Sequential Treatment For Recurrent Localized Prostate Cancer

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Clinical Trials / Drug Trials
Article Date: 19 Apr 2008 - 0:00 PDT

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UroToday.com - Management of locally recurrent prostate cancer after initial treatment is the subject of several studies. The only level 1 data that exists is on the use of adjuvant radiotherapy to the prostatic fossa after prostatectomy for T3 and/or margin positive disease. Bolla et al. [1] showed an improvement, both in biochemical and clinical progression-free survival in patients that received early adjuvant radiotherapy to the prostatic fossa. A slightly increased incidence of local toxicity (1.6%) was observed in the radiotherapy arm of the trial, while adjuvant radiotherapy was interrupted in 3.1% of men due to toxicity. In the wait-and-see arm of the trial, 220 men experienced a relapse, of which only 51% received salvage radiotherapy to the prostatic fossa, with a median interval to study inclusion of 2.2 years. These data shows that early adjuvant treatment improved clinical progression-free survival, when compared to a group of men who did not or receive, or who received salvage treatment rather late and at the expense of an increase in local toxicity. For this reason others suggest that careful monitoring and early salvage radiotherapy to the prostatic fossa may provide similar long- term disease control, in particular when salvage radiotherapy is initiated before PSA reaches levels of 0.5 ng/ml [2,3].

From our analysis, it was suggested that salvage surgery after local radiotherapy results in considerably greater genitourinary toxicity when compared to salvage radiotherapy after prostatectomy. Two important aspects need to be addressed. First, since adjuvant radiotherapy, shortly after surgery, may be associated with increased local toxicity, when compared to radiotherapy more than 6 months after surgery, the findings regarding local genitourinary toxicity should not be extrapolated to adjuvant treatment. Second, novel techniques of fascia preservation during prostatectomy have, at least in our institute, led to an improved outcome of erectile function after primary prostatectomy, which may further support the choice of initial surgery for some patients. Then again, nerve sparing in salvage surgery is notably difficult and seems not to have benefited from renewed insight into periprostatic nerve anatomy.

These retrospective data from a small group of highly selected patients show results from "our daily urological practice" and may not apply to other institutes. The selection of treatment is a highly biased event in local prostate cancer management. Yet for us the findings imply that disease control between the two groups of men is surprisingly similar with a slight benefit for initial surgery with respect to genitourinary complications.

Written by Henk G van der Poel, MD, as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations, etc., of their research by referencing the published abstract.

Reference List

1. Bolla M, Van Poppel H, Collette L, van Cangh P, Vekemans K, Da Pozzo L, de Reijke TM, Verbaeys A, Bosset JF, van Velthoven R, Marechal JM, Scalliet P, Haustermans K, Pierart M: Postoperative radiotherapy after radical prostatectomy: a randomised controlled trial (EORTC trial 22911). Lancet 2005;366:572-8.

2. Jacinto AA, Fede AB, Fagundes LA, Salvajoli JV, Castilho MS, Viani GA, Fogaroli RC, Novaes PE, Pellizzon AC, Maia MA, Ferrigno R: Salvage radiotherapy for biochemical relapse after complete PSA response following radical prostatectomy: outcome and prognostic factors for patients who have never received hormonal therapy. Radiat Oncol 2007;2:8.

3. Stephenson AJ, Shariat SF, Zelefsky MJ, Kattan MW, Butler EB, Teh BS, Klein EA, Kupelian PA, Roehrborn CG, Pistenmaa DA, Pacholke HD, Liauw SL, Katz MS, Leibel SA, Scardino PT, Slawin KM: Salvage radiotherapy for recurrent prostate cancer after radical prostatectomy. JAMA 2004;291:1325-32.

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