Raadpleeg ook onze lijst van niet-toxische ondersteuning bij prostaatkanker. : 

https://kanker-actueel.nl/NL/studiepublicaties-van-niet-toxische-middelen-en-behandelingen-uitgesplitst-in-aparte-lijst-gerelateerd-aan-specifiek-prostaatkanker-uit-literatuurlijst-van-arts-bioloog-drs-engelbert-valstar.html

Update 30 augustus 2017:

Op ASCO 2017 werd deze studie: Management of Patients with Advanced Prostate Cancer: The Report of the Advanced Prostate Cancer Consensus Conference APCCC 2017

gepubliceerd waarin 60 specialisten op het gebied van prostaatkanker hun mening geven over 10 discussiegebieden bij de behandeling van prostaatkanker in verschillende stadia. Opvallend dat bij veel discussiepunten er behoorlijk verschillend werd gedacht over voorgestelde behandelingen en er voor veel punten geen consensus was. Ik ga de studie niet vertalen, daarvoor is het teveel en u kunt de vertaling gebruiken van goolge translation rechtsboven dit artikel. Nogmaals zie dit studierapport dat volledig gratis is in te zien: 

Management of Patients with Advanced Prostate Cancer: The Report of the Advanced Prostate Cancer Consensus Conference APCCC 2017

26 augustus 2017: Bron: Journal of Clinical Oncology and National Cancer Institute

Vorig jaar publiceerde het NCI een studie: Short Androgen Suppression and Radiation Dose Escalation for Intermediate- and High-Risk Localized Prostate Cancer: Results of EORTC Trial 22991 waaruit bleek dat prostaatkankerpatiënten gebaat zijn met een korte periode van hormoontherapie naast bestraling - radiotherapie. 6 maanden aanvullend hormoontherapie zou voldoende zijn.

Nu komt het NCI met aanvullende gegevens en richtlijnen voor de uroloog en oncoloog wanneer wel en niet hormoontherapie zinvol is. Patiënten (60 plus) met een Gleasonscore van 7 of minder bij de diagnose en/of prostaatkankerpatiënten (alle leeftijden) met een groter risico op hart- en vaatziektes zouden beter geen hormoontherapie kunnen krijgen naast bestraling. Het risico om te overlijden aan hartfalen zou groter zijn dan overlijden aan prostaatkanker.

Dit blijkt uit een gedetailleerde analyse van de patienten die wel of niet profiteerden van hormoontherapie.

Hier een grafiek uit deze studie: Weighing Risk of Cardiovascular Mortality Against Potential Benefit of Hormonal Therapy in Intermediate-Risk Prostate Cancer

Tekst loopt verder onder grafieken. Eerste grafiek geeft de risicofactoren aan.

Table 1.  Distribution of individual cardiac risk factors as defined in Framingham Heart Study (33)*

Risk factorsDefinitions
Blood pressure, %  
   Optimal Systolic < 120 mm Hg; diastolic < 80 mm Hg
   Borderline Systolic 120–139 mm Hg or diastolic 80–89 mm Hg
   High Systolic ≥140 mm Hg, diastolic ≥90 mm Hg, or treatment for hypertension
Serum LDL cholesterol level, %  
   Optimal <2.59 mmol/L (<100 mg/dL)
   Borderline 2.59–4.12 mmol/L (100–159 mg/dL)
   High 4.12 mmol/L (>159 mg/dL)
Serum HDL cholesterol level, %  
Optimal >1.53 mmol/L (>59 mg/dL)
   Borderline 1.04–1.53 mmol/L (40–59 mg/dL)
   Low <1.04 mmol/L (<40 mg/dL)
Glucose tolerance, %  
   Optimal Fasting glucose level < 6.11 mmol/L (<110 mg/dL) or 2 h glucose level < 7.77 mmol/L (<140 mg/dL)
   Borderline Fasting glucose level 6.11–6.94 mmol/L (110–125 mg/dL) or 2-h glucose level 7.77–11.04 mmol/L (140–199 mg/dL)
   High Known diabetes or fasting glucose level > 6.94 mmol/L (>125 mg/dL) or 2 h glucose level >11.04 mmol/L (>199 mg/dL)
Smoking, %  
   Optimal Never
   Borderline Former
   High Current

*HDL = high-density lipoprotein; LDL = low-density lipoprotein.

Figure 1.

Schematic overviews of the model. A) Abbreviated decision tree and Markov model used to compare two strategies for treating intermediate-risk prostate cancer as done in the EORTC22991 trial. B) Influence diagram shows the network of five disease-related health states and comorbidity and toxicity health states (C) linked by transitional variables. GI = gastrointestinal; GU = genitourinary; MI = myocardial infarction.

The primary end point is quality-adjusted life expectancy. Men transition between different health states, including no evidence of disease, biochemical failure, and distant metastases (Figure 1B).

Het NCI heeft samen met Medscape een model gemaakt dat richtlijnen aangeeft voor urologen en oncologen wanneer het aan een prostaatkankerpatient wel en wanneer het beter is geen hormoontherapie te geven.

Als u  de hele tekst wilt lezen dan klik op deze link: Weighing Risk of Cardiovascular Mortality Against Potential Benefit of Hormonal Therapy in Intermediate-Risk Prostate Cancer

Hier de conclusie tekst met referentielijst:

In conclusion, we found that most men with intermediate-risk prostatecancer are expected to benefit from HT if they survive beyond seven years. However, patients with multiple cardiac risk factors may have a decrement in survival with HT. In the absence of randomized data, the current study suggests that younger patients with no cardiac risk factors should receive RT with HT. However, patients at very low risk of biochemical failure or who have a history of MI should be treated with RT alone regardless of cardiac risk.

Discussion

The EORTC 22991 trial demonstrates a clear PC control benefit by adding HT to dose-escalated RT with regard to bDFS compared with RT alone, with 7.2 years' median follow-up. While OS data are not yet mature, it is possible that with longer follow-up a survival benefit will be observed with HT, given that improvements in bDFS can result in an OS benefit. It remains to be determined, however, which subgroups of patients with intermediate-risk PC benefit most from HT. This is of particular interest given the recently proposed subdivisions of intermediate-risk disease into favorable and unfavorable groups based on Gleason score pattern, PSA, and percent positive cores.[48–54] Furthermore, the presence of clinically significant comorbidity, and in particular cardiovascular disease, may offset the benefit of HT either because of the marginal benefit in a patient with limited overall life expectancy and/or a true negative interaction between cardiovascular disease and HT. Additionally, HT is associated with statistically significant adverse side effects, including fatigue and sexual dysfunction. This was further demonstrated in the EORTC 22991 trial as sexual function was more severely affected in patients who received RT + HT compared with RT alone (27.0% vs 19.4%, P = 0.010).

Given the complicated nature of patient identification and treatment selection, decision analyses can help clinicians strategize by comparing risks and benefits associated with different treatment options. Therefore, we created a decision analysis to replicate outcomes of the EORTC 22992 study and to generate expected outcomes with additional follow-up after stratifying men by age and cardiovascular risk. In our model, a benefit to HT was not observed until just beyond the median follow-up of the EORTC 22992 (7.2 years). This suggests that benefits of adding six months of HT to RT are expected to manifest with longer follow-up, with the exception of men with a history of MI, where no benefit was observed with lifetime follow-up. Our model also showed that the healthiest men with the longest life expectancy benefited the most from HT. For instance, the magnitude of benefit was much larger in men age 50 years with optimal risk compared with men age 70 years with four cardiac risk factors (2.6 vs 0.4 QALYs). These results can be explained by the greater competing risks of death and shorter life expectancy in older men with cardiac risk factors.

When exploring ranges of values on sensitivity analyses, the results were consistent over a wide variety of assumptions. We found that HT is not likely to improve QALYs in men at low risk for biochemical failure (≤8.7% at five years). In a retrospective analysis that stratified patients treated with dose-escalated RT with or without HT into favorable intermediate-risk, marginal, and unfavorable intermediate-risk groups, the five-year bDFS for patients treated with RT alone was 94% in the favorable-risk group compared with 74% in unfavorable-risk group. Therefore, our analysis suggests that men with intermediate-risk PC with a low risk of biochemical failure—similar to favorable intermediate-risk disease—achieve optimal QALYs with RT alone, regardless of the number of cardiac risk factors. Using our model to extrapolate beyond what is reported in the EORTC 22991 trial, the men most likely to benefit from HT include those with unfavorable intermediate-risk PC and up to four cardiac risk factors. Conversely, men with favorable intermediate-risk disease or those with history of MI are unlikely to benefit. Sensitivity analyses also revealed that the up-front, transient side effects from HT are negated by avoiding lifetime HT at the time of recurrence in men who received RT with HT. This should be considered during the decision-making process in candidates for HT.

Men with a history of MI have a shorter life expectancy relative to men without previous MI. Therefore, in our model, harms associated with HT—including unwanted side effects and the potential increased risks of cardiac mortality—outweigh improvements in PCSM in men with clinically significant cardiovascular disease. HT was observed to negatively impact men with a history of MI (−0.3 to −0.4 QALYs) because the reductions in QALYs from HT were more apparent in men with the shortest life expectancy. Similarly, when 0.5 utility was assumed for the no evidence of disease health state in average-risk men in our model, the benefits of HT were reduced (1.1 vs 0.3 QALYs).

While several population-based studies have showed positive associations between HT and both the incidence of cardiovascular disease and worsened death from cardiovascular disease,[18,19,21,23,25] postrandomization analyses have produced conflicting data. While some analyses suggest increased risk of MI and lack of benefit of HT,[27,58] others do not report an increased risk of MI and cardiovascular mortality in men with PC who received HT.[59–61] The discrepancy among these studies is perhaps explained by the fact that the prospective randomized trials did not evaluate cardiovascular outcomes in men with a documented history of MI.[1–7,62] For example, in the meta-analysis by Nguyen et al., trials included in the analysis did not stratify by preexisting cardiovascular comorbidity.

Our study is consistent with population-based analyses, which show that reductions in PC mortality from HT are offset by net harm in men with baseline cardiovascular disease.[18–27] Whether HT is necessary for favorable intermediate-risk PC will be addressed by RTOG 0815. In the absence of mature data from this trial, the current study and other retrospective series demonstrate that dose-escalated RT may be sufficient for patients with intermediate-risk PC and cardiovascular risk factors.[48–53]

This study has several limitations. First, the underlying risk of MI development and mortality was derived from the Framingham Heart Study, which was undertaken prior to introduction of sophisticated cardiovascular imaging and percutaneous coronary intervention. The present study suggests that we should incorporate a more sophisticated cardiac risk stratification scheme that includes noninvasive anatomic and physiologic assessment of coronary artery disease.

Second, we did not model four months of HT, an option for men with intermediate-risk PC based on the RTOG 9910 randomized trial. However, this trial did not incorporate dose escalation, and it may be underpowered in men with unfavorable intermediate-risk PC who might benefit from more than four months of HT. Specifically, the proportion of men in RTOG 9910 with favorable intermediate-risk PC, a subgroup of intermediate-risk PC where HT may not be necessary to reduce the risk of PCSM, is unknown.

Third, there is uncertainty inherent to quality of life estimates. In our study, there were no thresholds found for health state utilities. The utility estimates were based on a widely cited source of 162 men age 60 years or older (52% of whom had been diagnosed with prostate cancer) who were highly motivated volunteers. Finally, a Markov model is not a substitute for a prospective randomized controlled trial. A randomized trial comparing HT + RT to RT alone in patients stratified by both favorable and unfavorable intermediate-PC risk and cardiac risk is the optimal method of assessing the impact of HT on cardiovascular outcomes.

In conclusion, we found that most men with intermediate-risk PC are expected to benefit from HT if they survive beyond seven years. However, patients with multiple cardiac risk factors may have a decrement in survival with HT. In the absence of randomized data, the current study suggests that younger patients with no cardiac risk factors should receive RT with HT. However, patients at very low risk of biochemical failure or who have a history of MI should be treated with RT alone regardless of cardiac risk.

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J Natl Cancer Inst. 2016;109(6) © 2016 Oxford University Press


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