Oncotarget, Vol. 5, No. 24
www.impactjournals.com/oncotarget/
Androgen deprivation recurrence
therapy
prevents
bladder
cancer
Koji Izumi1, Masataka Taguri2, Hiroshi Miyamoto3, Yoshinori Hara4, Takeshi Kishida5, Kimio Chiba6, Tetsuo Murai7, Kotaro Hirai8, Kotaro Suzuki9, Kiyoshi Fujinami10, Teiichiro Ueki11, Koichi Udagawa12, Kazuo Kitami13, Masatoshi Moriyama14, Yasuhide Miyoshi15, Futoshi Tsuchiya16, Ichiro Ikeda17, Kazuki Kobayashi18, Maho Sato2, Satoshi Morita19, Kazumi Noguchi15, Hiroji Uemura1 1
Department of Urology, Yokohama City University Grasduate School of Medicine, Yokohama, Japan
2
Department of Biostatistics and Epidemiology, Yokohama City University Medical Center, Yokohama, Japan
3
Departments of Pathology and Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
4
Department of Urology, Odawara Municipal Hospital, Odawara, Japan
5
Department of Urology, Kanagawa Cancer Center, Yokohama, Japan
6
Department of Urology, Kawasaki Municipal Ida Hospital, Kawasaki, Japan
7
Department of Urology, International Goodwill Hospital, Yokohama, Japan
8
Department of Urology, Sagamihara National Hospital, Sagamihara, Japan
9
Department of Urology, Saiseikai Yokohamashi Nanbu Hospital, Yokohama, Japan
10
Department of Urology, Chigasaki Municipal Hospital, Chigasaki, Japan
11
Department of Urology, Japanese Red Cross Hadano Hospital, Hadano, Japan
12
Department of Urology, Hiratsuka Kyousai Hospital, Hiratsuka, Japan
13
Department of Urology, Fujisawa City Hospital, Fujisawa, Japan
14
Department of Urology, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan
15
Department of Urology, Yokohama City University Medical Center, Yokohama, Japan
16
Department of Urology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
17
Department of Urology, Yokohama Minami Kyousai Hospital, Yokohama, Japan
18
Department of Urology, Yokosuka Kyousai Hospital, Yokosuka, Japan
19
Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
Correspondence to: Hiroji Uemura, e-mail:
[email protected] Keywords: Bladder cancer, recurrence, androgen, androgen deprivation therapy Received: November 05, 2014 Accepted: December 03, 2014 Published: December 24, 2014
ABSTRACT Although accumulating preclinical evidence indicates the involvement of androgen receptor signals in bladder cancer (BC) development, its clinical relevance remains unclear. We aimed to evaluate the predictive role of androgen deprivation therapy (ADT) in BC recurrence in prostate cancer (PC) patients. We retrospectively reviewed 20,328 patients with PC diagnosed during 1991– 2013 and identified 239 (1.2%) men having primary BC. After excluding ineligible patients, 162 patients made up a final cohort. With a median follow-up of 62 months, 38 (50%) of 76 control patients without ADT experienced BC recurrence, while 19 (22%) of 86 did in ADT group. Thus, patients having received ADT for their PC showed a significantly lower risk of BC recurrence (5-year actuarial recurrence-free survival: 76% v 40%; P < 0.001) and also had a significantly smaller number of recurrence episodes (5-year cumulative recurrence: 0.44 v 1.54; P < 0.001), compared to the control patients. A multivariable analysis www.impactjournals.com/oncotarget
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revealed ADT as an independent prognosticator (hazard ratio, 0.29; 95% confidence interval, 0.17–0.49) for BC recurrence. This is the first clinical study showing that ADT significantly reduces the risk of BC recurrence.
PC patients, than otherwise healthy men, probably due to shared molecular carcinogenic process between these two cancers [16]. Upon reviewing the background information, we have inclined to consider that circulating androgens would be responsible for AR-mediated gender difference in bladder tumorigenesis and cancer progression. If that is the case, we reasoned that ADT could influence the development of BC in PC patients. To test this hypothesis, we undertook a multicenter retrospective cohort study involving 20, 328 PC patients, including those having received ADT, and found surprisingly that ADT significantly reduced the risk of BC recurrence.
INTRODUCTION Urinary bladder cancer (BC) is the fourth and seventh most common malignancy in the US [1] and worldwide [2], respectively, in men. Most BCs are initially non-muscleinvasive and can be treated by transurethral resection (TUR). However, the recurrence rate of BC is quite high (50%–70%) and progression to invasive state takes place occasionally [3]. Although bladder instillation therapy using anthracyclines or Bacillus Calmette-Guérin (BCG) is reported to be effective, the risk of recurrence even after the instillation treatment remains as high as 36%–51% [3]. In addition, due to the lifelong necessity to monitor the recurrence of BC, the medical cost per BC patient from diagnosis to death is the highest among all cancer types [4]. One intriguing feature in BC is the three- to four-fold higher incidence in men than in women [1, 2]. Although excessive exposure to industrial chemicals and cigarette smoke may have contributed to this male predilection, men remain at a substantially higher risk of BC than women even after controlling for these carcinogenic factors [5, 6]. These findings prompted us to fathom the mechanism underlying such male predilection. In fact, we and others have found molecular evidence indicating, in animal models, that androgen receptor (AR) signals are involved in BC development [7–9]. It is therefore suggested that androgen-mediated activation of AR signaling would promote bladder tumorigenesis and cancer progression. There are basically two relevant states which may clearly explain the male predilection of BC. First, non-neoplastic urothelial and BC tissues in men express higher levels of AR and/or molecules related to its downstream pathway than those in women. Second, more simply, higher levels of circulating androgens in men would stimulate and maintain higher activation state of AR signaling in urothelial/ carcinoma cells. Examinations on the first hypothesis failed to demonstrate it to be the case [9–13]. Clinical studies have neither been successful to reveal the relationship between clinical course of patients or pathological state of BCs and AR level in BCs. On the other hand, the second hypothesis has not been examined so far in a well-controlled manner and remains to be an open question. Prostate cancer (PC) is one of the most prevalent malignancies for men in developed countries [2]. As for its treatment, androgen deprivation therapy (ADT) stands as a critical treatment option [14]. It is used primarily for advanced PC in Europe and North America, while more widely used in Japan, even for some localized PC patients [15]. Interestingly, patients with PC are known to have a higher risk of coincidental BC, reported to be 1.2–3.4% of www.impactjournals.com/oncotarget
RESULTS Patient characteristics Table 1 shows the patient characteristics of the study cohort. The median follow-up for the entire cohort was 62 months (interquartile range, 19 to 95 months). Of the 162 patients, 86 were treated with ADT, and the remaining 76 did not receive ADT for their PC. The age of the patients was significantly higher in the ADT group than in the control group without ADT (P = 0.028). Among the reported clinicopathological factors of BC recurrence, i.e., tumor grade, stage, size, multiplicity and concomitant carcinoma in situ (CIS), the number of grade 2 tumors was significantly higher in the ADT group (P = 0.032). There was no significant difference in prophylactic bladder instillation therapy between the two groups. Regarding the features of PC, the prostate-specific antigen (PSA) level (P = 0.016) and tumor T stage (P = 0.047) were significantly higher, and brachytherapy was significantly less likely to have been performed (P < 0.001) in the ADT group compared to the control group.
ADT and recurrence-free survival (RFS) We performed a Kaplan-Meier analysis coupled with a log-rank test to assess possible associations between ADT and BC recurrence. Overall, 19 (22%) of the 86 patients with ADT versus 38 (50%) of the 76 patients without ADT developed BC recurrence (P < 0.001). The 5-year actuarial RFS rates for the ADT and control patients were 76% and 40%, respectively. The ADT patients thus showed significantly improved RFS compared to the control patients without ADT (P < 0.001; Fig. 2). To further explore the time-response relationship, we subdivided the patients into three groups according to ADT proportion 12666
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Figure 1: Flow of participants through study.
Table 1: Baseline Characteristics of the Patients with and without Androgen Deprivation Therapy (ADT) Characteristics
Control, n (%)
ADT, n (%)
No. of patients
76 (46.9)
86 (53.1)
Age , y
71.5 (54–92)
74.0 (59–88)
a
BC
Tumor grade
P 0.028 0.032
1
26 (35.6)
16 (20.5)
2
27 (37.0)
45 (57.7)
3
20 (27.4)
17 (21.8)
Pathological T stage
0.118
Ta
54 (75.0)
51 (62.2)
≥T1
18 (25.0)
31 (37.8)
Tumor size
1.000
