11 / 96
P
rostate
cancer
– T
herapy
with
radium
-223
R
ev
A
ssoc
M
ed
B
ras
2017; 63(12):1019-1023
1021
However, previous use of docetaxel led to a greater number
of hematological adverse events in both Ra223 and pla-
cebo patients. However, grade 3 and 4 myelosuppression
rates were low, with differences only in thrombocytope-
nia rates. In addition, previous use of docetaxel did not
influence the number of non-hematological events.
6
(
A
)
The main non-hematological adverse events reported
in the studies were diarrhea, constipation, vomiting, nau-
sea, fatigue, bone pain and peripheral edema.
3,5,6,9,10
(
A
)
M
arkers
Evaluating the different dosages of Ra223 (25, 50 and 80
kBq/kg) in a total of 122 patients, there was a better al-
kaline phosphatase (AP) and prostate specific antigen
(PSA) response in the groups receiving the highest doses
(50 and 80 kBq/kg). No patient in the 25 kBq/kg group
achieved a 50% reduction in PSA.
9
(
A
)
In the ALSYMPCA study, there was a significant de-
cline in AP and a longer time interval for elevation of this
marker in patients treated with Ra223 compared to pla-
cebo. There was also a significant reduction of PSA in the
Ra223 (16%) versus placebo (6%) group, in addition to a
longer time interval to raise this parameter.
5
(
A
)
In both studies described above, the AP and PSA val-
ues were analyzed after 12 weeks and the reduction was
considered significant if greater than 30% of the initial
value. This longer time to increase AP and PSA also oc-
curred in the Ra223 group compared to placebo, regard-
less of previous docetaxel use (p<0.05).
6
(
A
)
I
mprovement
of
pain
and
quality
of
life
A study with 100 mCRPC patients aimed at evaluating
different single doses of Ra223 (5, 25, 50 and 100 kBq/kg)
and had as primary outcome improvement of pain with-
in 16 weeks after treatment. In this study, the groups
receiving the highest Ra223 dosages (50 and 100 KBq/Kg)
required less of other forms of analgesia for pain control
than the groups receiving lower Ra223 dosages (5 and
25 kBq/kg).
8
(
A
)
In the analysis of pain reduction alone among the
different doses of Ra223 (25, 50 and 80 kBq/kg) given to
122 patients, there was a tendency for better results using
50 kBq/kg.
9
(
A
) Despite the dose-response effect on pain
reduction, there is no such analysis compared to placebo.
A subgroup analysis of patients from the ALSYMPCA
5
study evaluated the improvement of quality of life. More
patients treated with Ra223 showed improvement in
quality of life assessment tests compared to patients
treated with placebo (29.2% versus 18.5%; p=0.004).
10
(
A
)
H
ospitalization
rate
Another study evaluated the hospitalization rate within
the 12 months following treatment with Ra223 compared
to placebo-treated patients. Patients receiving Ra223 had
a lower hospitalization rate than those treated with pla-
cebo (37% and 45.5%, respectively), regardless of whether
a skeletal event occurred. In addition, the number of days
of hospitalization in the Ra223 group was lower than in
the placebo group (4.4 versus 6.6 days; p=0.004).
11
(
A
)
E
vidence
summary
We were able to perform a meta-analysis of two outcomes
studied: survival and bone event. The other outcomes could
not be investigated by meta-analysis due to the lack of neces-
sary data or use of the same population in different studies.
S
urvival
Two studies
4,5
(
A
) totaling 985 patients (647 in the Ra223
group and 338 in the placebo group) were included in this
analysis. In this comparison, at 0% heterogeneity, there was
a 10% decline in mortality (95CI 4-16) in favor of Ra223
treatment.
12
(
A
) Thus, 10 patients need to be treated to
avoid one death compared to no treatment (Figure 1).
B
one
events
Two studies were included in the analysis
3,7
(
A
) totaling
985 patients (647 treated with radium-223 and 338 with
a placebo). In this comparison there is a non-significant
reduction in the risk of bone events of 5% (95CI -1–11)
in favor of treatment with Ra223 and heterogeneity is 0%.
This means that there is no significant difference (p<0.05)
in the risk of bone events when comparing treatment and
non-treatment with radio-223 (Figure 2).
R
ecommendation
Ra223 is effective for the treatment of patients with
mCRPC, with a reduction in mortality of 10% and an
increase in mean survival over 3 months. There is no re-
duction in the number of bone events in these patients
and no improvement in pain was observed except for the
dose-response aspect.
Other benefits have been demonstrated, such as im-
proved quality of life, increased time to skeletal events,
reduced hospitalization and effect on markers such as
PSA and AP.
The most common adverse events are both hemato-
logic (anemia, neutropenia and thrombocytopenia) and
non-hematological (diarrhea, constipation, vomiting,
nausea, fatigue, bone pain and peripheral edema).