(UroToday.com) As part of a plenary presentation at the European Association of Urology (EAU) Virtual 2020 meeting assessing “Modern prostate cancer imaging in daily practice”, Peter Nyirády, MD, PhD, DSc, followed Annika Herlemann MD’s presentation by suggesting we start with early treatment for patients with biochemical recurrence following initial local therapy. He began by highlighting a number of details that physicians must convey to their patients before embarking on the treatment of biochemical recurrence:
- The natural history of prostate-specific antigen (PSA) only recurrence may be prolonged
- Measure PSA may not lead to clinically relevant outcomes including radiographic recurrence or prostate cancer-related death
- Only 30% of patients with BCR eventually develop clinical recurrence
That said, the overall goal is to delay the onset of metastatic disease and death, but must be weighed against risks of overtreatment and detriments to quality of life. Post-surgical radiotherapy has been the approach best studied in this context. While early studies showed a benefit to adjuvant radiation therapy (RT), more recent data has suggested that early salvage radiotherapy may allow for comparable oncologic control while avoiding significant overtreatment.
Certainly, for patients who receive salvage RT, most will be progression-free at 5-years later and the vast majority will achieve and undetectable PSA. He highlighted the seminal Trock paper demonstrating that the greatest benefit to salvage RT is realized by patients with shorter prostate-specific antigen doubling time (PSA-DT). On the basis of these data and others, the EAU scoring system has allowed for risk stratification:
Dr. Nyirády then highlighted recent work from the ICECaP project demonstrating that MFS is our best surrogate for overall survival (OS), rather than PSA driven endpoints.
He then addressed the role of concurrent ADT with salvage RT. In a retrospective study, he highlighted data showing that the benefit of androgen-deprivation therapy (ADT) was restricted to patients with high-risk disease including pT3b/4, ISUP >4, and those with PSA >0.4ng/mL at the time of salvage RT. Similar factors were found to be predictive of benefit for ADT with respect to clinical recurrence.
He highlighted a variety of treatment options for patients with recurrence following radiotherapy (including salvage RP, cryotherapy, brachytherapy, and HIFU), with an emphasis that the quality of evidence for any local therapy is poor and thus strong recommendations can’t be made. While salvage RP offers likely the highest chance of cure, it should be restricted to healthy patients with a long life expectancy and a reasonable chance of cure.
Data for other approaches is even more limited and patients should be appropriately counseled regarding this prior to embarking on therapy.
He closed by highlighting guideline recommendations in this disease space, as follows:
Presented by: Peter Nyirády, MD, PhD, DSc, Head of Department, Department of Urology, Semmelweis University, Budapest, Hungary
Written by: Christopher J.D. Wallis, Urologic Oncology Fellow, Vanderbilt University Medical Center, Nashville, TN, USA, Twitter: @WallisCJD, at the Virtual 2020 EAU Annual Meeting #EAU20, July 17-19, 2020.