The American Society of Clinical Oncology recently held their annual conference, and it has generated a lott of buzz in the online PC community. There is so much news coming out of this meeting, it is overloading my mailbox. So I will try to present a few of these stories as best as I can.
The following article touts the benefits of *adjuvant radiation therapy,* after RP, *even for higher-risk patients*: It is called: High-Risk Disease After Radical Retropublic Prostatectomy: The Case for Adjuvant External Beam Radiation Therapy.
First of all, let me explain some terms. “Adjuvant Radiation” is radiation therapy (RT) given after surgery but before there has been any noticeable rise in the patient’s PSA level. It is essentially a prophylactic measure. “Salvage Radiation,” on the other hand, is administered after the patient’s PSA has begun to rise.
I posted an article some time ago urging patients to explore the potential benefits of adding radiation to surgery (see “Consider Adding Rad to Surgery”), and this new report underscores my point. It goes so far as to say that even for high-risk cases, adjuvant radiation (XRT) may confer a significant benefit. Last time I investigated this, I kept on reading about XRT being “underutilized,” in spite of its proven value. Well, this needs to change.
It had been thought that radiation after surgery would only work if the cancer were truly localized. That is to say, if the patient’s PSA starts to rise post RP, RT would work only if the remaining cancer was confined to the prostate bed (fossa), usually indicated by a positive margin. Now they are thinking that even people whose cancer has spread beyond the fossa may benefit from XRT. Also, they underscore the point that some high-grade cancer, or metastasis, may result from *localized* residual prostate cancer that has entered the system. In other words, metastatic cancer is not always qualitatively different from localized cancer.
Everybody agrees on one thing: if you are going to have post-RP rad, do it yesterday! Don’t wait.
I strongly suggest that if you have intermediate- (Gleason 7) or higher-grade cancer, talk to a radiation oncologist about the possibility of adding adjuvant or salvage radiotherapy. Adjuvant is preferable. The sooner the better. Remember, your surgeon may not suggest this, so you have to be proactive.
What is the downside of adding rad immediately after surgery? The rad itself is painless, although it may be inconvenient to go for 40-or-so brief sessions. My husband had salvage rad six months ago, and so far, he hasn’t had a single symptom. But these may develop over time. Overall, RT is a kind and gentle treatment compared to what’s out there, and if you can increase your chances of survival by giving the PC a 1-2 punch, I would go for it.
Then I would sit back in my La-Z-Boy knowing I did everything possible to keep the cancer at bay. Make believe it’s the Showtime Rotisserie:
Just set it and forget it.
Anyway, here is the article I’ve been referencing (I’ve highlighted some items):
|High-Risk Disease After Radical Retropublic Prostatectomy: The Case for Adjuvant External Beam Radiation Therapy|
|Saturday, 16 February 2008|
|SAN FRANCISCO, CA (UroToday.com) – Dr. Anthony Zeitman presented the argument for adjuvant radiotherapy (XRT) following radical prostatectomy (RP). He stated that high-risk CaP after RP is not always a systemic disease. An adverse RP pathology report includes grade, stage, and lymph node and margin status. In the Johns Hopkins database, those with adverse pathology had a high failure rate.But where does the recurrence present? Is it local, distant or more commonly both? *Yet distant failure can derive from an initial local recurrence*.Two studies included prostate fossa biopsy for a rising PSA post-RP and 41-54% had documented CaP. This likely underestimates the true number.Salvage XRT with a median followup of 45 months as reported by Stephenson in 2004, demonstrated an initial response, but only about 40% were still disease free at 5 years. Dr. Zeitman stated that local failure can precede a late wave of metastasis. This* biphasic recurrence suggests that XRT for local control might possibly decrease the likelihood of the subsequent metastasis. In EORTC 22911 men were randomized to adjuvant vs. delayed therapy.
**The risk of PSA failure was about half in the*adjuvant* XRT group.
**Freedom from clinical failure was 15% better with adjuvant therapy.**
*The cumulative incidence of late morbidity [side effects] was small*, with erectile dysfunction being one aspect that was worse.*
In 2007 the data was republished with central pathological review. There seemed to be no advantage with adjuvant XRT if the patient had a negative surgical margin. A positive surgical margin had a similar outcome regardless of the location of the positive surgical margin. The salvage XRT in the delayed arm was given at a median time of 2.2 years.
In SWOG 8794 473 men with a median followup of 10 years had a similar outcome to EORTC 22911.
**The 10 year biochemical disease free survival was 47% and 23% respectively for adjuvant and salvage groups.**
In a new trial UK-NCIC, intermediate risk patients are randomized to adjuvant XRT vs. observation with salvage XRT. The low risk patients are not treated and all the high-risk patients get adjuvant XRT. Dr. Zeitman stated that it is too early to assess the survival outcome, but the data shows that the need for androgen deprivation therapy is delayed.
*The onus in on the uro-oncologist to discuss these data with the patient with an adverse pathology report.*