1: Celecoxib does not improve survival for men with advanced or metastatic prostate cancer

The STAMPEDE trial is a large multiarm, multistage, randomised controlled trial that is testing if combining hormone therapy with drugs or radiotherapy improves survival for men with advanced or metastatic prostate cancer. We previously described exciting results from this trial, that showed that adding docetaxel to hormone therapy (standard of care (SOC)) increased survival by an average of 10 months over SOC alone. Two additional arms have now published in the Journal of Clinical Oncology: SOC + Celecoxib (Cel) with or without Zoledronic Acid (ZA). Due to lack of evidence of improved survival within the trial, Cel use was discontinued early, although patient follow up continued as planned. Men were followed for a median of 5.8 years and there was no evidence that 5 year survival was improved by the addition of Cel or Cel + ZA to SOC (5 year  survival 54%, 59% and 53% respectively). Previous analysis also failed to show any survival benefit of adding ZA alone to SOC. Interestingly, subgroup analyses for patients with metastatic disease (M1) suggested that men who received Cel + ZA + SOC had a decreased risk of death (HR, 0.78; p=0.03) compared to men on SOC alone, as well as improved 5 year survival (47% vs 37%). These data were not sufficiently powered to provide conclusive evidence, however they indicate that it may be worthwhile studying hormone therapy in combination with Celecoxib and Zoledronic Acid in a future clinical trial.  

2: Patient reported outcomes: treatments for localised prostate cancer have different side effect profiles

Two studies published in JAMA by Barocas et al. and Chen et al., confirm results from the landmark ProtecT trial (discussed in the September 2016 issue) that men with localised prostate cancer have different side effect profiles depending on whether they receive surgery, radiation or active surveillance. Unlike ProtecT, these American studies were population-based, non-randomised and weren’t designed to measure oncological outcomes. Instead, they were attempting to address some of the criticisms levelled against ProtecT; namely that the treatments used in ProtecT are no longer standard of care and that the participants were almost exclusively white. These two new studies followed men diagnosed between 2011-2013 who had been treated with contemporary techniques, including robotic radical prostatectomy and IMRT. In addition, the cohorts were more ethnically diverse, with over 14% African American participation. Despite these differences, the results were consistent with ProtecT, showing that surgery had the greatest effect on erectile function and urinary incontinence, while radiotherapy was associated with more severe bowel problems. Men on active surveillance had the mildest symptoms, although there was evidence of worsening sexual and urinary function over time as men aged or moved onto more radical treatments. Barocas et al. also showed that at three years there was no significant difference in quality of life measures between men in the different treatment groups. Taken together, these three studies provide valuable information that can help men with low risk localised disease make an informed choice about the treatment and side effect profile that is most acceptable to them. 

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3: Having a vasectomy does not increase your risk of prostate cancer

Analysis from 84,753 men involved in the prospective EPIC study shows that vasectomies do not increase the overall risk of developing prostate cancer (HR, 1.05; 95% CI, 0.96-1.15) or prostate cancer specific death (HR, 0.88; 95% CI, 0.68-1.12). However, there was an increased risk for low-intermediate grade (HR, 1.14; 95% CI, 1.01-1.29) but not high-grade prostate cancer. There has been conflicting evidence about a potential link between vasectomies and prostate cancer with one meta-analysis finding no association, while analysis from the Harvard Health Follow-Up Study (HPFS) found a 10% higher overall risk and a 22% higher risk for high grade prostate cancer. It was hypothesised that this increased risk might be due to higher health-seeking behaviour or PSA testing among men who had vasectomies. This current study tested this hypothesis in a subset of the cohort, and indeed men who had vasectomies were also 54% more likely to have had a PSA test then men without a vasectomy (OR, 1.54; 95% CI, 1.35-1.76). In conclusion, this large study shows that having a vasectomy does not increase a man's chance of getting prostate cancer and suggests that any increased risk seen in previous studies is likely accounted for by differences in the rates of PSA testing and health-seeking behaviour of men who have had a vasectomy. 

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