The first randomized clinical trial comparing active surveillance, surgery and external beam radiation tells us little :-(

This was supposed to be HUGE! The first clinical trial ever where patients were randomly assigned to active surveillance (AS), radical prostatectomy (RP) or external beam radiotherapy (EBRT). The results were published in The New England Journal of Medicine (see this link). They started signing up men in the UK in 1999 and continued recruitment for 10 years. By 2009, they screened over 82,000 men for prostate cancer and found 1,643 men with newly diagnosed localized prostate cancer who were willing to be randomized to initial treatment with AS, RP or EBRT, about a third in each. They then followed them for a median of ten years to see how well they did with each therapy. Imagine the effort involved! Sounds good so far -- what could go wrong?

The bottom line was that all 3 therapies did about the same in preventing death. AS was found to cause higher rates of disease progression and metastases. We will explore why below.

There were several problems that arose.

1. They planned to detect mortality differences, but couldn't.

They thought there would be more deaths in the ten years of follow-up, but almost all the men defied those expectations. That's partly because of all the great new life-prolonging drugs that became available in the 21st century; drugs like docetaxel, Xtandi, Zytiga, and Xofigo. Also, in a clinical trial, patients are very closely diagnosed, treated, and monitored. They get far better care than the average patient in community practice. There were only 17 prostate-cancer related deaths

Men also survived longer because of progress in treating other diseases. But most of all, men lived longer because they frequently visited doctors as part of the study, during which they were  closely monitored for other illnesses. There were only 152 deaths from all other causes, only 9% of the total sample size. Men were 50 to 69 years of age  (62 years median) at the start of the study and were tracked for 10 years. On average, based on US actuarial tables, about 18% should have died from all causes. So the mortality rate was half of what was expected. On the average, men in the UK live two years longer than men in the US - not enough to account for the difference.

No worries. Instead of looking for mortality differences, the researchers had a secondary objective to look for differences in disease progression and rates of metastases. Those are excellent surrogate endpoints. But...

2. The intended treatment wasn't always what patients wound up doing

Although men were randomized to one of the 3 therapies, a lot of the men apparently changed their minds, as was their right. The authors of the study analyzed everything based on the intended treatment at the time they were randomized. This is how they said they would analyze the data, and they stuck with the plan. The switching that occurred was as follows:

• Of the 545 men randomly assigned to AS,  482 (88%) stayed with it at least for 9 months. The rest decided to have surgery, radiation, no therapy, or dropped out.
• Of the 553 men randomly assigned to RP, 391 (71%) did have surgery within the first 9 months following randomization. Most of the remainder switched to AS, the rest to radiation or other treatment, and a few chose no treatment or dropped out.
• Of the 545 men randomly assigned to EBRT, 405 (74%) did have EBRT within the first 9 months following randomization. Most of the remainder switched to AS, the rest to surgery, other treatment, no treatment or dropped out.
• In all, 22% of the men did not have the therapy they were originally randomized to, yet they are including in the analysis as if they did. It is unknown how this may have skewed the findings.

3. Their AS protocol was nothing like contemporary protocols.

     a. Inclusion criteria were much less restrictive

In contemporary AS protocols, almost all men are in the "low risk" category. "Low Risk" means they are stage T1c or T2a, their Gleason score is 6, and their PSA is less than 10. Some of the more restrictive AS programs, like Johns Hopkins, also include the "Epstein criteria." That means there were no more than 2 positive cores, no more than 50% cancer in any positive cores, and the PSA density must be less than 0.15 ng/ml/g. For the first time this year, NCCN included AS as an option for men with Gleason score 3+4 if no more than half the cores were positive, but only if they were otherwise low risk.

In the ProtecT trial, the only inclusion criterion was that the men had to have localized prostate cancer. See this link for their protocol. This means that they allowed men who were higher stage (T2b and T2c), higher grade (Gleason score ≥ 7), and higher PSA (PSA could be as high as 10-20 ng/ml). In fact, they previously reported that, among the AS cohort:

• 10% had an initial PSA between 10 and 20 ng/ml
• 22% had an initial Gleason score≥ 7 (2% were GS 8-10)
• 25% had a clinical stage of T2 - they do not break that into subcategories, presumably most were T2a

So, many of those higher risk men would have been screened out of a contemporary AS program. The authors did not analyze this higher risk subgroup to tell us how many of the 33 cases of metastases or 112 cases of clinical progression were among them, but they do report (Table 2) that of the 8 prostate-cancer deaths in the AS group, 5 were among men with Gleason score ≥ 7 at diagnosis (vs. 2 each for RP and EBRT). The remaining 3 deaths among those diagnosed as Gleason 6 was similar to the number for RP (3) and EBRT (2). It seems that all extra deaths were attributable to higher Gleason scores in their AS program.

     b. Monitoring of men on AS was below contemporary standards.

In contemporary AS protocols, there is always a confirmatory follow-up biopsy within a year of the first screening biopsy. The repeat biopsy schedule varies from that point on, and may be every year, as it was originally at Johns Hopkins. Some AS protocols utilize mpMRI to search for suspicious areas and only biopsy as suspicion arises, others implement a biopsy schedule that may vary depending on the findings of the last biopsy. Some do TRUS biopsies, some do mpMRI-targeted biopsies, some combine the two, and some do follow-up transperineal template-mapping biopsies. But all good AS programs include follow-up biopsies.

In the ProtecT trial, patients were screened for a high PSA (> 20 ng/ml), emergent symptoms, or a 12-month PSA increase ≥ 50%. So those who had a form of prostate cancer with a low PSA output (such as some of those with predominant Gleason pattern 5) would never be discovered until symptomatic metastases occurred. I don’t know what percent ever got a second biopsy.

We recently saw what happened in Göteborg when there was no pre-determined biopsy schedule: 54 out of 474 men (11%) failed on AS. They used a similar monitoring system as the ProtecT trial: quarterly, and then semi-annual PSA tests, and re-biopsy at the discretion of the doctor.

I sometimes talk to patients who get periodic PSA tests and claim they are on active surveillance. They are putting themselves in danger. Time and again, PSA kinetics have been rejected as a sole indicator of progression for very good reasons, mainly (1) PSA is affected by many non-cancer causes, and (2) some of the most virulent prostate cancer cells put out very little PSA. There is no substitute for confirmatory and follow-up biopsies.

Let's put perspective just how egregious a difference it is when active surveillance does not include follow-up biopsies. Current estimates are that one in three TRUS-guided biopsies (12 through the rectum) will miss a higher grade of cancer. So, if one biopsy failed to detect a higher grade cancer with odds of 33%, then the odds of missing it on two biopsies is (.33) squared, etc. As the following table shows, the odds of missing the higher grade cancer with annual biopsies for ten years is about 1 in a hundred-thousand.

Biopsy	Odds of missing higher grade in ALL the biopsies
1st	33%
2nd	11%
3rd	4%
4th	1%
5th	0.4%
6th	0.1%
7th	0.04%
8th	0.01%
9th	0.005%
10th	0.001%

Now, at Johns Hopkins, for example, it was their active surveillance policy to have annual biopsies, and they used the Epstein criteria discussed above. After 15 years of follow-up, the metastasis-free survival rate was 99.4%. Laurence Klotz at Sunnybrook in Toronto has the longest running trial of active surveillance in North America. They allowed some patients as high as favorable intermediate risk, and while there was always a confirmatory biopsy in the first year, their biopsy schedule was not as rigorous as Johns Hopkins. After 20 years, of follow-up, they report metastasis-free survival of 97.2%. In the ProtecT trial, there were 33 men out of the 545 men in the AS cohort - 6.1% had already been diagnosed with metastases after only 10 years of follow-up. The outcomes of the AS cohort are very out-of-line compared to active surveillance programs that have more rigorous selection criteria and monitoring protocols.

Selection criteria	Biopsy schedule	Active Surveillance Program	Follow-up	Metastasis-free survival
Strictest: Epstein protocol	Annual	Johns Hopkins	15 years	99.4%
Less strict: favorable risk only	Confirmatory and periodic thereafter	Sunnybrook	20 years	97.2%
Any localized regardless of PSA or grade	none	ProtecT	10 years	93.9%

4. Their EBRT protocol was below today's standards.

In the years prior to 1999 when they were planning this study, there were very different radiation therapies in place than have now become standard of care. This is a problem with all long-term clinical trials involving radiation technology. By the time we get the results, they are irrelevant because the technology and understanding has progressed so much. For an expanded discussion of this issue, see this link.

They used an older technology (3D-CRT) to deliver only 74 Gy in 37 treatments while adding 3-6 months of hormone therapy before and during treatment. Now, with IGRT/IMRT technology, the patients would safely receive about 80 Gy. Low and favorable risk patients probably do not benefit from adjuvant ADT -- it adds sexual side effects without adding to cancer control in most of them. Some have questioned whether the increase is justified for low or intermediate risk patients (see this link), but, as we saw, 10 years is not long enough to judge that, and there is no consequence to the higher dose in terms of side effects. It is entirely possible that the low dose they gave patients only delayed progression but did not cure the cancer.  If that is true, we may see the EBRT outcomes deteriorate when they present their planned 15-year follow-up.

ProtecT was a vast and expensive undertaking. It will probably never be repeated, and there isn't likely to ever be a US equivalent. Sadly, we can't learn very much from their current analysis of this major study, although it may yield more fruit with some subsequent analyses.

Most of the recurrences after primary radiation failure are salvageable

Salvage therapy is curative in about half of men who have a biochemical failure after primary therapy. That's true whether the primary therapy was surgery or radiation. It's true when the salvage therapy was radiation after surgery. And it's true whether the salvage therapy was surgery, cryotherapy, or brachytherapy after radiation. Salvage success rates can be as high as 3 in 4, in certain well-selected patients treated with appropriate therapies (see this link, for example), but it can be a lot lower too. Salvage therapy always increases the complications over what they were for the primary therapy, so we would avoid it if we knew it was likely to be futile. Thanks to the new generation of PET scans, we are beginning to understand why, and what we may be able to do to improve those odds.

For any salvage therapy to be effective, two conditions must be met:

1.  The recurrence must be local. Local means in the prostate, seminal vesicles, the prostate bed, nearby organs (e.g., bladder, rectum, etc.), and/or in the pelvic lymph nodes.
2.  The recurrence must not be distant. Distant means metastases in the bones; remote organs like the lungs, liver, or remote lymph nodes; or in systemic circulation in the bloodstream.

In the past, it has been difficult to ascertain that both conditions were met. Bone scans are not very reliable when the PSA is below 20 ng/ml, and they are not specific for metastases. Moreover, by the time the PSA increases that much, the cancer is almost certainly distant and incurable. The NaF18 PET/CT scan can detect metastases sometimes at a PSA as low as 4 ng/ml, but it only detects bone metastases, and it is not specific for metastases. An Ultra-Small Superparamagnetic Iron Oxide (USPIO) MRI may sometimes detect metastases, but only in lymph nodes.  A multiparametric MRI may sometimes detect local recurrences, and may be used to target areas for biopsy in the prostate and prostate bed. It may be reliable after primary radiation (see this link). However, it tells us nothing about distant metastases.  CT scans only detect the larger lesions that may be suspect. A transperineal template mapping biopsy may detect prostate cancer in the prostate, but tells us nothing about distant metastases. It should be noted that biopsied prostate tissue looks very different after radiation, and it should be analyzed by highly experienced pathologists.

Clinical trials have proved that adjuvant radiation after prostatectomy has better outcomes than waiting, and recent studies suggest that overtreatment may be avoided by using early salvage radiation rather than adjuvant radiation therapy. Perhaps early salvage therapy after primary radiation therapy may have improved outcomes too. That is, it may be more successful if started before the patient's PSA reaches the nadir+2 level, which is the official definition of biochemical recurrence after primary radiation therapy.

The FDA-approved C-11 Choline PET/CT (or the similar C-11 Acetate PET/CT) fills some of the critical information gaps. It can detect prostate cancer in the radiation-treated prostate, the local area, and throughout the entire body at a PSA as low as 2 ng/ml, especially if the PSA has been rapidly rising. However, its sensitivity is not very good for small sites of cancer (they must be larger than 5mm), or cancer in lymph nodes. And when used to detect cancer within the prostate, prostatitis and BPH may generate false positives. Some of the new experimental PET scans (e.g., DCFPyL) may be more sensitive. Now that we have an adequate tool for detecting both of the above-mentioned conditions (local and not distant), we are beginning to be able to select which recurrences can be cured with salvage therapy, and which can only be managed with lifelong hormone therapy.

Parker et al. report on the Mayo Clinic experience with 184 patients with rising PSAs after primary radiation therapy on whom the C-11 Choline PET/CT was used to detect local and/or distant prostate cancer progression.

• 87% of patients were PET-positive.
• The C-11 Choline PET/CT correctly identified 98% of patients who were later found to have residual prostate cancer on subsequent histological analysis. 
• However, 42% of patients that were identified as negative by the C-11 Choline PET scan later suffered from cancer progression - they were false negatives.
• Patients were especially likely to be PET-positive if they had higher pretreatment PSA, were high risk, had higher PSA level at the time of the PET scan, had a greater increase from nadir PSA, had a shorter PSA doubling time, and had a higher PSA velocity. All of those with PSA≥ 10 ng/ml were PET-positive.
• Risk category, PSA increase from nadir, and time since primary radiation therapy were independently associated with PET-positivity, and can help predict when recurrences are salvageable.
• 59% of PET-positive patients were confirmed by histological analysis (either biopsy or salvage prostatectomy). 76% were confirmed by a multiparametric MRI.
• 46% of those who were PET-positive had cancer only in the prostate and seminal vesicles. These patients were potentially salvageable with any of the salvage therapies mentioned above.
• An additional 16% (62% in total) had cancer in the soft tissue pelvic region. These may be salvageable with extended pelvic lymph node dissection (ePLND) or radiation in select areas of the pelvis that were not treated originally.
• While only a few patients (21) had a PET scan before their PSA reached nadir+2, half of them had a local recurrence only, and are potentially salvageable. This suggests that the  patient does not have to wait for nadir+2. However on this small sample, the salvageability does not seem to be very different for those who detect it earlier.

This study confirms the findings of the larger study at Memorial Sloan Kettering (MSKCC) (reviewed at this link).  In that study, 55% had a recurrence in the prostate and/or seminal vesicles only, compared to 46% at Mayo. At MSKCC, an additional 8% had recurrences in the pelvic lymph nodes only, compared to 16% at Mayo. There were important differences between the studies. At Mayo, unlike MSKCC, patients may have had brachytherapy as all or part of their primary therapy, they may have had enlarged lymph nodes from the start, they had significantly lower doses of radiation (76 Gy vs ~80 Gy), they were younger (65 vs 69), fewer had adjuvant hormone therapy (30% vs 54%), they all had rising PSA but not necessarily nadir+2, and they all received a C-11 Choline PET/CT, there was less histological confirmation (59% vs 71%), and the median follow-up time was shorter (68 months vs 83 months).

As noted in the commentary of the MSKCC study, these findings may not apply when the primary therapy used a very high biologically effective radiation dose, such as with brachy boost therapy, SBRT, or high dose rate brachytherapy.

It makes sense to rule out the possibility of distant metastases using an advanced PET scan. Even at a cost of $2,500 or so, it may save the patient much more than that for the cost of salvage therapy. However, unless the PET scan is done at Mayo using C-11 Choline, is done as part of the clinical trial using the newly FDA-approved PET indicator fluciclovine, or is one of the free ones at NIH, the out-of-pocket cost may be formidable. Hopefully, the FDA will approve more of them, and availability will expand. Unfortunately for those considering early salvage after a prostatectomy failure, none of them are accurate for PSAs that low (≤0.2 ng/ml).

The authors constructed a nomogram to help the prospective patient predict whether his recurrence, detected with a C-11 Choline PET/CT, is likely to be a salvageable recurrence or unsalvageable recurrence. In the first table, fill in the number of points that comes closest to your situation, and add them up. In the second table, look up the probability of a distant recurrence (unsalvageable) that comes closest to your total number of points.

Risk Factor	Points to assign	My Points
PSA increase from nadir	2 ng/ml: 13 5 ng/ml: 32 10 ng/ml: 63 15 ng/ml: 95
Years since RT	1 yr: 100 2 yrs: 95 3 yrs: 90 5 yrs: 80 10 yrs: 52 20 yrs: 0
Risk Group	Low: 0 Intermediate: 8 High: 45
	TOTAL

My Total Points	Probability of recurrence outside of the pelvic area
66	5%
88	10%
120	25%
153	50%
185	75%
216	90%
240	95%

This nomogram outperformed using a PSA threshold alone in its predictive power, and may help the patient decide whether potentially-curative salvage therapy or lifelong hormone therapy is the better course of action.

I'm not sure why radiation dose was not significantly correlated with the site of recurrence at Mayo (p = 0.1) as it was in the MSKCC study. In fact at MSKCC, those who received doses of at least 79.2 Gy had half the rate of recurrence compared to those who only received 75.6 Gy (which seemed to be the norm at Mayo). It may be that those who were treated at Mayo only received higher doses when their cancer was already systemic. We know that this is on the steep part of the dose/response curve where even a small increase in dose can increase its effectiveness greatly. Whatever the reason for the data discrepancy, higher doses do prevent local recurrences.

(update 11/18/2018) Hayman et al. reported on 49 men who had a biochemical recurrence after whole pelvic primary radiation therapy and long-term ADT who were clinically staged as node positive (N1) via MRI. Using imaging (probably a PET/CT scan) they found the site(s) of recurrence in 46 of the men:

• 25 (54%) had a recurrence in the prostate only
• None had a recurrence in lymph nodes only
• 21 (46%) had a recurrence that included a distant metastasis

This is very similar to Mayo and MSK.

note: Thanks to Dr. Will Parker for letting me review the full text of his published study.

Testosterone to TREAT prostate cancer - are they crazy? No - it just may work. (mHSPC)

This is Part 2. In Part 1 we saw why bipolar androgen therapy (BAT) may be effective for men with metastatic castration-resistant prostate cancer (mCRPC), and the evidence so far in support of that. In this part, we'll look at what we know about BAT in men with metastases who are still hormone sensitive (mHSPC). As you recall, BAT is an experimental therapy for metastatic prostate cancer involving the administration of rapidly alternating treatments of androgen deprivation (ADT) with high-dose testosterone.

In theory, the high doses of testosterone will help the patient feel better and perhaps offset some of the symptoms of ADT (e.g., loss of libido, hot flashes, bone loss, lean muscle loss, mental symptoms).

In pilot trials so far, BAT was able to restore sensitivity to second-line hormone therapy, like Zytiga or Xtandi, in some men who had become resistant to their effects. If it can reverse castration resistance, can it also slow down the development of castration resistance? 

Schweizer et al. report on 29 patients:

• None of the men in the study had started on androgen deprivation yet.
• None had symptoms.
• 10 had a low burden of metastases.
• 19 had no detectable metastases, but had recurrent disease after an attempt at a cure (i.e., their cancer was micrometastatic)
• They were all hormone sensitive. That means their PSA went down to less than 4 ng/ml after 6 months of ADT

They then received 3 months of testosterone injections, and then 3 months of ADT. Those cycles continued for a total of 18 months. 

• They report that 17 men (59%) were still able to achieve their PSA goal (<4 ng/ml) at the end of 18 months. That is, they were still hormone sensitive.
• Of the 10 patients with detectable metastases at the start, metastases had shrunk completely in 4, and partially in 4. So 8 in 10 (80%) had a positive radiographic response to BAT.
• Six patients had metastatic progression. 
• So, 13-15 of the 19 (68-79%) men with recurrent PC with no detectable metastases at the start still had no detectable metastases after 18 months of BAT.
• Evaluations of quality of life improved.

(Update 8/16/22) Denmeade et al. looked at responders and non-responders.

• Responders achieved PSA<4 ng/ml after BAT
• Non-responders had PSA≥4 ng/ml after BAT
• They also looked at responders with a PSA≤9 ng/ml, and non-responders with a PSA>9 ng/ml after BAT

After 5 years of follow-up:

• Progression-free survival was 21 months among non-responders with PSA>9 months vs. not reached if PSA≤ 9 months
• Overall survival was 80 months among non-responders with PSA>9 months vs. not reached if PSA≤ 9 months

High PSA after BAT is an indicator that the therapy did not work.

Since the CHAARTED and STAMPEDE clinical trials, the new standard of care for mHSPC is the combination of ADT and docetaxel chemotherapy. Where would BAT fit in? We saw in Part 1 that BAT may work particularly well in conjunction with chemotherapy that targets the DNA responsible for cell replication. Docetaxel is usually administered in 6 three-week cycles. It may turn out that after an ADT induction period of 6 months, patients may be optimally treated by a high dose of testosterone and docetaxel concurrently. Testosterone would help the chemo patient feel better, and would also tend to raise his red blood cell counts, counteracting any chemo-induced anemia.

Another consideration is whether radiation ought to be included in the mix of early treatments. A few recent studies (see this link and this one) suggest that prostate radiation might still be beneficial to the metastatic patient. Moreover, a lab study suggests that radiation and BAT may be a particularly potent combination.

At this point, all of this is pure speculation. Future expanded clinical trials will have to determine whether BAT is useful for men with mHSPC, and what the optimal sequencing of therapies should be.

Testosterone to TREAT prostate cancer - are they crazy? No - it just may work. (mCRPC)

(frequently updated)

Background

When prostate cancer metastasizes and becomes castration-resistant (mCRPC) after a period of androgen deprivation therapy (ADT), a number of biochemical changes to the androgen receptor (AR) take place within the cancer cell. Among those changes:

• The androgen receptor (AR) multiplies on the cancer cell surface so that even the smallest amount of testosterone or other circulating androgens can activate it.
• Even without an androgen ligand, the androgen receptor moves from the surface of the cell to the inside where it is protected. These internalized androgen receptors play a role in encouraging cell replication and in self-destruction (apoptosis) of cells in which the DNA  has become irreparably damaged.
• The cell manufactures its own androgens internally. These activate the internalized androgen receptors.
• The androgen receptor mutates into truncated versions that can be activated by a host of other molecules (other than testosterone), or don't require other molecules at all to activate it. Recently, researchers at Johns Hopkins identified a version called the "AR-V7 splice variant" that allows the cancer cell to multiply even when all androgens are completely eliminated. It is induced by long term androgen deprivation (see this link).

There may also be tissue-based effects. This means that, in a tumor, there are a variety of cell types. Castration resistance is not an all-or-none situation. Some cells within any given tumor will always remain hormone sensitive. Some cells, like cancer stem cells, have never been hormone sensitive. All of these cell types interact. Hormone-sensitive cells signal castration-resistant cells to become more like them. At the same time, castration-resistant cells signal hormone-sensitive cells to become more like them. Over time, the hormone-sensitive cells (being the ones that are killed by ADT)  lose the battle as the equilibrium shifts towards castration resistance.

How testosterone can help

Supraphysiologic doses, meaning serum levels greater than 1000 ng/dL, may help in several ways:

• Testosterone prevents the androgen receptor from multiplying on the cell surface, and decreases the  number of androgen receptors already there, thereby increasing the cancer cell's sensitivity to subsequent androgen ablation (see this link). It also prevents the cell from becoming super-sensitized to androgens.
• Inside the cell, high levels of testosterone prevent the internalized androgen receptors from encouraging cell replication - too much testosterone, as well as too little testosterone, discourages cancer cell replication (see this link).
• High levels of testosterone and other androgens may induce damage the cancer cell's DNA (see this link). One of the interesting hypotheses is that combining high testosterone with a chemotherapy that is known to cause DNA damage will be particularly effective (see below).
• Testosterone may be able to reverse the AR-V7 splice variant that is known to cause resistance to even second-line hormonal therapies like Zytiga and Xtandi (see this link).
• On the tumor tissue level, testosterone supports the growth of hormone-sensitive cells while destroying castration-resistant cells, as described. This shifts the equilibrium back towards androgen deprivation sensitivity.
• Selective Androgen Receptor Modulators (SARMs) may be able to provide similar benefits without some of the drawbacks (see this link).

Why can't we just give continuous high doses of testosterone?

It's been known for a while that testosterone plays a role in keeping healthy prostate cells healthy. We have observed that hypogonadal men (men who have low natural levels of testosterone) are more likely to have prostate cancer, and more virulent types. For a thorough recent review of this subject, see this link. In fact, one pilot study showed that men with mCRPC who had higher plasma testosterone levels (but still at castration levels) survived twice as long. They responded better to chemotherapy as well (see this link).

In 2009, Robert Liebowitz et al. reported on 96 patients who received very high dose testosterone replacement therapy (TRT) after some kind of prostate cancer treatment. For 59 of those men, the only treatment had been androgen deprivation. 12% were detectably metastatic. 60% had PSA progression while on TRT, but few had metastatic progression in that time period. For most of those, discontinuing TRT reversed the PSA progression.

There was a small (12 man) safety trial at Memorial Sloan Kettering. None of the men achieved supraphysiological serum testosterone levels from the transdermal gel they used. One man had to discontinue when he experienced spinal pain, but there weren't any other major side effects. Of the 12 men, 7 had decreased PSA (one had a 50% decrease). The other 5 had increased PSA, 2 by more than 50%. There was no regression of metastases in any of the men.

Other small trials of TRT alone had mixed results (see this link and this one).

So TRT alone doesn't seem to work. Both effects are necessary: (1) the TRT re-establishes hormone sensitivity, and then (2) the ADT kills off the hormone-sensitive cancer cells. For disease stabilization or regression, it seems to be necessary to alternate TRT with ADT. This is called bipolar androgen therapy (BAT).

I'm on intermittent hormone therapy - doesn't that accomplish the same thing?

Unfortunately, no. It had been hoped that intermittent ADT would accomplish two benefits:

1. Delay the development of castration resistance, and thereby prolong survival, and
2. Give men a break during which quality of life would improve temporarily

In fact, it accomplishes neither for most men. Intermittent ADT is sometimes inferior to continuous androgen ablation, perhaps especially for those with low metastatic burden. Castration resistance occurs at the same time with either intermittent or continuous ADT, and intermittent has not been shown to prolong survival.

After a long while on ADT, it takes a long time for a man's testicles to recover the ability to generate amounts of testosterone that are adequate to recover libido and help a man feel better. As far as the cancer is concerned, the cancer couldn't adapt if it were suddenly shocked by a large surge of testosterone. But during the "off-cycle,"as the amount of testosterone slowly increases, his cancer is able to adapt.  The cancer consequently thrives on the incremental increases rather than being killed by it. By the time the testosterone reaches a level that makes a measurable difference to his quality of life, the cancer has proliferated. His PSA has then gotten so high that the ADT "holiday" must be ended.

It sounds good in theory, but does it work in clinical practice?

Schweizer et al. conducted a pilot test at Johns Hopkins. They treated 16 asymptomatic men who were diagnosed a metastatic and castration-resistant. They were all still on ADT. They gave the men high doses of injected testosterone and treatment with the chemo drug etoposide (see above), which is normally ineffective in treating prostate cancer. After at least 3 cycles:

• Half of them enjoyed a decline in PSA, most of those by more than a 50% decline
• Half had a radiographic response, including 1 patient who had no discernable metastases
• Half the patients did not respond at all, and PSA continued to rise
• Responders had a higher pre-BAT PSA than non-responders
• 10 of 10 patients (100%) responded to second-line ADT (Xtandi, Zytiga or Casodex) after BAT (some were resistant to those therapies before BAT)
• 3 patients had severe toxicity attributable to etoposide.

It appears that BAT may at least delay progression in at least some men with mCRPC. It seems to resensitize their cancers to hormonal agents, even when it didn't succeed in decreasing PSA or evident (radiographic) progression. It does not increase survival (see the TRANSFORMER RCT below). However, the men periodically enjoyed enhanced quality of life from periodic high levels of testosterone. It's unclear whether etoposide chemotherapy added much to the response.

How can we tell who will respond and who will get worse?

Markowski et al. reported on 6 men treated with BAT. A PSMA PET scan (DCFPyL) 3 months into BAT treatment revealed that 3 of them had already progressed to having new metastases.

Before it can gain widespread use, is imperative that predictive biomarkers be found. So far, genomic analysis has failed to discover any.

Can it overcome resistance to Zytiga or Xtandi?

(Update 6/2017) Denmeade's group reported on 30 minimally symptomatic mCRPC men who had progressed on Xtandi.

• 30% saw PSA reduced by at least 50%
• 43% saw PSA increase from baseline; in 17%, PSA more than doubled.
• 36% had some regression of disease
• Median 8.6 months of radiographic/clinical progression-free survival
• 54% responded to re-challenge with Xtandi with a subsequent drop in PSA by at least 50% and progression-free survival of 4.8 months
• A third of those with the resistant AR-V7 mutation responded to BAT, and had lowered AR-V7 levels
• 2 converted from AR-V7 positive to AR-V7 negative
• There were adverse side effects while on BAT. Transient pain flare was the most common, affecting 40%. A few men suffered very serious side effects: pulmonary embolism, heart attack, urinary obstruction, gallstones and fatal sepsis.

(Update July 2020) In the RESTORE randomized clinical trial (RCT), the researchers are investigating whether BAT can restore sensitivity to Zytiga and Xtandi to mCRPC men who have already progressed while using those. They are excluding those who have already had chemotherapy, and no chemo is used in this trial.  They give monthly testosterone injections until there is radiographic progression. The RESTORE trial found that BAT was able to restore responsiveness to Xtandi but much less to Zytiga.

• Following testosterone therapy, PSA declined by 50% in 30% of the group who'd previously taken Xtandi, and in 17% of the group who'd previously taken Zytiga. On these small groups, the difference wasn't statistically significant.
• After BAT, PSA declined by ≥50% in 68% on rechallenge with Xtandi and lasted 13 months
• After BAT, PSA declined by ≥50% in 16% on rechallenge with Zytiga and lasted 8 months
• There was no benefit to rechallenge with either in men with the AR-V7 mutation

(Update December 2020) The "C-arm" of the RESTORE trial comprised 29 castration-resistant (mostly metastatic) patients who received only ADT but no second-line hormonal therapies. 

• Only 4 men (14%) had a PSA decline ≥50% due to the testosterone therapy
• Only 4 men had a reduction in their metastases. All of those had lymph node metastases only.
• Testosterone therapy lasted for 9 months (median) before radiographic progression was detected
• Maximum PSA response was achieved in 56 days. Only 7 patients had any PSA reduction.
• PSA more than doubled in 52%, and increased markedly in 14% more.
• 31% had some radiographic reduction of metastases.
• Median radiographic progression-free survival was 8.5 months
• Musculoskeletal pain was experienced by 40%
• Other prevalent side effects were: hypertension (21%), breast tenderness (21%), leg swelling (17%), fatigue (14%), and difficulty breathing (10%). One patient died of a stroke.
• 18 patients later received Zytiga or Xtandi, with excellent results.
• There weren't any discernable genomic determinants of response.

Based on the RESTORE trial, this trial suggests that BAT should be reserved for patients who:

1. have already progressed on Xtandi, or 
2. a short duration of BAT may make the first use of Xtandi last longer. 

Both of those hypotheses should be tested in larger trials. It also brings into question whether PSA reduction should be used as an endpoint. PSMA PET/CT may be a better indicator of early progression on BAT (see this link). There is still no clue as to why only 31% respond.

In the TRANSFORMER RCT,  195 chemo-naive mCRPC men who failed therapy with Zytiga were randomized to receive either BAT or Xtandi. Everyone crossed over to the therapy they didn't previously get. With up to 2 years of follow-up:

• Comparing BAT to Xtandi (before crossover), there were no significant differences in the time to clinical or radiographic progression (5.7 months in both groups) or reduction in PSA by ≥ 50% "PSA50" (28% and 25%)
• After crossover, PSA50 was 78% for Zytiga->BAT->Xtandi vs 23% for Zytiga->Xtandi->BAT
• After crossover, PSA-progression-free survival was 11 months for Zytiga->BAT->Xtandi vs 4 months for Zytiga->Xtandi->BAT
• Those who went from Zytiga -> BAT -> Xtandi survived 37 months vs 29 months for those who went from Zytiga -> Xtandi (not significantly different)
• BAT improved patient-evaluated quality of life
• 3 patients received Keytruda after BAT and did very well. This observation led to the COMBAT trial using a different immune checkpoint inhibitor (Opdivo)
• (update 5/7/24) Patients who never achieved serum T below 20 ng/dl did better with BAT than Xtandi.

Including BAT right after Zytiga failure and then using Xtandi increased the time to PSA progression, delayed radiographic progression, and reduced PSA. But waiting until after a failure on both drugs had no effect. This trial suggests that BAT may be useful after Zytiga but before Xtandi, particularly if T response to ADT has been less than optimal.

(Update Oct. 5, 2022) An exploratory analysis helps to explain why BAT has limited effectiveness (only 20-30% of  CRPC men derive any benefit from BAT), and what might be done to make it more effective. They focussed on the protein called c-MYC, which is known to be upregulated in advanced prostate cancer. They found:

• High androgen receptor (AR) activity is required for BAT to work. Only about ⅓ of CRPC men have high AR activity.
• But AR inhibition first is needed for T to raise its activity
• High AR activity downregulates c-MYC. 
• High doses of testosterone (T) increases AR activity.
• Xtandi (but not Zytiga or other advanced antiandrogens) prevents acquired resistance to T because it upregulates the AR while it inhibits it.

AR activity (requiring tumor biopsy) may be a valuable biomarker.

They are running a clinical trial to test cycling between T and Xtandi after Zytiga failure.

(update January 2021) In the COMBAT trial, 45 heavily-pretreated men who were mCRPC and who have progressed on either Zytiga or Xtandi, received BAT followed by Opdivo (nivolumab - an immune checkpoint inhibitor).

• ⅔ had at least some PSA reduction
• 40% had a PSA reduction ≥ 50%
• Median overall survival was 28 months
• 24% had a measurable reduction in disease; 11% for 11 or more months
• Median radiographic progression-free survival was 5.7 months
• 1 patient had a complete PSA response
• However, in 27% PSA got much worse after BAT
• BAT seems to inhibit MYC - a genetic driver of prostate cancer

This trial suggests that BAT may prime prostate cancer cells so that they are more sensitive to checkpoint inhibitors.

(Updated 9/21/21) 30 heavily-pretreated men who were mCRPC and who have progressed on either Zytiga or Xtandi, received BAT and the PARP inhibitor olaparib. Half had DNA damage repair defects. This was hypothesized based on lab findings.

• ¾ had at least some PSA reduction
• 47% had a PSA reduction ≥ 50% (44% if 2 who dropped out for progression are added)
• 23% had a 12-wk PSA increase ≥50% (28% if 2 who dropped out for progression are added)
• Median progression-free survival was 14.8 months if they were mutation-free vs. 7.5 months if they had the defects.
• 2 patients had a complete PSA response
• 5 of 8 90+% responders were free of DNA damage repair defects
• 3 of 6 90+% progressors had DNA damage repair defects
• 5 patients had serious (grade ≥ 3) toxicity, including one death

This trial suggests that BAT + olaparib achieved good response regardless of DNA damage repair defect status. Excellent responders had mutations of the T53 gene or DNA repair genes (see this link). The cause of responder/non-responder differences remains elusive.

(update 6/3/2022) A small trial suggests that there may be genomic predictors. They found that some mCRPC patients got a better PSA response from BAT if they had germline (inherited) or somatic (tumor biopsy) genomic mutations of the tp53 gene and one of either RBI gene or PTEN gene loss. There are no clear indications - the results were mixed:

• PSA decreased in 10 of 17 men with tp53 and PTEN loss
• in 8, PSA decreased more than 50%
• in 1, PSA became undetectable
• PSA increased in 7 of 17 men with tp53 and PTEN loss
• in 3 of those 7, PSA more than doubled
• PSA decreased in 2 of 2 men with tp53 and RB1 loss
• PSA increased in 3 of 3 men with RB1 and PTEN loss, so tp53 loss seems to be necessary for a BAT benefit

They also pointed out that in the recent trial of cabazitaxel+carboplatin at MD Anderson, the same genomic predictors of success were found. They propose a comparative trial of the 2 therapies in men who have mutations in tp53 and one of the two (either rb1 or pten).

(Update 11/8/2018) A new clinical trial at the University of Colorado, Denver will try transdermal testosterone instead of injections alternating with enzalutamide.

(update 6/2024) A new clinical trial at Roswell Park, Buffalo to restore sensitivity to ARSi.

(Update Jan 11, 2020) A new clinical trial at Johns Hopkins will combine BAT and Xofigo. Prior treatment with chemo and/or no more than one kind of second-line antiandrogen are allowed but not required. Recall that the RESTORE trial suggested that response was limited to lymph nodes only, so Xofigo may be a complementary treatment. Treatments that induce double strand breaks, like BAT and Xofigo, may be complementary, especially when combined with immunotherapy (see this link).

Other clinical trials include combining with Provenge, combining with Carboplatin, and using on patients who have genomic repair defects other than BRCA: ATM, CDK12, or CHEK2.

It will be important to determine, in future clinical trials, which men will respond to BAT and which men will not. Sadly, there may only be a survival benefit in a small subset of patients, although there is a quality of life benefit. Importantly, all clinical studies so far have only been Phase 2 trials in very small groups of patients. Larger trials will be necessary to prove safety and efficacy. There are already concerns about safety, so patients should not attempt BAT outside of a carefully monitored clinical trial.

There may be particular situations where BAT may be an effective therapy, but data are so far lacking: 

• What, if any, is its benefit in men who are metastatic but still hormone-responsive (mHSPC)? (see this link)
• Does it have any benefit in men who have already had docetaxel chemotherapy? 
• Considering that metastases shrank in some men on BAT, should it be tried in symptomatic men as well? 
• What is its effect on AR-V7-positive or negative men? 
• Should it be used in combination with other therapies, such as PARP1 inhibitors, immunotherapies, and radiological therapies? 
• What is the optimal sequencing of therapies? 
• Is there any benefit to BAT  used along with radiation therapy in high-risk men (see this link)?