Adjuvant and Salvage Radiotherapy After Prostatectomy: AUA/ASTRO Guideline

American Urological Association Education and Research, Inc., Linthicum, Maryland, and the American Society for Radiation Oncology, Fairfax, Virginia.
The Journal of urology (Impact Factor: 3.75). 05/2013; 190(2). DOI: 10.1016/j.juro.2013.05.032
Source: PubMed

ABSTRACT PURPOSE: The purpose of this guideline is to provide a clinical framework for the use of radiotherapy after radical prostatectomy as adjuvant or salvage therapy. MATERIALS AND METHODS: A systematic literature review using the PubMed®, Embase, and Cochrane databases was conducted to identify peer-reviewed publications relevant to the use of radiotherapy after prostatectomy. The review yielded 294 articles; these publications were used to create the evidence-based guideline statements. Additional guidance is provided as Clinical Principles when insufficient evidence existed. RESULTS: Guideline statements are provided for patient counseling, the use of radiotherapy in the adjuvant and salvage contexts, defining biochemical recurrence, and conducting a re-staging evaluation. CONCLUSIONS: Physicians should offer adjuvant radiotherapy to patients with adverse pathologic findings at prostatectomy (i.e., seminal vesicle invastion, positive surgical margins, extraprostatic extension) and should offer salvage radiotherapy to patients with prostatic specific antigen or local recurrence after prostatectomy in whom there is no evidence of distant metastatic disease. The offer of radiotherapy should be made in the context of a thoughtful discussion of possible short- and long-term side effects of radiotherapy as well as the potential benefits of preventing recurrence. The decision to administer radiotherapy should be made by the patient and the multi-disciplinary treatment team with full consideration of the patient's history, values, preferences, quality of life, and functional status. Please visit the ASTRO and AUA websites ( and to view this guideline in its entirety, including the full literature review.

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    • "We developed a decision-analytic model to establish a framework to evaluate the potential costeffectiveness of ProsVue as an adjunctive prognostic marker to CAPRA-S risk stratification in comparison with the use of postoperative characteristics alone as characterized by the CAPRA-S risk group (i.e., standard care). The evaluation is limited to patients with intermediate-risk and high-risk CAPRA-S scores consistent with treatment guidelines [8]. We report findings across a range of scenarios, including those in which the effect of the ProsVue slope is limited to decreasing the use of ART when the ProsVue slope value is 2 pg/mL/mo or less (i.e., the threshold in the US Food and Drug Administration [FDA] label indication to report that a patient is " at reduced risk " of clinical recurrence) and those in which ART increases when the ProsVue slope value is more than 2 pg/mL/mo. "
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    ABSTRACT: Objectives The NADiA ProsVue is a prognostic system that measures prostate-specific antigen slope to identify men at lower risk of clinical recurrence of prostate cancer after radical prostatectomy. We developed a decision-modeling framework to evaluate its cost-effectiveness to guide the use of adjuvant radiotherapy (ART). Methods We populated the model using patient-level data and external sources. Patients were classified as intermediate risk or high risk on the basis of Cancer of the Prostate Risk Assessment-Postsurgical (CAPRA-S) nomogram and then stratified by the ProsVue slope (≤2 pg/mL/mo; >2 pg/mL/mo) and receipt of ART. In sensitivity analyses, we varied the effect of the ProsVue slope on the use of ART and other model parameters. Results The cost-effectiveness of the ProsVue-guided strategy varied widely because of small differences in quality-adjusted life-years (QALYs) at 10 years. In the intermediate-risk group, when the use of ART decreased from 20% (standard care) to 7.5% among patients with a ProsVue slope value of 2 pg/mL/mo or less, the incremental cost-effectiveness ratio was $25,160/QALY. In the high-risk group, the use of ART would have to decrease from 40% (standard care) to 11.5% among those with a ProsVue slope value of 2 pg/mL/mo or less to obtain a ratio of $50,000/QALY. The cost-effectiveness ratios were sensitive to varying benefits of salvage therapy, quality of life, and costs of ART and ProsVue testing. Conclusions The effect of the ProsVue system on costs will be dependent on the extent to which ART decreases among men identified as having a low risk of recurrence. Its effect on QALYs will remain conditional on uncertain clinical and quality-of-life benefits associated with ART.
    Value in Health 07/2014; 17(5). DOI:10.1016/j.jval.2014.04.010
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    • "The efficacy of SRT is highly dependent on the prostate-specific antigen (PSA) level at the time of treatment [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17]. For this reason, SRT should be ideally administered early, at the first sign of PSA recurrence [5] [6] [18]. Nevertheless, even when timely RT is provided, a proportion of patients will experience subsequent progression [18]. "
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    ABSTRACT: Early salvage radiotherapy (eSRT) represents the only curative option for prostate cancer patients experiencing biochemical recurrence (BCR) for local recurrence after radical prostatectomy (RP). To develop and internally validate a novel nomogram predicting BCR after eSRT in patients treated with RP. Using a multi-institutional cohort, 472 node-negative patients who experienced BCR after RP were identified. All patients received eSRT, defined as local radiation to the prostate and seminal vesicle bed, delivered at prostate-specific antigen (PSA) ≤0.5 ng/ml. BCR after eSRT was defined as two consecutive PSA values ≥0.2 ng/ml. Uni- and multivariable Cox regression models predicting BCR after eSRT were fitted. Regression-based coefficients were used to develop a nomogram predicting the risk of 5-yr BCR after eSRT. The discrimination of the nomogram was quantified with the Harrell concordance index and the calibration plot method. Two hundred bootstrap resamples were used for internal validation. Mean follow-up was 58 mo (median: 48 mo). Overall, 5-yr BCR-free survival rate after eSRT was 73.4%. In univariable analyses, pathologic stage, Gleason score, and positive surgical margins were associated with the risk of BCR after eSRT (all p ≤ 0.04). These results were confirmed in multivariable analysis, where all the previously mentioned covariates as well as pre-RT PSA were significantly associated with BCR after eSRT (all p ≤ 0.04). A coefficient-based nomogram demonstrated a bootstrap-corrected discrimination of 0.74. Our study is limited by its retrospective nature and use of BCR as an end point. eSRT leads to excellent cancer control in patients with BCR for presumed local failure after RP. We developed the first nomogram to predict outcome after eSRT. Our model facilitates risk stratification and patient counselling regarding the use of secondary therapy for individuals experiencing BCR after RP. Salvage radiotherapy leads to optimal cancer control in patients who experience recurrence after radical prostatectomy. We developed a novel tool to identify the best candidates for salvage treatment and to allow selection of patients to be considered for additional forms of therapy.
    European Urology 12/2013; 66(3). DOI:10.1016/j.eururo.2013.11.045
  • European Urology 09/2013; 66(2). DOI:10.1016/j.eururo.2013.09.016
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