The researchers analyzed data from the VHA database from April 2013 to March 2018. They studied men who had only been treated with androgen-deprivation therapy (ADT), also called hormone therapy or castration. ADT can involve surgery to remove the testicles, which is called bilateral orchiectomy. Or it can involve treatment with medicine, such as luteinizing hormone-releasing hormone (LHRH) agonists, LHRH antagonists, and anti-androgens. Among the men with prostate cancer that progressed after ADT, the researchers then further searched for men who received abiraterone acetate or enzalutamide. This analysis included data from 2,123 white men and 787 African-American men with mCRPC, with average ages of 74 for white men and 71 for African-American men. The African-American men had more high blood pressure, type 2 diabetes, and liver problems than the white men.
In this study, the data showed that African-American men who were treated with either abiraterone acetate or enzalutamide lived for a median of 30 months, about 2.5 years. The median is the midpoint, meaning that half of the men lived less than 30 months and the other half lived longer than that. For white men treated with either of the drugs, the median survival was 26 months, which is a little over 2 years. These results were adjusted for demographic and clinical characteristics found in the VHA database.
Recent studies presented at the 2018 ASCO Annual Meeting also showed that African-American men with prostate cancer lived longer than white men if they were treated with docetaxel (Taxotere) and abiraterone acetate. African-American men are more likely to develop the disease when they are younger and the tumors may be more aggressive. In general, African-American men are also more likely to die from prostate cancer than white men. Research is ongoing to find out more about the biology that drives these racial differences in prostate cancer, with the goal of improving treatments and understanding why African-American men have a higher incidence of the disease.
What does this mean? The anti-androgens abiraterone acetate and enzalutamide work better in African-American men, even though they are known to be at a greater risk of dying from prostate cancer. There are unknown biological reasons for these racial differences in prostate cancer, and researchers are working to learn more.
“We’ve historically seen that prostate cancer is more common, more aggressive, and more lethal in African Americans, compared with men of other racial groups. Despite having more non-cancer related health complications, we found that treatment with newer hormonal medicines led to a significantly greater survival for African-American men in this analysis, compared with white men.”
— lead study author Megan McNamara, MD Duke University School of Medicine Durham, North Carolina
Metastatic castration-resistant prostate cancer has a high response rate to radiolabeled targeted drug
A study of 50 men with mCRPC found that treatment with a radioactive targeted drug was very effective and lengthened lives for a median of around 13 months. A median is the midpoint, meaning that half of the results are on each side of the median. All of the men in this clinical trial had mCRPC that had prostate specific membrane antigen (PSMA) on the surface of the cancer cells. PSMA can indicate the aggressiveness of the prostate cancer. PSMA can be detected using positron emission tomography (PET) scans.
The drug in this clinical trial is called lutetium-177 PSMA-617 (LuPSMA). LuPSMA seeks out cancer cells with high levels of PSMA on the surface and then delivers radiation to those cells in order to destroy them. The radiation is delivered by the lutetium-177, a radioisotope that releases beta radiation, which can destroy cancer cells, and gamma rays, which can be seen using PET scans. During treatment, PET scans can be used to find out if the treatment is stopping or shrinking tumors. With this approach, LuPSMA delivers high doses of radiation directly to the cancer cells and lessens the potential damage to normal cells. A broader term to describe this type of treatment is peptide receptor radionuclide therapy (PRRT).
The men in this study were between 50 and 87 years old and had rapidly doubling prostate-specific antigen (PSA) levels, a sign of aggressive disease. The prostate cancer was not stopped by treatment with chemotherapy or anti-androgens. LuPSMA was given intravenously (into the veins of patients) for up to 4 cycles every 6 weeks. Researchers used PSA levels and PET scans to check whether the treatment was working. If the cancer continued to grow and spread, more cycles of LuPSMA were given.
In 32 of the 50 men, PSA levels were lowered by 50% or more. In 22 men, the PSA level reduction was 80% or more. PSA levels did not increase in these men for a median of nearly 7 months, indicating that the treatment had stopped the cancer. For 14 men, the cancer continued to grow and spread after treatment, and they received a median of 2 more cycles of LuPSMA. Of those 14, 9 men saw their PSA levels lower by 50% or more. Those 9 men who received additional treatment lived for a median of 33 months.
The most common side effects were dry mouth, nausea, and fatigue. This is because PSMA is also found on cells in the salivary and tear glands. About 10% of the men had more serious side effects, including anemia and low blood platelet counts, also called thrombocytopenia.
“It’s exciting to see that LuPSMA can potentially offer benefits for many men with these very aggressive cancers, with few side effects and significant improvements in quality of life. Importantly, we saw continued benefits with LuPSMA treatment in some men whose cancer progressed.”
— lead study author Michael Hofman, MD Peter MacCallum Cancer Centre Melbourne, Australia
Combined pembrolizumab and axitinib helps people with advanced kidney cancer live longer
Results from the phase III KEYNOTE-426 global clinical trial found that pembrolizumab (Keytruda) plus axitinib (Inlyta) may be more effective than sunitinib (Sutent) as a first treatment for kidney cancer that has spread to distant sites, called metastatic. The type of kidney cancer studied in this clinical trial was clear cell renal cell carcinoma (RCC), which is the most common type of kidney cancer. Pembrolizumab is a type of immunotherapy called an immune checkpoint inhibitor that targets a protein called PD-L1. Axitinib and sunitinib are a type of targeted therapy for kidney cancer called tyrosine kinase inhibitors that block a protein called VEGF.
Combining immunotherapy with targeted therapy is a new approach to treatment for this type of cancer. When given alone, targeted therapy and immunotherapy tend to work in about a third of people with kidney cancer. In an earlier phase of this clinical trial, researchers saw that a combination of targeted therapy and immunotherapy caused tumors to stop growing or shrink in 70% of patients. The goal of this phase III clinical trial was to see if the combination treatment helped people live longer and was safe to use.
This study included 861 people with metastatic clear cell RCC who had not received any previous systemic treatment, with 432 receiving pembrolizumab plus axitinib and 429 receiving sunitinib alone. The average age of the people was 62 years, and 70% of them were men.
After a median of about 13 months of follow-up, nearly 60% of patients were still receiving the combination treatment, compared with about 43% of patients still receiving sunitinib alone. At 1 year, nearly 90% of the patients taking the combination treatment were still alive, compared with about 78% of the patients taking sunitinib. Those taking the combination treatment had their disease stopped for a median of 15 months, compared with a median of 11 months for those taking sunitinib alone.
All of these drugs come with risks of serious side effects. This study only included people whose health was measured to be strong enough to receive the drugs. Serious side effects developed in nearly 63% of those taking the combination and 58% of those taking sunitinib. And, 6% had to stop the combination treatment because of side effects and 10% had to stop taking sunitinib.
What does this mean? This combination of immunotherapy and targeted therapy may offer a new approach to initially treating metastatic clear cell renal cell carcinoma. Patients should talk with their doctor about the risk of side effects before starting immunotherapy or targeted therapy.
“By adding pembrolizumab to a VEGF-targeted therapy, we are seeing powerful anticancer responses, including improved survival—and importantly, the results are seen in broad groups of patients.”
— co-lead study author Thomas Powles, MD Barts Cancer Institute London, United Kingdom
Carol Michaels is the founder of Recovery Fitness®,a nationally recognized exercise program designed to help people diagnosed with cancer recover from surgery and other treatments. She is an award-winning exercise specialist, author, presenter, and consultant. She received her degree from the Wharton School of the University of Pennsylvania. Carol has produced DVDs and created the Cancer Specialist Recovery course in partnership with the National Federation of Professional Trainers. Her book, Exercises for Cancer Survivors, is designed to help anyone undergoing cancer surgery or other treatments.
The other big benefit of exercise is that it can reduce the side effects of common prostate cancer treatments, such as androgen deprivation therapy (ADT). The side effects of ADT can include muscle loss, an increase in fat mass, and the bone disease of osteoporosis. Risk for diabetes and heart disease also increases with ADT. In addition, exercise can reduce the stress, anxiety, and depression often experienced by men with prostate cancer.
Below is some basic information on starting an exercise program during and after prostate cancer treatment. Be sure to talk with your doctor before you get moving.
What kind of exercise should I do after prostate cancer treatment?
The Department of Health and Human Services recommends that adults get at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity each week. Aerobic exercise, such as walking, jogging, or swimming, is important because it burns calories to keep weight under control. However, men with prostate cancer should avoid prolonged bicycling because of the pressure the seat puts on the perineal area, which is between the scrotum and the anus.
A good fitness routine should also emphasize strength training, which will help increase muscle mass and bone density and decrease body fat. This is especially important because your treatments may cause sarcopenia, which is a change in your fat-to-muscle ratio. Strength training can be performed with weights, bands, machines, or your own body weight. Balance exercises that help with coordination may also be helpful.
How can I strengthen my muscles?
The muscle that surrounds the prostate may be weakened from cancer surgery or other treatments. This can cause urinary incontinence, which is a loss of bladder control. There are different types of incontinence, ranging from mild to severe. For example, stress incontinence can cause a person to leak urine during activities such as coughing, laughing, sneezing, or exercising. Urge incontinence is loss of urine with a sudden, urgent need to urinate, while continuous incontinence is not being able to control the bladder at all.
Kegel exercises can strengthen your pelvic floor muscles. These muscles support the bladder and bowel and are used to stop the flow of urine. Kegels are great for men with prostate cancer because they can help control incontinence without medication or surgery, as well as may improve erectile issues.
It’s smart to start Kegel exercises before surgery and other treatments. To perform a Kegel, tighten and release your pelvic floor muscles. To activate them, pretend you’re stopping and starting a flow of urine. Perform 10 Kegels, holding the stopping contraction tight for 5 seconds each time. Take a 5-second break between each repetition. Try to do 4 sets per day. It may take several weeks or months to work up to these recommendations.
What exercise precautions do I need to take?
Always consult your doctor before you begin an exercise program. Prostate cancer and its treatments can cause specific side effects that may require you to modify your exercise program. If you’re experiencing any of the side effects below, stop exercising and talk to a member of the health care team.
Fatigue. Physical fatigue can make it harder to exercise vigorously. Monitor your energy levels and adapt your exercises accordingly.
Osteoporosis. If you’ve been diagnosed with osteoporosis, ask your doctor which weight-bearing exercises you can do safely to strengthen your bones.
Bone metastases. When cancer cells spread, or metastasize, to the bone, there’s a higher risk of a fracture occurring. Perform balance exercises and other exercises that have a low risk of falling.
Cardiopulmonary issues. If you have weakened heart muscles or an irregular heartbeat, be sure to begin your exercise program under medical supervision.
Lymphedema. This common side effect can occur after the removal of lymph nodes and is identified by swelling of a part of the body, such as a leg or trunk. Maintaining range of motion and avoiding infection is important when you have lymphedema. You need to progress slowly and may need to modify some exercises. Always contact your doctor if you have any kind of swelling.
Peripheral neuropathy. This common side effect of cancer treatment affects the nervous system, causing numbness, loss of sensation, tingling, and pain in different areas of the body. If neuropathy is affecting your hands, it may be hard to safely hold hand weights. Using tubing or bands with handles is safer. Balance training is also important.
Neutropenia. Cancer treatment can cause neutropenia, a decrease in white blood cells. This may increase your risk of infection. Avoid places that are crowded and not cleaned regularly, like gyms. Ask your doctor about an exercise program you can do at home.
Myelosuppression. When you have myelosuppression, your bone marrow slows its production of blood cells and platelets, making you more likely to bruise and bleed. This means you should use caution with exercise machines and equipment. If white blood cells are decreased, there may be a higher risk for infection (see Neutropenia, above.)
In this podcast, Brian I. Rini, MD, and Jorge A. Garcia, MD, talk about the treatment landscape for kidney and prostate cancers and some of the research highlights from this meeting that involve these 2 genitourinary (GU) cancers.
Combining axitinib (Inlyta), a targeted therapy, and avelumab (Bavencio), an immunotherapy, to treat metastatic kidney cancer [3:11].
Combining atezolizumab (Tecentriq) and bevacizumab (Avastin) to treat kidney cancer [7:04].
The possibility of using immunotherapy to treat sarcomatoid kidney tumors [9:34].
The current understanding of the treatment of metastatic prostate cancer [11:47]
New data for the treatment of low-volume metastatic prostate cancer [16:52]
What happens when abiraterone acetate (Zytiga) is combined with radium-223 to treat advanced castration-resistant prostate cancer [19:23]
Dr. Rini is a Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. He is the Cancer.Net Associate Editor for Genitourinary Cancers. Dr. Garcia is an Assistant Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Dr. Garcia is the Cancer.Net Specialty Editor for Genitourinary Cancers. Both Dr. Rini and Dr. Garcia are staff members of the Department of Solid Tumor Oncology at Cleveland Clinic Taussig Cancer Institute.
Was this podcast useful?Please subscribe, rate, and review Cancer.Net Podcasts on Apple Podcasts or Google Play. This prerecorded podcast can be listened to online or downloaded to your computer. A transcript is also available. For more information, visit the Cancer.Net podcast page.
A small study that showed that some patients with advanced kidney cancer were able to stop immunotherapy early without having the disease worsen [1:22].
Research on a potential connection between a person’s gut bacteria, or “gut microbiome,” and how well immunotherapy works. In the study discussed here, researchers found that immunotherapy was less effective for people with kidney cancer who had used antibiotics less than a month before starting treatment [2:47].
A study on free-floating cancer DNA from blood tests showed that these tests could help identify new molecular targets in advanced prostate cancer. These tests are often called circulating tumor DNA tests and may also be referred to as a “liquid biopsy” [4:15].
Dr. Pal is a member of ASCO’s Cancer Communications Committee and a medical oncologist at the City of Hope Comprehensive Cancer Center in Duarte, California.
This is a prerecorded audio podcast. It can be listened to online or downloaded to your computer. A transcript of this podcast is also available. For more information, visit the Cancer.Net podcast page.
Voices on Cancer is a Cancer.Net Blog series where advocates share their stories and the lessons they have learned about being a cancer advocate. Dennis Golden is a prostate cancer survivor and the CEO and founder of the National Prostate Cancer Awareness Foundation Inc. (PCaAWARE). He founded PCaAWARE to educate men and their partners about this disease that affects more than 160,000 men a year.
My advocacy story
Every year, the results of my annual physical exams were routine. My prostate-specific antigen (PSA) blood test results were normal. The digital rectal exam (DRE) found no signs to worry about. Like most men, I felt this meant that I was in the clear and that there was no need to ask additional questions.
That mindset changed in December 2012, when the results of a PSA blood test were elevated. At that point, my doctor suggested that it might be a good idea to visit the urologist. I dreaded the prospect of undergoing exams and tests that might make me feel embarrassed, but at my wife’s insistence, I made an appointment anyway. Several weeks later, the urologist confirmed that I had an aggressive form of prostate cancer. In April 2013, my prostate was surgically removed.
Taking your talents and turning them into advocacy tools
I took my gifts as a professional speaker and used them to create PCaAware and serve its mission. Here are some ways you can review your unique talents and put them to work in your advocacy mission.
Ask yourself, “What is my gift?”I don’t mean your skills. Skills can be learned. A gift is something you are born with. What is one thing you do so naturally that you cannot explain it? My gift is speaking. I use my gift to make people aware of the power of living in the present. Find and use your gift.
Start every day with this question: “How will I engage people today to make difference?”At the end of the day, ask yourself what you did to make a difference. Using this motivation daily will force you to rely on the abilities that you have. Reviewing what you did each day will help you identify your talents.
Live in the present. Look at the abilities you have now, not at the skills you hope to have. Think about how your talents can be used to help others. Put yourself to work in bringing about change today.
In my work at a busy prostate cancer clinic, I discuss all available treatment options with men who are experiencing erectile problems after surgery or radiation therapy. The discussion proceeds in an orderly fashion, with the oral agents (pills) described first, then the penile pump, the alprostadil pellet, penile self-injection, and lastly the penile implant, since this is the order in which most men try these interventions. The oral agents help about half of the time, dependent on degree of nerve-sparing during radical prostatectomy as well as pre-treatment erectile function and age. If those fail, some men are interested in the penile pump; however, I do share with them that I have not found that to be successful with most patients. Many patients, and in particular their partners, are not satisfied with it due to the mechanical nature of the device and the degree to which it interrupts the flow of the sexual encounter. The alprostadil pellets are expensive and many men experience a burning sensation in the urethra and do not continue using the treatment. Penile implants tend to be a measure of last resort, involving major surgery that many men are reluctant to undergo.
When I talk to them about penile self-injection, many men cross their legs in an automatic reflex. They are often horrified at the idea of doing this, even though it is a technique that is easy to master and has good results, even years after treatment and an extended period of profound erectile dysfunction. It can take multiple appointments and increasing desperation before they are ready to try this, and I understand why this is a challenging idea for many. I agreed reluctantly to do the test doses for these men. I used to refer them to one of my urologist colleagues when they agreed to try this technique because it felt a little uncomfortable for me to see them in counseling and then to see their naked genitals. But the wait to see the urologist for this was usually months long and they often did not receive comprehensive education about how to draw up the medication and the technique of injecting themselves. I would see men who had given up on the intervention because they were not sure how to do it or were anxious that they would harm themselves, or who tried it once and gave up when the result was less than optimal. So I had a little talk with myself and decided that I needed to get over myself and start doing the teaching and the test dose.
Recently I was stopped by a patient as I walked past the examination rooms in the clinic.
“Dr. Katz, can I talk to you for a minute?”
I stopped, my mind trying really hard to recall his name and what, if anything, I had managed to help him with.
“I want you to know that those injections have made such a difference in my life,” he said, his icy blue eyes filling with tears. “I don’t think you know how bad I was feeling about myself as a man,” he continued, “and it might seem silly, but being able to, you know…. Well, I feel like myself again.”
He had his hand on my shoulder as he talked, and the grip of his hand was strong.
“I do know how important it is,” I said, “but it takes a lot of courage to get over the fear and to finally agree to it.”
“Exactly!” he replied, the tears now gone and replaced by a twinkle in his eyes. “I have told so many men at the support group about what a difference that little needle has made—but so many of them just can’t seem to get over themselves.”
We talked for a few more minutes and then he shook my hand and thanked me again.
I walked back to my office with a big grin on my face and a bounce in my step. Almost every week I see approximately 1 patient for a test dose. They always bring their partner/spouse with them and I demonstrate the procedure on a rubber model penis that I have for this purpose. Then I leave the room to gather my supplies and when I come back, they are seated sideways on the examination table with a draw sheet over their lap. I show them how to draw up the medication, how to check the dose, and then I do the injection. It’s over in about 30 seconds and then I leave the room for 20 minutes. I tell them that I don’t need to see the results because the look on their face will tell me if it worked or not. A couple of men have tried to fool me by putting on a sad face when I come back to check on them, but after about 5 seconds they burst into laughter and tell me that they were only teasing, the results were akin to when they were 20 years old. It is immensely gratifying to me to see their joy—and I’m pretty sure that it is for them too.
I had to get over myself—my reluctance was mostly about personal discomfort—and focus on the needs of the patients who desperately wanted this part of their lives back. And my patients in turn had to get over themselves and their valid fear of sticking a needle into a very sensitive part of their anatomy. This mutual getting over ourselves has been a happy outcome for all of us.
The theme of the 2018 American Society of Clinical Oncology (ASCO) Annual Meeting is Delivering Discoveries: Expanding the Reach of Precision Medicine. Precision medicine has led to many advances in cancer care, but there is still much to learn in this growing field of research. Even more, as ASCO President Bruce E. Johnson, MD, FASCO, writes in this year’s Clinical Cancer Advances report, the promise of precision medicine “is only as good as our ability to make these treatments available to all patients.” While much of the cancer research at this year’s meeting will focus on precision medicine, there is also an ongoing effort to increase access to these treatments for all patients.
More than 32,000 oncology professionals from around the world are at the ASCO Annual Meeting, presenting and discussing the latest research in cancer treatment and patient care. Learn about the research released today:
Geriatric assessment improves communication between oncologists and older patients
Treatments for advanced prostate cancer may work better in black men
Women with head and neck cancer may be undertreated
Treatment for colorectal cancer costs twice as much for U.S. patients than Canadian neighbors
Geriatric assessment improves communication between oncologists and older patients
Results from a federally funded clinical trial found that using a geriatric assessment in the care of older adults with advanced cancer improves doctor-patient communication and patient satisfaction. About 70% of people with cancer are 65 or older, and this is expected to increase over the next 20 years.
A geriatric assessment is an evaluation of many concerns that are specific to older adults and that are not normally covered during a routine clinical visit. Topics covered include different aspects of physical and mental health, nutrition, and social support. This assessment can help find individuals who might have health problems that are not related to cancer and who may have a higher risk of cancer treatment-related side effects. ASCO recommends that people with cancer who are 65 or older and who are receiving chemotherapy should receive a geriatric assessment to identify any additional problems these people may have. Previous research has shown that geriatric assessments are most widely used in major cancer centers with geriatric oncology programs, but not as often in other types of clinics.
In this study, 31 community oncology practices were randomly assigned to 1 of 2 groups, either a geriatric assessment group or to a usual care group. These practices provided information on 542 people, all of whom were 70 or older, had incurable advanced tumors or lymphoma, and had at least 1 impairment identified during the geriatric assessment.
The geriatric assessment in this study evaluated:
Function, which is the ability to participate in the activities of daily life
Physical performance, such as balance, history of falls, and overall physical health
Comorbidity, which is when someone has more than 1 disease or disorder at the same time as the cancer diagnosis
Cognition, such as memory problems
Physical and cognitive abilities of the patients were tested by trained coordinators in the clinic, and the other factors were reported by the patients through a questionnaire. Altogether, this took less than 1 hour of the person’s time.
All of the patients received a geriatric assessment in this study, but only the oncologists at the practices in the geriatric assessment arm received a summary of the results of the assessment as well as recommendations for how to treat potential problems. In the usual care group, oncologists only received information if the geriatric assessment found that the older adult had serious cognition problems or depression. During clinic visits within 4 weeks after the geriatric assessment, the researchers recorded and transcribed the communication during 1 clinic visit for each person in the study.
The researchers defined quality doctor-patient communication as conversations in which the doctor gathered more information about age-related concerns and the doctor thoroughly addressed the older adult’s concerns. Patient satisfaction with the quality of the doctor-patient communication was evaluated by using a phone questionnaire with each patient after the clinic visit.
In the geriatric assessment group, there was an average of 3.5 more discussions about age-related concerns than in the usual care group. There was an average of 2 more high-quality doctor-patient conversations in the geriatric assessment group than in the usual care group. And, older adults and doctors had an average of 2 more conversations that led to medical care, called interventions, in the geriatric assessment group than in the usual care group. Examples of these interventions included physical therapy for those with a history of falls, removing or reducing high-risk medications for those taking more than 5 prescriptions, and assessing decision-making ability in those with cognition problems. The people in the geriatric assessment arm also had more discussions about nearly all of their age-related concerns that were measured by the geriatric assessment and were happier with the quality of their communication with the doctor.
“As oncologists, we need to step away from focusing solely on the cancer, especially in our older patients. While living longer is important, there are many non-cancer related health issues that are as, if not more important. Both patients and their caregivers clearly want the oncologist to discuss age-related concerns. Our study shows that geriatric assessment can help oncologists meet these needs for their older patients.”
— lead study author Supriya Gupta Mohile, MD Previous recipient of Conquer Cancer YIA University of Rochester Rochester, New York
Treatments for advanced prostate cancer may work better in black men
Black men treated with chemotherapy have survival rates equal to or higher than those of white men
In this first study, researchers analyzed data from 9 different phase III clinical trials, which in total covered more than 8,820 men of different races with mCRPC who were treated with chemotherapy. The researchers had to bring together this data from different clinical trials because not enough black men were included in each of the studies individually to scientifically compare whether the chemotherapy regimen worked as well as in white men. Among the patients’ data that was analyzed for this study, 7,528 (85%) were white men and 500 (6%) were black men. Data for only white men and black men were analyzed because the intention of this study was to test whether black men with mCRPC really have a worse prognosis, which is the chance of recovery.
The treatment plans used in all of the clinical trials in this study were docetaxel (Docefrez, Taxotere) plus prednisone (multiple brand names) or docetaxel plus prednisone plus other treatments. The researchers also compared the data for black men and white men using similar factors that affect a person’s prognosis, such as age, site of metastasis, prostate-specific antigen (PSA) levels and performance status, which is a measure of a person’s general well-being and ability to perform the activities of daily living.
The analysis shows that black men have at least the same chances of survival as white men. The median survival for black men and white men was the same (21 months). The median is the midpoint, which means that half of the people were on each side of the median. Further analysis shows that when men with similar prognostic factors are compared, black men have a 19% lower risk of death than white men. It is important to remember that this analysis is based on data for just 500 black men compared with more than 7,000 white men, so more research is needed to learn more about the different ways in which prostate cancer works in black men and in white men.
“By pooling data across clinical trials, this study provided a unique opportunity to evaluate how race might affect prostate cancer response to treatment. This study underscores the importance of increasing the participation of racial minorities in clinical trials. Every patient who participates in a clinical trial contributes to improving care, and all patients should have the opportunity to receive needed therapies.”
— lead study author Susan Halabi, PhD Duke University Durham, North Carolina
Abiraterone appears to be more effective at treating prostate cancer in black men
In the second, separate study, the Abi Race clinical trial included 100 men with mCRPC: 50 black men and 50 white men. During the clinical trial, all the men were treated with a hormone therapy called abiraterone acetate (Zytiga), along with prednisone (Deltasone), until the cancer worsened or side effects forced them to stop. The researchers measured the time it took for the cancer to worsen, called progression-free survival (PFS), by using imaging scans and the PSA blood test.
The study’s results showed abiraterone was effective at stopping or slowing advanced prostate cancer in both black men and white men. When that effectiveness was measured by imaging scans, both groups had a median PFS of nearly 17 months. This means that the cancer had visually stopped growing and spreading on scan images during that time span.
But when PFS was evaluated using the PSA blood test, there was a notable difference between black men and white men. The blood’s PSA level is 1 factor that can help indicate whether prostate cancer treatment is working. If the PSA level goes down after treatment, men may live longer and have a better quality of life than if there is no decline in the PSA level. The median PFS when measured by PSA test results was nearly 17 months in black men and 11.5 months in white men.
In addition, treatment with abiraterone led to greater declines in PSA in black men than in white men. Nearly half (48%) of the black men had a 90% or better decline in PSA levels, compared with 38% of white men. Three out of every 4 black men had a 50% or better decline in PSA levels, compared with 2 out of every 3 white men. Most of the men in the study had a 30% or better decline in PSA levels (86% of black men and 76% of white men). Abiraterone did not lower PSA levels in 4 black men and 8 white men.
Side effects were similar across the 2 groups. Fatigue was more common in white men. Low potassium level is a side effect caused by abiraterone, and it was twice as common among black men than white men. If not treated, a low potassium level can be very dangerous.
“Black men are more than twice as likely to die of prostate cancer than white men and are generally thought to have worse prostate cancer outcomes. Our study suggests that when black men and white men with advanced prostate cancer are given the same hormone treatment, this is not the case. Our research underscores the importance of specifically studying genetically diverse populations and raising awareness to these results so that everyone who can benefit from abiraterone is offered this treatment.”
— lead study author Daniel George, MD Duke University Durham, North Carolina
The researchers of both studies think that there are biological differences in what drives prostate cancer in black men and white men. Other research has shown that the way hormones work in black men is different from how they work in white men, and this may help explain the different treatment effects. For both studies, the next step is to conduct a genomic analysis of blood and tumor samples to try to learn more about what is driving these differences.
These 2 studies also highlight how important it is to include black men and other underrepresented groups in prostate cancer clinical trials. The percentage of minority participants, including black people, in cancer clinical trials is often much lower than the percentage of the same people in the general population. This makes it hard to judge the effectiveness and safety of cancer treatments by race. This difference in representation in clinical trials also means that fewer people in minority groups receive new cancer treatments.
Women with head and neck cancer may be undertreated
Researchers analyzing cancer registry data found that women with head and neck cancer were less likely than men to receive intensive chemotherapy and radiation therapy and had a higher risk of dying from the disease.
In the United States this year, nearly 65,000 people will be diagnosed with head and neck cancers, which are more than twice as common in men than in women.
Developing a treatment plan for head and neck cancer depends on many factors, such as the overall well-being of the patient and whether the cancer is caused by the human papillomavirus (HPV). People who are in better general health can often receive more intensive treatments for the cancer, such as platinum-based chemotherapy combined with radiation therapy. HPV-related head and neck cancers respond better to treatment, so people with these cancers have a better chance of recovery. A previous study by the same authors found that HPV-related head and neck cancers are more common in men (77.4%) than in women (22.6%).
In this new study, the researchers studied health data from a Northern California hospital system for 223 women and 661 men, all of whom had stage II to stage IVB head and neck cancer. The researchers used a statistical method to estimate the chances someone would receive intensive cancer treatment. They also used a mathematical tool to compare the risk of dying from cancer to the risk of dying from other causes.
Overall, the study found several differences between women and men with head and neck cancer:
Treatment: The chances of receiving intensive chemotherapy were 35% for women compared with 46% for men. The chances of receiving radiation therapy were 60% for women and 70% for men.
Risk of death: At a median follow-up of nearly 3 years, 271 people died of cancer and 93 from other causes. The median is the midpoint, which means that half of the people were on each side of the median. Both men and women were more likely to die of cancer than of other causes, but the ratio of cancer deaths versus non-cancer deaths was 1.92 times higher for women than for men.
HPV-related cancers: More men than women had oropharyngeal cancers (55% men vs. 38% women), and HPV-related cancers occur more frequently in the oropharynx. The researchers suspect that because people with HPV-related head and neck cancers have a better chance of recovery and because more men than women have HPV-related cancer, this may help explain why women have a higher risk of dying of head and neck cancer than men.
“We weren’t looking for gender differences, so the results were really surprising. Besides undertreatment, there are a number of factors that could contribute to the differences in outcomes between women and men with head and neck cancer, and it’s clear we need further investigation. With this mathematical model, we have a tool that can help us identify patients likely to benefit from more intensive treatment, as well as those more likely to die from other non-cancer-related causes. The hope is that by integrating this model into our care, we can improve the care of all patients with head and neck cancer.”
— lead study author Jed A. Katzel, MD Kaiser Permanente Santa Clara, California
Treatment for colorectal cancer costs twice as much for U.S. patients than Canadian neighbors
An analysis of health claims data from 2 regions on either side of the U.S. and Canada border shows that common treatment for advanced colorectal cancer costs twice as much on the U.S. side. Despite the higher cost, the U.S. patients are not living longer than those in Canada.
The study team was made up of both U.S. and Canadian researchers interested in learning more about differences between single-payer insurance health care in Canada and the United States’ private insurance and government-run insurance system. They reviewed data from Canada’s British Columbia and from western Washington state, both of which have a mostly white population, a large Asian minority population, and similar levels of income and education. This study included data from 1,622 people with metastatic colorectal cancer from British Columbia and 575 from western Washington. The Canadian patients were older than those in Washington (median age 66 years vs. 60 years), probably because data on U.S. patients with Medicare were not available for this study. The median is the midpoint, which means that half of the people were on each side of the median.
Both regions also used initial systemic treatments for advanced colorectal cancer that provide the same benefit to people with cancer. People in Canada were most often treated with a chemotherapy combination called FOLFIRI plus a targeted therapy, bevacizumab (Avastin). In the United States, people were most often treated with a chemotherapy combination called FOLFOX.
The researchers found that more U.S. patients received initial systemic treatment (79%) than those in Canada (68%), but this difference may be due to the fact that the U.S. patients were younger. They also found that average treatment costs were higher in western Washington ($12,345) than in British Columbia ($6,195).
However, there were no significant differences in how long people lived between the 2 regions. For those who received systemic treatment, the median survival was 21.4 months in Washington state and 22.1 months in British Columbia. Among those who did not receive systemic treatment, median survival was 5.4 months in western Washington and 6.3 months in British Columbia. More research is needed to find out if there are differences in the patient’s quality of life between the regions.
“To our knowledge, this is the first study to directly compare treatment cost and use, along with health outcomes in two similar populations treated in different health care models. Understanding these differences may help us improve care and potentially lower health care costs.”
— lead study author Todd Yezefski, MD Fred Hutchinson Cancer Research Center University of Washington School of Medicine Seattle, Washington
Visit the Cancer.Net Blog every day for more reports from Chicago during the ASCO Annual Meeting. You can also keep up with the news by following Cancer.Net on Facebook and Twitter.
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Below are summaries of 4 studies that will be presented at the symposium:
Immunotherapy Added to Standard Treatment Slows Growth of Advanced Kidney Cancer
New Drug Delays Development of Metastatic Prostate Cancer
Adding Docetaxel to Hormone Therapy Improves Quality of Life For Men With Prostate Cancer
New Way to Predict Survival for People With Bladder Cancer
Immunotherapy Added to Standard Treatment Slows Growth of Advanced Kidney Cancer
Renal cell carcinomais the most common type of kidney cancer in adults, making up about 85% of kidney cancer diagnoses. When this cancer spreads to other parts of the body, it is called metastatic renal cell carcinoma. The first treatment option for this type of metastatic cancer is usually a targeted therapy, such as sunitinib (Sutent).
Now, a study suggests that a drug called atezolizumab (Tecentriq) given in addition to a targeted therapy called bevacizumab (Avastin) can be more effective than treatment with only sunitinib. Atezolizumab is a type of immunotherapy called an immune checkpoint inhibitor, which works by taking the brakes off the body’s immune system. Atezolizumab blocks a protein called PD-L1 on the surface of tumor cells, allowing the immune system to recognize and destroy those cells. Bevacizumab and sunitinib are targeted therapies that block the growth of blood vessels to the tumor to limit its growth.
This study included 915 adults who had not previously received treatment for metastatic renal cell carcinoma. The participants were grouped based on whether each person’s tumor cells had PD-L1. During the study, they received either the combination of drugs through an intravenous (IV) tube every 3 weeks or took a sunitinib pill daily for 4 weeks then 2 weeks off treatment.
“For an aggressive cancer like this, where less than 20% of people survive 5 years after diagnosis, we think a 3.5 month longer progression-free survival, given the tolerability for this new combination treatment regimen, is an important development.”
— lead study author Robert J. Motzer, MD Memorial Sloan Kettering Cancer Center New York
New Drug Delays Development of Metastatic Prostate Cancer
Results from a phase III clinical trial found that a drug called apalutamide can delay the development of metastatic cancer in men with non-metastatic castration-resistant prostate cancer.
The study, called SPARTAN, included 1,207 men who were at high risk for developing metastatic prostate cancer. In addition, they all had cancer that had stopped responding to androgen deprivation therapy (ADT). ADT is a hormonal therapy used to treat prostate cancer recurrence in many men. When a prostate cancer no longer responds to ADT, the prostate cancer is called castration resistant.
The men in the study received ADT and apalutamide or ADT and a placebo. A placebo is an inactive drug or treatment used in a clinical trial to help compare treatments. Results of the study were that apalutamide lowered the risk of metastasis and death by 72% when compared with the placebo group. Men who received apalutamide also lived about 2 years longer than those in the placebo group. In general, apalutamide did not have serious side effects. And quality of life for the men on the medicine was similar to other men with prostate cancer.
“Until this trial, there have been no drugs proven to benefit men with non-metastatic prostate cancer that has progressed despite standard hormonal therapy. These results show that apalutamide made a significant difference in prolonging the time before the development of metastasis.”
— lead study author Eric J. Small, MD, FASCO University of California San Francisco
Adding Docetaxel to Hormone Therapy Improves Quality of Life For Men With Prostate Cancer
This study is a new analysis of an ongoing clinical trial named Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy (STAMPEDE), which has collected information on the more than 9,000 men with advanced prostate cancer participating in the study since it began in 2005. For this analysis, researchers looked at information on quality of life from 592 men who had either metastatic or non-metastatic cancer.
To measure quality of life, researchers asked participants to rate various aspects of their health on a scale of 1 to 5. The aspects were:
How well they could care for themselves
How well they could perform daily activities
Pain and discomfort
Anxiety and depression
Then they used this information to predict how long a person would live using a measurement called quality-adjusted life years (QALY). QALY measures a person’s quality and quantity of life. By using this type of measurement, researchers found that the men with metastatic prostate cancer taking docetaxel plus hormone therapy could potentially live almost 11 months longer with a good quality of life for at least 6 months when compared with men receiving standard treatment. Researchers also found that men with non-metastatic prostate cancer who were taking docetaxel and hormone therapy could potentially live a little more than 9 months longer with a good quality of life for almost 5 months when compared with men receiving standard treatment.
What does this mean?
It was previously known that docetaxel could lengthen survival of men with metastatic prostate cancer, but the information about non-metastatic disease may help doctors in their efforts to reduce recurrence. In addition to possibly offering a better quality of life than standard treatment, docetaxel plus hormone therapy is a less costly option for men with non-metastatic prostate cancer due to the reduction in the need for additional treatment. In the study, adding the chemotherapy reduced the need to be treated later for recurrence by 40%.
“How does one measure wanting to live a few more months to see a grandchild born even if the therapy results in difficult side effects? Although there is a concern about side effects, primarily nausea and fatigue, it is clear that avoiding or delaying recurrence outweighs the upfront toxicity of chemotherapy and adds enough to overall quality of life so that using docetaxel is beneficial.”
— lead study author Nicholas D. James, MD, PhD University of Birmingham United Kingdom
New Way to Predict Survival for People With Bladder Cancer
Researchers have created a new method to predict how long people with bladder cancer will live if they are receiving an immunotherapy drug called atezolizumab (Tecentriq).
To develop this method, researchers used data from 2 clinical trials with a total of 405 participants treated with atezolizumab to see which medical factors were more closely linked to overall survival. This information helped them establish 6 factors that they used to calculate the overall survival:
How well a person can perform daily activities, often called “performance status”
Whether the cancer has spread to the liver
Number of platelets, which are the cells that help the blood to clot
“In just the past few years, the U.S. Food and Drug Administration has approved 5 new immunotherapies for urothelial cancers. Based on the rapid availability of new therapies, we thought it was important to try to assess which patients might benefit the most from atezolizumab, which is 1 type of these new therapies. We believe we’ve developed the first prognostic model that, once confirmed in larger studies, could provide a critical decision-making tool for clinicians.”
— lead study author Gregory Pond, PhD McMaster University Ontario, Canada
Anne Katz, PhD, RN, FAAN, is a certified sexuality counselor at CancerCare Manitoba and nurse counselor at the Manitoba Prostate Centre. She counsels patients with a history of cancer who are experiencing sexual and relationship challenges. Follow Dr. Katz on Twitter @DrAnneKatz.
I see these couples quite often: the man has been prescribed androgen deprivation therapy for prostate cancer and his partner is distressed. He no longer has erections, although for some that had been a problem for years. But even then, they tell me, he at least tried occasionally. Now there is nothing. No hugs, no kisses, no hand holding, no touch. The partners are usually women and their response to this change has been to look inward and to blame themselves. “What have I done?” they ask me. I suggest that they ask their partner that; it is not for me to speak for the man. More often than not, he has no answer. He may shrug or look away, or some look to me to provide the response.
“Do you still love me?” some women ask, with a shaking voice.
These are couples who may have been together for upwards of 40 years. They have shared so much and been everything to each other, and now, in what was billed as the “golden years,” there is doubt about that.
“Well, of course I do…” is the usual gruff response, at times followed by a flash of anger that she could doubt him.
“Then why don’t you show me?” is the desperate response, too often followed by silence.
It’s at this point that I usually intervene and explain the role that testosterone, or in this instance, lack of testosterone plays in the display of affection and/or sexual response. Most couples seem surprised by what I tell them. “But I thought they were giving him hormones!” is a common response, in part because of the language we continue to use.
Hormones are interesting… Humans are more likely to notice the absence rather the presence of these. My female patients suffer the absence of estrogen after surgical or medical menopause. Every day I listen to descriptions of vulvo-vaginal atrophy that challenge women who have survived breast cancer, their worst fear, and yet the consequences make sex so painful that the fear of cancer is overcome by the fear of intercourse. The loss of testosterone turns most men into solitary figures who never reach out to their partner in love or passion. And their partners suffer until they can stand it no longer; they come to my office seeking answers for their loneliness.
It is often difficult for partners to understand what happens to men on androgen deprivation therapy. I am not sure that the men understand it either, even though they experience the many side effects of the treatment. Men and their partners accept the hot flashes and night sweats. Many women aren’t bothered by the increased sensitivity that makes men cry at heart-tugging commercials on television. Some are bothered by the irritability that their partners develop; they do their best to smooth over the rough edges that cause conflict and harsh words. But the loss of touch seems to wound the most.
Women seem to internalize the loss of touch and sex and blame themselves. They look for reasons that they may be less attractive, less willing, less interesting to their partner. In couples where the man has mostly been the initiator of sex, women are left wondering why he no longer initiates anything, and the answer seems to lie within themselves rather than with the medication.
If patients and their partners are informed about the potential for loss of libido and what this means beyond sex, then they should anticipate that loss of libido may mean loss of sexual interest as well as loss of all touch, resulting in loss of connection and emotional intimacy too. Touch is often the forerunner of sex for many couples. Loss of libido results in loss of all impetus for the man to touch his partner—as initiation for sex or as an expression of affection. The partner then interprets this as the absence of affection or attraction.
In my work with these couples, I make suggestions about the importance of communication in asking for what is needed: a hug, an affirmation of love, a hand to hold when watching TV. I encourage the partner to initiate touch more—not to wait for what has been the usual way for many years, but to reach out and touch the man so that he is reminded. I suggest to the man that he create triggers that prompt him to hug or kiss his partner, even just a peck on the cheek. Perhaps the trigger is the start of the evening news, or after he brushes his teeth in the morning. I remind the partner that it might feel fake or forced at first, but that with time it may become routine and perhaps even feel spontaneous. I reinforce that this is not about them, although it may feel like it.
This post was first published in longer form inThe ASCO Post, July 10, 2017.
Robert Harrison lives in Clayton, North Carolina. He is the founding President of the Patient and Family Advisory Board at North Carolina Cancer Hospital in Chapel Hill and is a patient advocate for 3 university-based cancer research centers.
I was diagnosed with stage IV prostate cancer in 2002. I had no idea the disease and its treatment would cause me to gain more than 50 pounds and nearly cripple me with pain. I had a transurethral resection of the prostate following my diagnosis and have had multiple testosterone-suppression medications and immunotherapy treatments ever since.
My treatments have allowed me to live with chronic cancer, but I was concerned that my weight could lead to a heart attack or stroke. Plus, the androgen-deprivation therapy was causing such severe loss of muscle mass, I had constant joint and bone pain and needed a walking cane.
At one point, after 12 rounds of docetaxel, a trip from my house to the mailbox and back took herculean effort. I felt if I didn’t do something soon, I might die, not from the cancer but from its aftermath.
As a former athlete, I thought I could devise my own exercise routine and diet plan, and the weight would fall off. But I was wrong, and in the process I injured myself.
I learned about an exercise physiologist at a cancer center hundreds of miles from my home. After contacting her, we began strength and aerobic fitness sessions (via Skype and e-mail) that were tailored specifically to meet my abilities and needs. Through these sessions and information from a nutritionist at my clinic about healthy food selection and portion size, I lost 50 pounds and have made significant gains in muscular strength and mobility. My oncologist said my improved lifestyle is probably as helpful to maintaining control of my cancer as the medication he prescribes.
Living a full life
Hearing that you have incurable cancer is traumatizing, but I don’t consider myself to be on a cancer journey. There are so many facets to my life that aren’t related to cancer, and they bring me joy. My wife and I have been married for 50 years and have a loving family, which includes our children, grandchildren, and a great-grandchild; our siblings; and wonderful friends. Our lives are full and rich, so I reject the notion I am on a cancer journey. Rather, I am on a life journey, and cancer is an unwanted companion on that journey, but it is just one part of my life. I’ve learned that just being alive carries uncertainty, and there are no guarantees. Cancer may be what ends my life, or it may be a distracted driver on the highway. Until then, I plan to live every day as fully as possible.