Salvage radiation treatment for prostate cancer recurrence

Salvage radiation treatment (or salvage radiotherapy) may be suggested if your loved one experiences a rising PSA after radical prostatectomy (which is termed his first-line treatment). Unfortunately, it is estimated that up to 30% of men who have had radical prostatectomy will develop a biochemical recurrence within 10 years of their surgery.

Salvage radiation usually means that your loved one will have external beam radiation (some men may receive hormone therapy for a few months prior to treatment). While salvage brachytherapy is sometimes performed on men who have a recurrence of prostate cancer after they have had external beam radiation, it is not as common after surgery for prostate cancer.

Researchers seem to agree that a man’s response will be more successful if he has treatment at the earliest sign of recurrence. When researchers analyzed current studies, they determined that there was a three-fold survival improvement with salvage radiation when it was begun within 2 years of a man’s recurrence. Salvage radiotherapy begun more than 2 years after recurrence provided no significant increase in prostate cancer–specific survival.

A study by Stephenson et al looked at 501 men who were treated at different medical centers and determined that the overall probability that a man would not have cancer progression (called progression-free survival) was 45% four years following salvage radiation treatment. In an extended study analysis, progression-free survival at 6 years was 32% and at 10 years it was 20%. Another study reported 10-year progression-free survival rates of 25% to 30%. But more (and larger) long-term studies are needed to determine just how effective this therapy can be in prolonging a man’s survival.

Some of the variables that may factor into a man’s success include his PSA value at the time of radiation treatment, his Gleason sum, and whether he had positive surgical margins, extracapsular extension, and no cancer in the seminal vesicles. These are all questions to ask your loved one’s doctor so you will thoroughly understand what the chances are for successful treatment.

It may encourage you to know that Moul et al suggest that even men who have potentially life-threatening prostate cancer may still achieve long-term PSA recurrence-free outcomes with salvage radiation therapy. They also suggest that even if a man has a rapid PSA doubling time, it should not be assumed that he has metastatic cancer, and that he might still be a candidate for treatment.

When analyzing the data presented by Stephenson et al, even men who had Gleason scores of 8-10, negative surgical margins, or a PSA doubling time of less than 10 months had a 1 in 5 chance of achieving long-term progression-free response when radiation treatment was initiated when their PSA level was less than 2.0 ng/mL.

A study by Burri et al looked at 37 men who had a prostate cancer recurrence after initial radiation (32 had external-beam radiation therapy and 5 had brachytherapy) and underwent salvage brachytherapy. After a median follow-up of 86 months, salvage prostate brachytherapy was associated with a 10-year freedom from biochemical failure of 54% and cause-specific survival of 96%. Men who had a presalvage PSA <6 ng/mL did better than other men.

Updated 10/11

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References:

Burri RJ, Stone NN, Unger P, Stock RG. Long-term outcome and toxicity of salvage brachytherapy for local failure after initial radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2010 Aug 1;77(5):1338-44.

Chin J. Clarifying the role of salvage radiotherapy. CUAJ. 2008;2(5):508-509.

Graham SM, Holzbeierlein JM. Adjuvant radiation therapy after radical prostatectomy: when is it indicated? Curr Urol Rep. 2009;10(3):194-8.

Moul JW, Banez LL, Freedland SJ. Rising PSA in nonmetastatic prostate cancer. Oncology. 2007;21(12):1436-1454.

Sia MS, Pickles T, Morton G, Souhami L, et al. Salvage radiotherapy following biochemical relapse after radical prostatectomy: proceedings of the Genito-Urinary Radiation Oncologists of Canada consensus meeting. Can Urol Assoc. 2008;2(5): 500–507.

Stephenson AJ, Scardino PT, Kattan MW, et al. Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy. Cleveland J Clin Oncol. 2007;25(15):2035-41.

Trock B, Han, M, Freedland SJ, et al. Prostate Cancer–Specific Survival Following Salvage Radiotherapy vs Observation in Men With Biochemical Recurrence After Radical Prostatectomy. JAMA.2008;299(23):2760-2769.

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