requires an adequate immune system.
    71. 71. Tumor Growth Rate † † † VaccineTumor Burden Cytotoxic Therapy Time
    72. 72. PROSTVAC – Interesting Case HistoryPSA Radical prostatectomy Vaccine treatment Second vaccine treatment External beam radiation Age Gleason grade: 4 + 3 = 7 Age at which Doubling time PSA would equal 1000 -No other therapy for Trend before radical prostatectomy ( ) 5.8 months 65 years prostate cancer Trend after radical prostatectomy. External beam radiation ( ) 9.6 months 75 years Trend after first vaccine trial ( ) 28.6 months 93 years -Normal testosterone Trend after second vaccine trial ( ) 27 years
    73. 73. Current and Emerging Therapies in CRPC
    74. 74. Planned Phase IIIRandomize patients intoArm A: PSA TRICOM vaccine with GM-CSF (n =400); ArmB: PSA TRICOM vaccine + placebo (n = 400); ArmC: Empty Vector + placebo GM-CSF (n = 400) Primaryendpoint: OSPower = 90% α = 0.005Critical HR 0.82 74
    75. 75. Summary• Localized Disease – RP, EBRT, Brachytherapy• Androgen Deprivation Therapy (ADT) – High risk disease with EBRT – LN+ disease following RP – Metastatic disease• Sipuleucel-T• Chemotherapy – Docetaxel with prednisone – Cabazitaxel with prednisone• Abiraterone• Enzalutamide• Zoledronate or denosumab (decrease skeletal related events) 75
    76. 76. Future Directions• Which patient needs treatment?• Adjuvant systemic therapy for high risk patients• Timing of hormonal therapy• Multimodality therapy• New agents / combinations / sequencing 76