Munich, Germany (UroToday.com) Dr. Thomas Wiegel, radiation oncologist, from University Hospital Ulm, presented on the importance of adjuvant therapy (ART) rather than salvage therapy (ST) post-prostatectomy.
Primary case favoring aduvant rather than salvage radiation therapy among patients with node negative disease is Level I evidence favoring ART. Dr. Wiegel highlighted three such trials. SWOG Phase III trial showed a clear benefit in overall survival with patients undergoing ART (Thompson et al, J Urol 2009). EORTC 22911 showed a benefit in biochemical recurrence free survival and clinical progression but failed to show benefit in overall survival. Centralized pathologic review upgraded and downgraded patients with surgical margin rate. Subsequently, most progression-free survival benefit in ART was seen in patients with surgical margin positivity. ARO 96-02 and AUO AP/09/95 study showed improved progression free survival (primary end-point) with ART. It did not show a benefit with distant metastatic free survival, as the study was not powered.
Recently, further evidence shows that ART may also be beneficial in patients with pathological node positive disease. However, the evidence is retrospective. A study by Abdollah et al (Eur Urol 2014) shows that N+ patients who received ART in addition to HT had improved cancer-specific mortality free survival. The data is even stronger in patients who had positive surgical margins.
ART results in lower overtreatment for best-selected patients than in patients who undergo salvage radiation therapy. Patients with positive surgical margins benefit most from ART. When patients had salvage therapy, they tend to fail sooner and that depends on level of PSA at the time of rising PSA. Therefore, a significant over treatment exists for ST where patients may not at all benefit from therapy.
Dr. Wiegel then presents the AUA/ASTRO guideline statement on the use of ART—“ Physicians should offer adjuvant RT to patients with adverse pathologic findings at prostatectomy, including SVI, positive surgical margins, or EPE because of demonstrated reductions in biochemical recurrence, local recurrence, and clinical progression” (STANDARD).
He summarizes that there exists a clear level I evidence for node negative patients who have positive surgical margins (pT2 and pT3). There is no overtreatment with ART in pT3 patients, +surgical margins, and Gleason Score 7-10. Retrospective data also exists for patients with pathological node-positive disease. Additionally, there is lower rate of side effects with salvage radiotherapy.
Presented By:
T. Wiegel, Ulm (DE)
Reported By:
Mohammed Haseebuddin, MD, at the 31st Annual EAU Congress - March 12 - 15, 2016 – Munich, Germany
Fox Chase Cancer Center