Patient selection, cancer control, and complications after salvage local therapy for postradiation prostate‐specific antigen failure

Abstract

Among men who experience prostate-specific antigen (PSA) failure after external beam radiation or brachytherapy (RT), many will harbor occult micrometastases; however, a significant minority will have a true local-only failure and, thus, potentially may benefit from a salvage local therapy. Those most likely to have a local-only failure initially have low-risk disease (PSA <10 ng/mL, Gleason score 6, clinical T1c or T2a tumor status), pretreatment PSA velocity <2.0 ng/mL per year at the time of initial presentation, interval to PSA failure >3 years, PSA doubling time >12 months, negative bone scan and pelvic imaging, and positive rebiopsy. In addition, men with presalvage PSA levels >10 ng/mL, presalvage T3/ T4 disease, or presalvage Gleason scores 7 on a rebiopsy sample without significant RT effects are unlikely to be cured by salvage local therapy. Based on a review of all series of post-RT salvage prostatectomy, cryosurgery, and brachytherapy published in English since 1990, morbidity can be substantial. Although urinary incontinence appeared to be greater after salvage prostatectomy (41%) or cryosurgery (36%) than after brachytherapy (6%), patients who received salvage brachytherapy faced a 17% risk of grade 3 or 4 genitourinary complications and a fistula risk that averaged 3.4% across all series. From this review, the authors concluded that prospective randomized studies are needed to determine the relative efficacy of the 3 major local salvage modalities and that additional research is needed to identify factors associated with an increased risk of significant complications to improve patient selection and to augment the benefit/risk ratio associated with attempts to cure local-only recurrences after radiation therapy.

Focal salvage therapy for localized prostate cancer recurrence after external beam radiotherapy

“…The biochemical cancer control rates that result from these salvage therapies are on the order of 40% to 60% over 2 to 5 years follow-up. [6][7][8] We previously reported our early results using focal therapy in men with primary disease. 9 Focal salvage therapy has been proposed as an alternative that may provide treatment for localized, radiorecurrent disease while reducing the impact on functional status.…”

Multivariable model development and internal validation for prostate cancer specific survival and overall survival after whole-gland salvage Iodine-125 prostate brachytherapy

“…Categories of predictors were based on common prognostic categories from the literature (e.g. PSA ≤10 and >10 ng/ml and PSADT≤ 10 months and >10 months 16 ). Receiver operating characteristic (ROC)-analysis was performed for PSA-density and PSA-velocity to identify cutoff values with maximal sensitivity and specificity, since groups were unequal when categories based on the literature were adopted.…”

“…Interestingly, factors before primary radiotherapy do not show an effect on survival. Selection of salvage patients is often performed based on these characteristics 16,23 . These findings could be an indication of their relative insignificance for patient selection.…”

Emerging Treatments for Recurrent Prostate Cancer

“…[15] Lack of consistency in trials with regards to the use of ADT and in the definition of failure following salvage treatment means that indirect comparison of the efficacy of these novel therapies is challenging.…”