Adjuvant and Salvage Radiotherapy after Prostatectomy American Society of Clinical Oncology Clinical Practice Guideline Endorsement

SUMMARY: The American Society of Clinical Oncology (ASCO) recently endorsed the Clinical Practice Guidelines recommended by the American Urological Association (AUA)/American Society for Radiation Oncology (ASTRO), on Adjuvant and Salvage Radiotherapy after Prostatectomy. These guidelines target Medical and Radiation Oncologists, Primary care providers, Urologists, other health care providers and address patient counseling, use of radiotherapy in the adjuvant and salvage settings, definition of biochemical recurrence and restaging evaluation. The following are the ASCO Key Recommendations for Adjuvant and Salvage Radiotherapy after Prostatectomy:

1. Patients who are being considered for management of localized prostate cancer with radical prostatectomy should be informed of the potential for adverse pathologic findings that portend a higher risk of cancer recurrence and that these findings may suggest a potential benefit of additional therapy after surgery.

2. Patients with adverse pathologic findings, including seminal vesicle invasion, positive surgical margins, and extraprostatic extension, should be informed that adjuvant radiotherapy, compared with radical prostatectomy only, reduces the risk of biochemical Prostate Specific Antigen (PSA) recurrence, local recurrence, and clinical progression of cancer. They should also be informed that the impact of adjuvant radiotherapy on subsequent metastases and overall survival is less clear; one of two randomized controlled trials that addressed these outcomes indicated a benefit, but the other trial did not demonstrate a benefit defined as reduced risk of metastasis and death.

3. Physicians should “OFFER” adjuvant radiotherapy to patients with adverse pathologic findings at prostatectomy, including seminal vesicle invasion, positive surgical margins, or extraprostatic extension, because of demonstrated reductions in biochemical recurrence, local recurrence and clinical progression.

4. Patients should be informed that the development of a PSA recurrence after surgery is associated with a higher risk of development of metastatic prostate cancer or death resulting from the disease. Congruent with this clinical principle, physicians should regularly monitor PSA after radical prostatectomy to enable early administration of salvage therapies if appropriate.

5. Clinicians should define biochemical recurrence as a detectable or increasing PSA value after surgery that is more than 0.2 ng/mL, with a second confirmatory level more than 0.2 ng/mL.

6. A restaging evaluation in a patient with a PSA recurrence may be considered although it is not clear at this time which imaging modalities to use, as all imaging modalities have limited sensitivity and specificity in the low PSA range.

7. Physicians should “OFFER” salvage radiotherapy to patients with PSA or local recurrence after radical prostatectomy, in whom there is no evidence of distant metastatic disease.

8. Patients should be informed that the effectiveness of radiotherapy for PSA recurrence is greatest when administered at lower levels of PSA (less than 1 ng/ml). Salvage radiotherapy in this patient population with a short PSA doubling time, has been shown to improve overall survival.

9. Patients should be informed of the possible short and long term urinary, bowel, and sexual adverse effects of radiotherapy as well as of the potential benefits of controlling disease recurrence.

This endorsement was made with certain qualifying statements, clarifying certain aspects of these guidelines.

a) The word “OFFER” should be interpreted as having a detailed discussion with the patient about the risks and benefits of adjuvant radiation.

b) Even though 0.2 ng/mL is considered a reasonable cut point for PSA recurrence, the benefits of using this cut point versus other cut points remains unclear.

c) Patient’s who have the greatest benefit in absolute risk reduction from adjuvant RT, are those with adverse pathologic findings as noted in the guidelines, with a high risk of recurrence or clinical progression.

In conclusion, the decision to administer adjuvant or salvage radiotherapy should be made by the patient and multidisciplinary treatment team, after discussing the risks and benefits of such intervention. Freedland SJ, Rumble RB, Finelli A, et al. J Clin Oncol 2014;32:3892-3898