Salvage radiation therapy after radical prostatectomy

Low versus high risk: the EAU analysis — The prognostic value of a biochemical recurrence following curative-intent treatment for prostate cancer was subsequently addressed in a systematic review of 77 studies conducted for the European Association of Urology (EAU) [57]. All of the 14 studies that compared biochemical recurrence versus no biochemical recurrence found biochemical recurrence to be an independent risk factor for the development of distant metastases, prostate cancer-specific mortality, and to a lesser extent, overall mortality. In the meta-analysis, among males undergoing radical prostatectomy, the main prognostic factors for distant metastases, prostate cancer-specific mortality, and overall mortality were a short PSA-DT (in most studies, < 12 months) and a pathologic Gleason score of 8 to 10. For males undergoing primary RT, the strongest prognostic factors for distant metastases, prostate cancer-specific mortality, and overall mortality were a short interval to biochemical failure (with most studies using < 18 months as the cutoff associated with an increased risk of clinical disease recurrence) and a biopsy Gleason score of 8 to 10.

These data prompted the EAU Prostate Cancer Guidelines Panel to propose a biochemical recurrence risk stratification system to predict which patients might progress after a biochemical recurrence [58]:

●Low-risk biochemical recurrence – PSA-DT >12 months and pathologic Gleason score < 8 after radical prostatectomy; interval to biochemical failure >18 months and biopsy Gleason score < 8 after RT.

●High-risk biochemical recurrence – PSA-DT ≤12 months or pathologic Gleason score ≥8 after radical prostatectomy; interval to biochemical failure ≤18 months or biopsy Gleason score ≥8 after RT.

The prognostic value of this risk grouping was externally validated in a series of 1040 males with a biochemical recurrence after radical prostatectomy [59]. After five years, metastasis-free survival was 99.7 percent in the low-risk group (95% CI 99-100 percent) and 86.7 percent in the high-risk group (95% CI 83.4-90.1 percent).

Despite the lack of prospective data validating the use of these specific risk groupings to decide whether and when to initiate salvage treatment, the EAU Prostate Cancer Guidelines Panel recommends offering close surveillance and possibly deferred salvage treatment to males with a low-risk biochemical recurrence [58]. They also recommend against offering early ADT to males with a low-risk biochemical recurrence. For a high-risk biochemical recurrence, restaging and early salvage therapy are indicated.

Clinicians still need to make individual decisions with individual patients. It is not always possible to defer initiation of salvage therapy in males with "low-risk" PSA-recurrent disease (eg, due to patient anxiety, a PSA-DT that is "close to" 12 months, or Gleason 4+3 = 7 disease rather than ≥8 on the pathology from radical prostatectomy). Careful use of intermittent ADT in males with a PSA recurrence is at least one way to balance the benefits and risks of salvage ADT.

I’ve noticed, through my own research , that treatments and doctors’ recommendations were different back in 2013 than they are today.

Can you ask them would it have been okay to wait and not do Salvage Radiation Therapy in 2013? or What would have been the outcome since your Gleason is 7 and doubling time is >12 months.

Both of my doctors, urologist and oncologist, agree. That the next treatment would be Lupron injections. But they want to wait until doubling time gets more frequent. Then I would possibly have another PSMA done. And maybe radiation if cancer is found in a different part of my body.

Salvage radiation is considered to have about 2/3 success rate and side effects rated under 2-3% but many on the forum have reported more side effects which raises the thought if one is low risk (Gleason 7 and PSA-DT>12 months) to wait and watch? Feel for firespooks...

What a total bummer - not many of us think past the possibility of salvage radiation failing…what do the doctors say are your next steps? Hormones, chemo? So sorry you have to go thru this.

Good that PSMA is not reveal anything. There are some studies that shows if Gleason is 3+4=7 and PSA-Doubling time >12 months, one can go 10-15 years metastases free survival although there may be more variables. Hopefully, it stays well...

Yes , my surgery was at 55. After my radiation, my PSA went to 0.01 for 2 years, then started slowly rising. I did have a PSMA scan done earlier this year. But it did not reveal anything.

If I do the math correctly, your surgery was at age 55. Did PSA drop after radiation in 2013? Looks like you have been dealing with it for quite some time. Was PSMA PET or MRI pelvis done? Did it reveal anything? Good luck...

My Gleason score is 3+4 =7 . My PSA before Prostatectomy was 5.53. Before salvage radiation was 0.22. Now PSA is 1.16. I am 73 years old.