Salvage radiation

Treatment for prostate cancer recurrence

It can be a huge blow to learn that your loved one's prostate cancer has come back following primary treatment (also called first-line treatment). 

Salvage radiation treatment or salvage radiotherapy may be suggested if he has a detectable and/or rising PSA after radical prostatectomy. 


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Pretty common

Up to 30% of men who have radical prostatectomy will develop a biochemical recurrence (also called biochemical relapse) within 10 years of their surgery.

Generally, a PSA of 0.2 ng/ml is now considered to be the threshold that defines biochemical relapse, once it has been confirmed after a second PSA measurement. 

It may encourage you to know that even if your man's PSA is now detectable, if it rises very slowly, it does not definitely mean that cancer will spread to distant areas of the body (called distant metastases).

What is salvage radiation?

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 to help make the cancer cells more susceptible 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.

When it works best

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

Other factors for success

Some of the variables that may factor into a man’s success include his:

  • PSA value at the time of radiation treatment
  • Gleason sum
  • 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.

Online prediction tool

Memorial Sloan Kettering now has an online salvage radiation therapy nomogram that can help predict if salvage radiotherapy (external beam) may be effective six years after treatment. 

It's a powerful little tool, but you should always discuss the results with a qualified medical professional. 


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What studies report

Although we lack data from large, randomized clinical trials, radiation therapy has been shown to be effective in preventing prostate cancer from progressing or spreading in retrospective clinical trials (which often examine men's medical records).

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.

Investigators 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.

PSA less than 2.0 ng/mL

In another study, Stephenson et al concluded that men 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, even if they had:

  • Gleason scores of 8-10
  • Negative surgical margins
  • A PSA doubling time of less than 10 months 

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 was:

  • 32% at 6 years
  • 20% at 10 years

More encouraging studies

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 3/15

Back to if cancer returns
Salvage radical prostatectomy
Salvage cryotherapy
Hormone treatment
Chemotherapy
Watchful waiting (or active surveillance)
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References:

Bartkowiak D, Bottke D, Wiegel T. Radiotherapy in the management of prostate cancer after radical prostatectomy.  http://www.medscape.com/viewarticle/804541_2.  Accessed March 30, 2015. 

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.

Always consult a medical professional.

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