Published OnlineFirst February 7, 2019; DOI: 10.1158/1055-9965.EPI-18-1002 Research Article Cancer Epidemiology, Biomarkers A Comprehensive Analysis of Steroid Hormones & Prevention and Progression of Localized High-Risk Prostate Cancer Eric Levesque 1, Patrick Caron2, Louis Lacombe1,Veronique Turcotte2, David Simonyan3, Yves Fradet1, Armen Aprikian4, Fred Saad5, Michel Carmel6, Simone Chevalier4, and Chantal Guillemette2 Abstract Background: In men with localized prostate cancer who are terone levels were higher in low-risk disease. Associations were undergoing radical prostatectomy (RP), it is uncertain whether observed between adrenal precursors and risk of cancer pro- their systemic hormonal environment is associated with out- gression. In high-risk patients, a one-unit increment in log- comes. The objective of the study was to examine the associ- transformed androstenediol (A5diol) and dehydroepiandros- ation between the circulating steroid metabolome with prog- terone-sulfate (DHEA-S) levels were linked to DFS with HR of nostic factors and progression. 1.47 (P ¼ 0.0017; q ¼ 0.026) and 1.24 (P ¼ 0.043; q ¼ 0.323), Methods: The prospective PROCURE cohort was recruited respectively. Although the number of metastatic events was from 2007 to 2012, and comprises 1,766 patients with local- limited, trends with metastasis-free survival were observed for ized prostate cancer who provided blood samples prior to RP. A5diol (HR ¼ 1.51; P ¼ 0.057) and DHEA-S levels (HR ¼ 1.43; The levels of 15 steroids were measured in plasma using mass P ¼ 0.054). spectrometry, and their association with prognostic factors and Conclusions: In men with localized prostate cancer, our disease-free survival (DFS) was established with logistic regres- data suggest that the preoperative steroid metabolome is sion and multivariable Cox proportional hazard models. associated with the risk of recurrence of high-risk disease. Results: The median follow-up time after surgery was 73.2 Impact: The associations of adrenal androgens with pro- months. Overall, 524 patients experienced biochemical failure gression of localized high-risk disease could help refine hor- and 75 developed metastatic disease. Testosterone and andros- monal strategies for these patients. Introduction (DHT), dehydroepiandrosterone-sulfate (DHEA-S), androstenedi- one (4-Dione or AD), androstanediol-glucuronide (3a-diol-G) and Prostate cancer is the most commonly diagnosed cancer and estradiol (E )—and the risk of developing prostate cancer (2). Also, the second most common cause of cancer-related deaths among 2 another large study did not find any association between prediag- North American men (1). Currently, approximately 85% of nostic circulating hormone levels (testosterone, DHT, E and 3a- newly diagnosed cases of prostate cancer are localized within 2, diol-G) and lethal prostate cancer (3). In the latter study, the the prostate. Despite the fact that sex steroid hormones play a authors did, however, find an association between an increased central role in prostate biology, a collaborative analysis of risk of lethal prostate cancer with higher prediagnostic levels of 18 prospective studies failed to demonstrate an association DHT in men with aggressive Gleason score (GS) 8 and stage T3 between six circulating steroids—testosterone, dihydrotestosterone disease (3). Results from phase III chemoprevention trials further support 1Centre Hospitalier Universitaire (CHU) de Quebec Research Centre and Faculty the role of sex steroid hormones in prostate cancer carcinogen- fi a of Medicine, Laval University, Quebec, Canada. 2CHU de Quebec Research esis (4, 5). Indeed, nasteride (a 5 -reductase type I inhibitor) Centre and Faculty of Pharmacy, Laval University, Quebec, Canada. 3Statistical and dutasteride (a dual 5-AR inhibitor targeting 5a-reductase type and Clinical Research Platform, CHU de Quebec Research Centre, Quebec, I and type II), both of which block the conversion of testosterone Canada. 4McGill University Health Centre, McGill University, Faculty of Medicine, into DHT in target cells, reduced the occurrence of prostate cancer 5 Quebec, Canada. Centre Hospitalier de l'Universite de Montreal, Faculty of by approximately 25% (4, 5). However, this reduction in prostate 6 Medicine, Universite de Montreal, Quebec, Canada. Universite de Sherbrooke, cancer risk comes at the expense of a controversial but potentially Faculty of Medicine, Quebec, Canada. increased risk of developing higher-grade prostate cancer (4, 5). Note: Supplementary data for this article are available at Cancer Epidemiology, In agreement with the finasteride and dutasteride findings, in Biomarkers & Prevention Online (http://cebp.aacrjournals.org/). men with a confirmed diagnosis of prostate cancer, previous Corresponding Authors: Eric Levesque, CHU de Quebec Research Centre and studies have suggested that low pretreatment levels of serum Laval University, 2705 Blvd. Laurier, Quebec G1V 4G2, Canada. Phone: 418-525- testosterone are associated with disease aggressiveness and clin- 4444; Fax: 418-654-2761; E-mail: [email protected]; and ical outcomes (6, 7). Chantal Guillemette, [email protected] However, other circulating hormones may contribute to clin- doi: 10.1158/1055-9965.EPI-18-1002 ical outcomes in men with localized disease. This is reinforced by Ó2019 American Association for Cancer Research. the fact that cancer cells possess the intracrine biosynthesis www.aacrjournals.org 701 Downloaded from cebp.aacrjournals.org on September 26, 2021. © 2019 American Association for Cancer Research. Published OnlineFirst February 7, 2019; DOI: 10.1158/1055-9965.EPI-18-1002 Levesque et al. surgeons. Serial prostate-specific antigen (PSA) measurements and clinical data were gathered during follow-up. A total of 1,908 single preoperative blood samples were available for steroid analysis. One hundred and forty-two patients were documented to have a prior exposure to a 5a-reductase inhibitor and, therefore, were excluded from the analyses leaving a total of 1,766 patients for this study. No other forms of hormonal manipulation were administered before blood sampling. The objective of the study was the assessment of associations of steroid hormone levels with prostate cancer prognostic factors and progression. After prosta- tectomy, patients were seen regularly and PSA was measured every 3 months for 2 years, every 4–6 months for 2 years, and then every 6–12 months or at the discretion of the physicians. Disease-free survival (DFS) was defined as the occurrence of biochemical recurrence (BCR), metastasis, and/or death (all-causes). BCR was defined as (i) the occurrence of a first PSA >0.2 ng/mL any time after surgery or (ii) a detectable PSA of <0.2 ng/mL that triggered initiation of salvage radiation or androgen abla- tion therapy (10–13). Before surgery, each patient provided written informed consent for research and the protocol was evaluated and approved by the Centre Hospitalier Universitaire (CHU) de Quebec (Quebec, Canada) and local Ethical Research Committees. Figure 1. Simplified schematic representation of the 15 steroid hormones measured in the PROCURE cohort. Steroids were profiled by multiplex MS assays in Plasma steroid measurements by MS preoperative plasma samples except for androstanedione (A-dione) and Blood samples were collected and processed at a preoperative androstane-3a-17b-diol (3a-diol). Abbreviations: testo, testosterone; 3b-diol, visit and banked at À80 C until analyzed. LC/MS-MS and GC-MS androstane-3b,17b-diol; 3a-diol-17G, androstane-3a,17b-diol-17-glucuronide. were used to measure plasma steroid levels as described previ- ously (Fig. 1; ref. 14). Ten unconjugated steroids were measured in a single assay using 250 mL of plasma, whereas sulfates and machinery to locally synthesize active androgens from precursors glucuronides were measured in two independent assays using such as DHEA-S, dehydroepiandrosterone (DHEA), 4-Dione or 20 mL and 100 mL of plasma, respectively. Analyses were per- AD, and androstenediol (A5diol) originating from extragonadal formed in a blinded fashion. Reference steroids were purchased peripheral sources, such as the adrenal glands (Fig. 1; refs. 8, 9). To from Steraloids. Internal standards (deuterated steroids) were our knowledge, a comprehensive assessment of the circulating added to samples and quality controls were included in each hormonal environment including precursors associated with run. The measured steroids and their limits of quantification were disease aggressiveness and clinical outcomes in men with newly as follows: DHEA, 100 pg/mL; progesterone (Prog), 50 pg/mL; diagnosed localized prostate cancer has not been assessed. This A5diol, 50 pg/mL; testosterone, 30 pg/mL; DHT, 10 pg/mL; lack of information is mostly due to the fact that the majorities of androsterone (AST), 50 pg/mL; androstane-3b,17b-diol (3b- previous studies conducted in localized disease were mostly Diol), 10 pg/mL; estrone (E1), 5 pg/mL; estradiol (E2), 1 pg/mL; focused on testosterone and relied on low specificity and accuracy 4-Dione or AD, 50 pg/mL; AST-glucuronide (AST-G), 1 ng/mL; radioimmunoassays measuring a single hormone at a time. The androstane-3a,17b-diol-3-glucuronide (3a-diol-3G), 0.25 ng/ use of gold standard mass spectrometry (MS) methods for accu- mL; androstane-3a,17b-diol-17-glucuronide (3a-diol-17-G), rate and specific assessment of various steroids is thus critical. 0.25 ng/mL; DHEA-S, 0.075 mg/mL; estrone-sulfate (E1-S), In this