Radiotherapy is a mainstay of treatment for localized prostate cancer. Biochemical recurrence after radiotherapy, defined as a prostate-specific antigen (PSA) rise of ≥ 2 ng/mL above nadir, occurs in up to 40% of intermediate- and high-risk patients within 10 years of treatment (Eur. Urol. 67, 1009–1016 (2015). Patients with biochemical recurrence are at increased risks of metastases and death (J. Clin. Oncol. 23, 6992–6998 (2005)).
In patients with biochemical recurrence after radiation, biopsy-proven localized disease, and no evidence of metastases, salvage prostatectomy may potentially improve survival and delay initiation of androgen deprivation therapy. This National Cancer Institute-sponsored multi-institutional study, CALGB 9687 (Alliance), prospectively evaluated the efficacy and morbidity of salvage prostatectomy in 41 men between 1997 and 2006 (Prostate Cancer Prostatic Dis. 2019 May; 22(2):309-316). At a median follow-up 91 months, these investigators observed robust 2-, 5- and 10-year progression-free survival rates of 51%, 39%, and 33% respectively; and 2-, 5- and 10-year overall survival rates of 100%, 89%, and 52%, respectively.
Nevertheless, peri- and post-operative morbidity was high, even within this group of high-volume centers. Twenty-two percent of patients required intraoperative blood transfusion, and 3 rectal and 1 obturator nerve injuries occurred. Prior to surgery, 45% of patients reported urinary incontinence, defined as ≥ 3 pads/day; after surgery, 88%, 85%, and 63% reported urinary incontinence at 6, 12, and 24 months after surgery, respectively. Similarly, 37% reported erectile dysfunction (ED) prior to surgery; 78%, 82% and 44% reported it 6, 12, and 24 months after surgery.
The take-home message is that, while salvage prostatectomy is associated with robust oncologic control, modern surgical techniques remain associated with substantial complications. Future studies should focus on comparative oncologic and quality-of-life analyses between salvage prostatectomy and minimally-invasive, lower-morbidity procedures including salvage cryoablation and salvage high-intensity focused ultrasound (HIFU).
Written by: J. Kellogg Parsons, MD, MHS, Urologist, Professor of Urology, UC San Diego Health, San Diego, California
Read the Full-Text Article: Management of Recurrent Prostate Cancer After Radiotherapy: Longterm Results from CALGB 9687 (Alliance), a Prospective Multiinstitutional Salvage Prostatectomy Series – Full-Text Article