Int Urol Nephrol (2012) 44:1039–1044 DOI 10.1007/s11255-012-0134-z UROLOGY – ORIGINAL PAPER Goserelin versus leuprolide in the chemical castration of patients with prostate cancer Élcio Dias Silva • Ubirajara Ferreira • Wagner Matheus • Eliney F. Faria • Gustavo D. Silva • Minori Saito • Auro A. S. de Souza • Azuil Laranjo Jr. • Otavio Clark • Luis Alberto Magna • Lı́sias Nogueira Castilho • Leonardo Oliveira Reis Received: 2 November 2011 / Accepted: 23 January 2012 / Published online: 8 February 2012  Springer Science+Business Media, B.V. 2012 Abstract Purpose To evaluate the relative efficiency of leuprolide 3.75 mg, leuprolide 7.5 mg, and goserelin 3.6 mg in relation to the reduction in serum testosterone, regarding the levels of castration. Materials and methods We evaluated prospectively 60 randomized patients with advanced prostate carcinoma, with indication for hormone blockade. The patients were divided into 3 groups of 20: Group (1) received leuprolide 3.75 mg; Group (2) received leuprolide 7.5 mg; and Group (3) received goserelin 3.6 mg. All groups were treated with monthly application of the respective drugs. The patients’ levels of serum testosterone were evaluated in two moments: before the treatment and 3 months after the treatment. Results The patients’ ages were similar within the three groups, with a median of 72, 70, and 70 in groups 1, 2, and 3, respectively. Of the patients that received leuprolide 3.75 mg, leuprolide 7.5 mg, and goserelin 3.6 mg, 26.3, 25, and 35%, respectively, did not reach castration levels, considering a testosterone cutoff B 50 ng/dl. And 68.4, 30, and 45%, respectively, did not reach castration levels, considering a testosterone cutoff B 20 ng/dl. É. D. Silva (&)
U. Ferreira
W. Matheus
E. F. Faria
G. D. Silva
M. Saito
A. A. S. de Souza
A. Laranjo Jr.
O. Clark
L. A. Magna
L. N. Castilho
L. O. Reis Campinas, Brazil e-mail: doutorelcio@terra.com.br Conclusions There were no statistically significant differences in the levels of castration when comparing leuprolide 3.75 mg, leuprolide 7.5 mg, and goserelin 3.6 mg, altogether. When compared in groups of two, there was a statistically significant difference between leuprolide 3.75 mg and leuprolide 7.5 mg, the latter presented better results in reaching castration levels, cutoff B 20 ng/dl. The importance of this difference, however, must be measured with caution, since the comparison of the three groups simultaneously did not reach the established significance level, even though it came close. Keywords Prostate cancer
Testosterone
Level of castration
GnRH agonist
LHRH agonist Introduction Incidence of the disease in Brazil Prostate cancer is the second greatest cause of death due to malignant tumors in men, coming second only to lung cancer. In 2010, there were an estimated 52,350 new cases of prostate cancer in Brazil. These numbers represent an estimated risk of 54 new cases to every 100 thousand men. The occurrence of prostate cancer is greater than that of breast cancer in women [1]. The prevalence of this tumor and the cost of its treatment should increase with the rising of the population’s life expectancy rate and with the present 123 1040 tendency of expanding the early discovery of the disease [2]. History of hormonal treatment for prostate cancer In 1836, Cooper [3] observed that tumors varied in size during the menstrual cycle, presenting a small size in the beginning of the cycle and in menopause. As a result, he established a correlation between the growth of the tumor and the hormonal cycle. Sixty years later, in 1896, Beatson reported the regression of metastatic mammary cancer lesions after bilateral oophorectomy in pre-menopausal women [4]. In 1941, Huggins reported that the majority of patients with advanced prostate cancer presented important clinical regressions after bilateral orchiectomy [5], which rendered him the Nobel Prize in Medicine in 1966. Androgen suppression is able to control the disease in advanced stages in 80–90% of men and results in a progression-free survival of approximately 12–33 months [6]. Several therapeutic approaches based on hormonal or androgen suppression were described, and some are widely used today in the treatment for advanced stages of the disease [7] Table 1. Table 1 Prostate cancer—commonly used drugs LHRH analogs Triptorelin Buserelin Goserelin Leuprolide LHRH antagonists Abarelix Cetrorelix Degarelix Antiandrogenics Cyproterone acetate Bicalutamide Flutamide Nilutamida Estrogens Diethylstilbestrol Other drugs Glucocorticoids Ketoconazole 123 Int Urol Nephrol (2012) 44:1039–1044 Although effective, the orchiectomy, which consists of surgical hormonal suppression, is a traumatic and mutilating approach, with a high impact on the patient’s psychological condition. Subcapsular or total orchiectomies are equivalent in achieving low testosterone levels. Some authors are performing the orchiectomy with ultrasonic surgical aspirators, with good results [8–11]. Chemical suppression or hormonal blocking with the use of luteinizing hormone-releasing hormone (LHRH) agonists and antiandrogenics began in the 80s and today represents an alternative to surgical castration. Published data show that agonists, such as goserelin and leuprolide, produce effects that are similar to those of castration [2, 7]. Regarding these drugs, several studies are being carried out for the purpose of determining the best moment to initiate the use, the most effective combinations, and the best routes for administration [6, 12]. Ideal value of serum testosterone to obtain chemical castration The main purpose of any type of hormonal blocking is to reach testosterone levels below 50 ng/dl, which is considered castration level [13]. However, there are controversies regarding the value of testosterone to consider the level of castration and the necessary dosage to reach such goal. The 50 ng/dl value of testosterone as a cutoff level for castration derives from the dosage method used in the 60s and 70s, which was known as ‘‘isotopederivative dilution technique,’’ which considered 50 as the lower limit for detection [14, 15]. The Food and Drug Administration (FDA) of the United States considers a testosterone value of 50 ng/dl as the lower limit of castration for the purpose of approving LHRH analogs. Several authors consider 20 ng/dl as the lower limit, since in the current methods for dosing this hormone, radioimmunoassay, and chemiluminescence, the expected values in patients submitted to orchiectomy are, in average, inferior to 20 ng/dl [16, 17]. Oefelein et al. obtained a testosterone average of 15 ng/dl in orchiectomized patients, and in 2005, Tombal also referred to an average of 15 ng/dl in orchiectomized patients [18, 19]. In Denmark, Rohl and Beuke [16] found 19.3 ng/dl as an average testosterone value in orchiectomized patients. They also emphasized the importance of Int Urol Nephrol (2012) 44:1039–1044 dosing total testosterone (TT) and dihydrotestosterone (DHT), since TT decreased 95%, while DHT decreased 70% and the DHT/TT ratio increased 5–7 times after the orchiectomy, which can alter the evolution of the prostate cancer. The importance of the cost of treatment In Brazil, the description leaflet for leuprolide contains conflicting information regarding the dosage (3.75–7.5 mg per month or 22.5 mg every 3 months). However, the dosage of goserelin is well established (3.6 mg per month or 10.8 mg every 3 months). In Brazil, there are significant differences related to the cost of the medication: While the prices of leuprolide 3.75 mg and goserelin 3.6 mg are equivalent, the use of leuprolide 7.5 mg would double the cost of the treatment. In addition, the cost of leuprolide 22.5 mg is also twice the price of goserelin 10.8 mg. The economic factor becomes even more crucial if we consider that patients with advanced prostate cancer can have a survival rate of more than 3 years [6]. Methods Sixty randomized patients with advanced prostate carcinoma were evaluated. They were divided into 3 groups of 20, based on a chronological order of arrival. GROUP 1: patients who received leuprolide 3.7 mg. This group had one patient excluded from the study due to a testosterone level of castration before he received the medication. GROUP 2: patients who received leuprolide 7.5 mg. GROUP 3: patients who received goserelin 3.6 mg. The patients were selected from the Uro-Oncology service of Hospital Santa Marcelina in São Paulo and from the Hospital do Câncer de Barretos. The patients who received leuprolide 3.75 mg and goserelin 3.6 mg were from Hospital Santa Marcelina and those who received leuprolide 7.5 mg were from the Hospital do Câncer de Barretos. The patients included in the study had advanced prostate cancer with indication for hormone blockade. Patients who had previously undergone hormone blockade treatments and patients who already 1041 presented castration testosterone levels were not included in the study. After reading and signing the study agreement, the selected patients were submitted to total testosterone tests and initiated the treatment with one of the three drugs. The drugs were administered once a month during 3 months. Total testosterone tests were carried out before the treatment and 3 months of treatment. After the conclusion of the proposed treatment, the patients were followed in the respective services, with the drugs that were appointed to the respective groups and under the same rules of procedure for patients with advanced prostate carcinoma. The testosterone dosage was taken with microparticle enzyme immunoassay (MEIA) in the patients of the groups that received leuprolide 3.75 mg and goserelin 3.6 mg and with eletrochemiluminescence—Testosterone II (cobas) Elecsys and cobas analyzers (Roche Diagnostics GmbH), in the group that received leuprolide 7.5 mg. The proportion of chemically castrated patients, for cutoffs defined B 50 and B 20 ng/dl of testosterone, was compared in the three groups (19 patients who received leuprolide 3.75 mg, 20 patients who received leuprolide 7.5 mg, and 20 patients who received goserelin 3.6 mg) using the chi-square, considering a significance level of 5% (p \ 0.05). Results Patients’ age The ages of the patients who received leuprolide 3.75 mg, leuprolide 7.5 mg, and goserelin 3.6 mg varied according to Table 2. Table 2 Patients age Patients age (in years) Leuprolide Leuprolide Goserelin 3.75 mg 7.5 mg 3.6 mg 58–88 56–81 58–86 Median, 72 Median, 70 Median, 70 Average, 71.4 Average, 69.6 Average, 71.3 123 1042 Int Urol Nephrol (2012) 44:1039–1044 Patients who received leuprolide 3.75 mg Five out of nineteen patients did not obtain castration levels that corresponds to 26.3% (when considering a cutoff B 50 ng/dl) and 13 patients did not obtain castration levels, which corresponds to 68.4% (when considering a cutoff B 20 ng/dl). Patients who received leuprolide 7.5 mg Five out of twenty patients did not obtain castration levels that corresponds to 25% (when considering a cutoff B 50 ng/dl) and 6 patients did not obtain castration levels, which corresponds to 30% (when considering a cutoff B 20 ng/dl). For the castration cutoff B 20 ng/dl testosterone, although the difference of proportion among the three groups did not vary significantly (6/19 or 31.6%; 14/20 or 70%; and 11/20 or 55% respectively; p = 0.054), we can identify a tendency toward difference, which is due to the difference between the two groups treated with leuprolide (p = 0.016), rather than the difference between each one of those and the group treated with goserelin (p = 0.140 and p = 0.327 respectively). The importance of this difference, however, must be measured with caution, since the comparison of the three groups simultaneously did not reach the established significance level, even though it came close. Discussion Patients who received goserelin 3.6 mg Seven out of twenty patients did not obtain castration levels that corresponds to 35% (when considering a cutoff B 50 ng/dl) and 9 patients did not obtain castration levels, which corresponds to 45% (when considering a cutoff B 20 ng/dl) Table 3. Summary of the obtained results. In total, 59 patients: • • 28.77% did not obtain levels B50 ng/dl. 47.80% did not obtain levels B20 ng/dl. Statistical analysis of the data For the castration cutoff B 50 ng/dl testosterone, 14 of 19 (73.7%) of the patients treated with 3.75 mg leuprolide, 15 of 20 (75%) of those treated with 7.5 mg leuprolide, and 13 of 20 (65%) of those treated with 3.6 mg of goserelin can be considered castrated, while the difference of proportions among the three groups cannot be considered significant (p = 0.751). Table 3 Failure to obtain testosterone castration levels Testosterone Summary of the obtained results Leuprolide 3.75 Leuprolide 7.5 Goserelin 3.6 26.3 25 35 68.4 30 45 Did not obtain B50 ng/dl (%) Did not obtain B20 ng/dl (%) 123 There are no randomized prospective studies that adequately evaluate the effectiveness of leuprolide 3.75 and 7.5 mg in comparison with goserelin 3.6 mg, regarding the achievement of testosterone values in levels of castration. The fact that a drug can be used with a determined dosage and with double dosage, indistinctively, is intriguing. The pharmaceutical industries responsible for leuprolide state that either one of the dosages, 3.75 or 7.5 mg, is efficient in obtaining testosterone castration levels for patients with advanced prostate cancer. This motivated us to analyze the effectiveness of these drugs, comparing them with goserelin, which is one of the most widely used drugs in these cases. Several authors have studied what would be an ideal dosage of testosterone in order to consider a castration. The analysis of the results of such dosages in orchiectomized patients, with the current techniques (radioimmunoassay and chemiluminescence), leads to the conclusion that the level of castration should be testosterone B 20 ng/dl, since this is the value obtained with the removal of the testicles. However, many authors still consider B 50 ng/dl values as sufficient for ‘‘castration level,’’ due to the fact that there is no difference in the follow-up of the patients regarding the decrease in PSA and the evolution of prostate cancer with either B 20 or B 50 ng/dl testosterone values. Esquena et al. [20], in the Hospital Vall d’Hebron, in Barcelona, achieved a failure rate of 16.7% in obtaining levels inferior to 50 ng/dl in 135 patients treated with LHRH analogs, and they suggest that in Int Urol Nephrol (2012) 44:1039–1044 these cases, the correct procedure is to perform an orchiectomy. They also emphasize the importance of always measuring and controlling the testosterone levels in patients treated with such analogs. Oefelein and Cornum [18], from Cleveland, found a failure rate of 5% in obtaining castration level when considering \50 ng/dl and 13% when considering \20 ng/dl values. In these cases, they also advise orchiectomy or complimentary treatment with antiandrogen and always recommend the control of the testosterone levels in patients treated with LHRH analogs. Novara et al. [14], from the University of Padova, in Italy, carried out a research of 20 authors that observed the results of testosterone dosage in patients being treated with LHRH analogs and, in general, did not obtain castration level in 3.2% when considering less than 50 ng/dl and 11.8% when considering less than 20 ng/dl. A formal meta-analysis carried out by the Prostate Cancer Trialists’ Collaborative Group (PCTCG), involving 27 studies with 8,275 patients, which corresponds to 98% of the randomized evidence in the world, shows that there was a modest increase in cancer-specific survival rate within 5 years with maximum androgen blockage (around 2%). This shows that even associating antiandrogens for patients treated with androgen suppression, regardless of whether they obtained castration level, we must not expect promising results regarding cancer-specific survival rates within 5 years [21, 22]. In our study, for castration level B 50 ng/dl of testosterone, 14/19 (73.7%) of patients treated with 3.75 mg of leuprolide, 15/20 (75%) of those treated with 7.5 mg of leuprolide, and 13/20 (65%) of those treated with 3.6 mg of goserelin can be considered castrated, while the difference of proportion between the three groups cannot be considered significant (p = 0.751). For the castration level B 20 ng/dl of testosterone, although the difference of proportion between the three groups did not vary significantly (6/19 or 31.6%; 14/20 or 70%; and 11/20 or 55% respectively; p = 0.054), we can identify a tendency toward difference, which is due to the difference between the two groups treated with leuprolide (p = 0.016), rather than the difference between each one of those and the group treated with goserelin (p = 0.140 e p = 0.327 respectively). 1043 The importance of this difference, however, must be measured with caution, since the comparison of the three groups simultaneously did not reach the established significance level, even though it came close. Our rates of failure to obtain castration levels of testosterone, in the treatment of patients with LHRH analogs, were, in average, in the 3 groups, of 28.8% when considering a value of 50 ng/dl and 47.8% when considering a value of 20 ng/dl, therefore superior to those described in the world literature. This makes us wonder for what reasons the medication used in Brazil does not produce the same results as the medication used in other countries, especially in the United States and in European countries. Conclusion There was no significant difference in obtaining castration levels with leuprolide 3.75 mg, leuprolide 7.5 mg, and goserelin 3.6 mg, when comparing the three substances altogether. When compared in groups of two, there was a statistically significant difference in the analysis of leuprolide 3.75 mg with leuprolide 7.5 mg, with the latter presenting a greater achievement of castration levels, when considering the value of 20 ng/dl. The importance of this difference, however, must be measured with caution, since the comparison of the three groups simultaneously did not reach the established significance level, even though it came close. The results in obtaining castration levels were below our expectations in relation to the studies carried out in other centers. 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