The publication of the joint guideline on radiation therapy after prostatectomy for patients with and without evidence of prostate cancer recurrence was announced by The American Society for Radiation Oncology (ASTRO) and the American Urological Association (AUA). The 81-page document represents an intensive collaboration among experts in the radiation oncology and urology fields, led by Richard K. Valicenti, MD, MA, professor and chair of the department of radiation oncology at the University of California Davis Comprehensive Cancer Center in Sacramento, on behalf of ASTRO, and Ian M. Thompson, MD, director of the Cancer Therapy and Research Center at the University of Texas Health Science Center at San Antonio and the Glenda and Gary Woods Distinguished Chair in genitourinary oncology, on behalf of the AUA. The Adjuvant and Salvage Radiotherapy After Prostatectomy: ASTRO/AUA Guideline is a comprehensive review of 324 research articles of English-language publications within the Pubmed, Embase and Cochrane databases, published from January 1, 1990 through December 15, 2012. The guideline is available online free as a PDF document at http://www.redjournal.org and http://www.auanet.org, and will be published in the August 1, 2013, print issue of the International Journal of Radiation Oncology • Biology • Physics (Red Journal), the official scientific journal of ASTRO, and in the August 2013 print issue of the Journal of Urology, the official journal of the AUA.
The strategies and approaches recommended were derived from evidence-based and consensus-based processes in the reviewed articles. The systematic review included articles that provided detailed efficacy in patients with detectable and undetectable prostatic specific antigen (PSA) levels, toxicity and quality of life impact, and optimal imaging strategies to determine the appropriateness of radiation therapy use in patients suspected of recurrence. Only studies in which PSA data were provided for 75 percent or more patients were included in the guideline.
The guideline document provides the following clinical principles, recommendations, standards and options:
1) patients who are being considered for management of localized prostate cancer with radical prostatectomy should be informed of the potential for adverse pathologic findings that portend a higher risk of cancer recurrence;
2) patients with adverse pathologic findings including seminal vesicle invasion, positive surgical margins and extraprostatic extension should be informed that adjuvant radiation therapy, compared to radical prostatectomy only, reduces the risk of biochemical (PSA) recurrence, local recurrence and clinical progression of cancer;
3) physicians should offer adjuvant radiation therapy to patients with adverse pathologic findings at the time of prostatectomy, including seminal vesicle invasion, positive surgical margins or extraprostatic extension because of demonstrated reductions in biochemical recurrence, local recurrence and clinical progression;
4) patients should be informed that the development of a PSA recurrence after surgery is associated with a higher risk of development of metastatic prostate cancer or death from the disease;
5) clinicians should define biochemical recurrence as a detectable or rising PSA value after surgery that is ≥ 0.2 ng/ml with a second confirmatory level ≥ 0.2 ng/ml;
6) a restaging evaluation in the patient with a PSA recurrence may be considered;
7) physicians should offer salvage radiation therapy to patients with PSA or local recurrence after radical prostatectomy in whom there is no evidence of distant metastatic disease;
8) patients should be informed that the effectiveness of radiation therapy for PSA recurrence is greatest when given at lower levels of PSA; and
9) patients should be informed of the possible short-term and long-term urinary, bowel and sexual side effects of radiation therapy, as well as the potential benefits of controlling disease recurrence.
In addition to Drs. Valicenti and Thompson, authors of the The Adjuvant and Salvage Radiotherapy After Prostatectomy: ASTRO/AUA Guideline include Eric A. Klein, MD, of the Cleveland Clinic; S. Larry Goldenberg, MD, of the Vancouver Prostate Centre at the University of British Columbia; Peter C. Albertsen, MD, of the University of Connecticut Health Center; Jeff M. Michalski, MD, MBA, FASTRO, of the Siteman Cancer Center at the Washington University School of Medicine in St. Louis; Mack Roach, III, MD, of the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco; Oliver Sartor, MD, of the Tulane University School of Medicine; Brian J. Davis, MD, PhD, of the Mayo Clinic; and Martha Faraday, PhD, of Four Oaks Inc.
"This guideline explicitly includes a multitude of significant clinical trial results from more than 20 years of thorough research," said Dr. Valicenti. "There is a critical need for evidence-based standards, recommendations and options to maximize our ultimate goal of increased patient survival and quality of life. This guideline is a compendium of the vast wealth of research available and provides a thorough treatment template for us to consider for prostate cancer patients after a radical prostatectomy."
"The work of the AUA and ASTRO staff, as well as our exceptional guideline panelists, was outstanding," said Dr. Thompson. "This guideline provides a very practical approach for the clinician to help guide in patient decision-making that will result in the very best patient outcomes."
"Many thanks to the dedicated efforts of Drs. Valicenti and Thompson for leading the extraordinary effort to issue this important document from both specialty organizations," said Michael L. Steinberg, MD, FASTRO, chairman of ASTRO's Board of Directors. "The Adjuvant and Salvage Radiotherapy After Prostatectomy: ASTRO/AUA Guideline is an essential tool for every practice as they determine the best treatment plan for prostate cancer patients after prostatectomy."