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Prostate Cancer Study Finds Low PSA Levels Predict Better Survival for High-Risk Patients

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Declines in prostate-specific antigen (PSA) level after treatment with the next-generation androgen receptor inhibitor drug enzalutamide predict improved survival rates in men with non-metastatic castration-resistant prostate cancer (nmCRPC), according to a new study published in The Journal of Urology, an Official Journal of the American Urological Association (AUA). The journal is published in the Lippincott portfolio by Wolters Kluwer.

“Our analysis of data from the PROSPER study shows a previously unappreciated relationship between changes in PSA levels and clinical outcomes in men with nmCRPC,” comments lead author Maha Hussain, MD, of Northwestern University Feinberg School of Medicine, Chicago. “The findings may help us to make personalised decisions regarding clinical follow-up and imaging studies for a group of patients at high risk of prostate cancer metastases.”

The researchers analysed data from the PROSPER trial, published in 2018, which enrolled men with nmCRPC and rapidly rising PSA levels. Increases in PSA signal an increased risk that cancer will spread, or metastasise, outside of the prostate gland. In patients with nmCRPC, rising PSA levels are often the first sign that the cancer is growing. The Urology Care Foundation has more information on nmCRPC.)

The ‘castration-resistant’ part of nmCRPC means that cancer no longer responds to standard hormone therapy. The PROSPER trial was designed to evaluate the effects of enzalutamide – a novel hormonal agent that works by directly blocking the androgen receptor to block androgen’s effects in the promotion of prostate cancer growth. The initial PROSPER results showed longer survival times in men who received enzalutamide added to androgen deprivation therapy.

Dr Hussain and colleagues used 12-month follow-up data from the PROSPER study to assess how PSA levels responded to enzalutamide. Changes in PSA levels and patient survival rates were compared for 905 patients treated with enzalutamide and 457 treated with a placebo.

Most patients had sharp reductions in PSA after enzalutamide treatment. More than 97% of men in the enzalutamide group had at least a 50% decrease in PSA. In 38% of patients, PSA levels decreased by at least 90%.

The analysis showed that the decline in PSA levels as a result of enzalutamide treatment was found to be a robust indicator of ultimate survival rates. The median metastasis-free survival, which measures the amount of time men survive without the spread of cancer, was found to be 37 months in patients with a PSA decline of 90% or more, while those with a PSA decrease of less than 50% had a median survival rate of approximately 22 months.

Overall survival time was also related to enzalutamide response, ranging from 41 months with less than a 50% decline in PSA to 54 months with a 90% decline or greater. For men who had a 90% decline or greater and a PSA nadir (low point) of 0.2 ng/mL or less, survival time increased to 64 months, with the median survival time “not reached”; meaning that longer follow-up would be needed to show the final overall survival benefit.

The researchers believe their findings have implications not only for predicting the outcomes of enzalutamide therapy but also for personalized treatment of nmCRPC. The study “further underscores the value of PSA as an intermediate biomarker for treatment benefit and risk of disease progression in patients with nmCRPC,” Dr Hussain and coauthors write. They call for further studies to clarify the dynamics of changes in PSA levels in response to enzalutamide, including the significance of reaching a PSA nadir of 0.2 ng/mL or less.

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