(UroToday.com) Tuesday afternoon’s plenary session during the 2024 World Congress of Endourology and Uro-Technology Conference in Seoul, Korea featured an insightful lecture by Dr. Thomas Ahlering, MD, on the role of adjuvant and salvage radiation therapy in the management of prostate cancer.
Dr. Ahlering provided a historical overview, noting that in the late 1980s and 1990s, radiation therapy was recognized primarily for reducing biochemical recurrence, though its impact on improving overall prostate cancer survival remained unclear. To address this, four randomized controlled trials (RCTs) were conducted, comparing adjuvant radiation therapy to observation. These trials included studies by SWOG, EORTC, ARO 96.02, and the FinnProstate Group.
However, Dr. Ahlering highlighted significant ethical and oversight issues in these trials. He noted that all four control arms used salvage radiation therapy (SRT) under the label "Observation or Wait and See," which he argued was inappropriate for assessing oncological benefit. According to Dr. Ahlering, the control groups should have included adjuvant androgen deprivation therapy (adjADT) or salvage androgen deprivation therapy (salADT) to provide a more accurate comparison.
Furthermore, Dr. Ahlering raised concerns about the SWOG 8794 trial, where mismatches in patient age and pathologic Gleason grade (pGG) raised questions about oversight. He also pointed out that the EORTC/Lancet trial allowed a change in the primary outcome from prostate cancer-specific survival (PCSS) to biochemical recurrence (BCR) and local control, which raises questions regarding the integrity of the study.
Dr. Ahlering was critical of the overall design of these trials, and he describes that what they really compared was adjuvant and salvage radiation therapy and not adjuvant radiation therapy to observation.
In his concluding remarks, Dr. Ahlering asserted that postoperative radiation therapy has yet to show any improvement in metastasis-free survival (MFS) or prostate cancer-specific survival (PCSS), nor has it added any oncological benefit. The Kaplan-Meier graphs from these trials, he argued, demonstrate that radiation therapy offers equal or no oncological benefit compared to other treatment options.
Dr. Ahlering's analysis raises critical questions about the historical and current approach to radiation therapy in prostate cancer treatment, urging for more rigorous and meticulously design trials in the future.
Presented by: Thomas Ahlering, MD. Professor and Vice Chairman, Department of Urology, University of California Irvine
Written by: Bruce Gao, MD, FRCSC, Endourology Fellow, Department of Urology, University of California Irvine, @b_gao on Twitter during the 2024 World Congress of Endourology and Uro-Technology: August 12 -16, 2024, Seoul, South Korea