San Antonio, Texas USA (UroToday.com) Salvage treatment is defined as the treatment of M0 patients with persistent or rising PSA (BCF) after primary treatment (radical prostatectomy or radiation). Since the definition includes the M0 state, all the following recommendations may change in the near future as imaging modalities improve. Not all patients with BCF need salvage treatment.
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Several attempts were done to define the population that would best benefit from salvage treatment. The risk factors that emerged were higher Gleason grade, higher pathological stage, PSA doubling time <6 months and short time from primary treatment to recurrence. Several clinical risk calculators are available (e.g. Memorial Sloan Kettering calculator) and can predict the risk of metastases and response to salvage therapy. Furthermore, the Decipher genomic classifier was validated for the prediction of 5 years metastases free survival after BCR. It was also shown that Decipher better predicts this specific outcome compared with risk calculators.
The main salvage treatments are surgery or radiation. Salvage radiation was shown to improve cancer specific survival, metastases and hormonal therapy free survival in patients with BCR after prostatectomy. In the SWOG 8794 salvage radiation reduced local and metastatic recurrence rates. It was also shown that lower PSA at time of salvage radiation predicted better outcome. Patients with PSA>1 did poorly. Also patients with high risk pathological features are the best candidates for early salvage radiation. RTOG 9601 trial demonstrated a significant benefit with adding bicalutamide for 6 months to salvage radiation. Same results were obtained in the GETUG – AFU16.
Salvage prostatectomy after initial radiation is also possible in select patients. The best candidates for salvage surgery are those with pre salvage PSA <4 and Gleason grade <8. The EAU guidelines recommend salvage surgery for Gleason <8, stage T2b and pre-op PSA<10.
Lastly salvage hormonal therapy is suitable only in select group of patients with high risk disease (short PSA doubling time and Gleason >7). It should not be offered as salvage treatment in general.
In conclusion, salvage treatment should be offered to men with BCF after primary treatment. Choosing the patients foe salvage treatment is done by using clinical or molecular risk calculators.
Presented By: Marc A. Dall’Era
Written By: Miki Haifler, MD, M.Sc., Society of Urologic Oncology Fellow, Fox Chase Cancer Center
17th Annual Meeting of the Society of Urologic Oncology - November 30 -December 2, 2016 – San Antonio, Texas USA