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ASTRO, AUA update guideline on radiotherapy after prostatectomy
The American Society for Radiation Oncology and American Urological Association have updated their joint clinical guideline on adjuvant and salvage radiotherapy after prostatectomy to reflect new research findings.
The new recommendations define the role of adjuvant radiotherapy, hormone therapy and genomic classifiers.
“As research in prostate cancer evolves and improves, data continue to accumulate in support of radiotherapy following radical prostatectomy,” Richard K. Valicenti, MD, FASTRO, co-chair of the guideline panel and professor and chairman of radiation oncology at the UC Davis Comprehensive Cancer Center, said in a press release. “We now know that radiotherapy and the combination of hormone therapy with radiation, following radical prostatectomy, have contributed to even more favorable outcomes for patients than seen previously.”
A joint panel formulated the 10-statement ASTRO/AUA Adjuvant and Salvage Radiotherapy after Prostatectomy Guideline based on 294 peer-reviewed articles published between 1990 and 2012 related to the use of radiotherapy after prostatectomy.
The first guideline amendment, in April 2018, incorporated 155 published references from 1990 to 2017 into the evidence base.
In one major update, the panel amended Guideline Statement 2 — which received a “Clinical Principles and Expert Opinion” grade, suggesting insufficient evidence — to incorporate data from three randomized, controlled trials assessing the use of adjuvant radiotherapy after radical prostatectomy. These findings included new long-term data from the ARO 96-02 trial, which evaluated adjuvant radiotherapy vs. a “wait-and-see” approach.
This statement recommends that clinicians inform patients with post-prostatectomy adverse pathologic findings — such as seminal vesicle invasion, positive surgical margins and extraprostatic extension — that adjuvant radiotherapy may confer benefits compared with radical prostatectomy alone. These include decreased risk for biochemical recurrence, local recurrence and clinical progression of cancer.
Patients also should also be notified that there is less conclusive evidence of the effect of adjuvant radiotherapy on future metastases and OS. One of the three randomized controlled trials suggested a benefit, but the other two did not. The guideline noted, however, that these trials were not intended to identify significant deceases in metastasis or death with adjuvant therapy.
“Evidence from three well-established randomized trials now confirm significant improvements in biochemical recurrence-free survival among patients with adverse pathological features with the use of adjuvant therapy,” panel co-chair Ian Thompson, MD, professor and chairman of the urology division at The University of Texas Health Sciences Center in San Antonio, said in the press release. “Our expectation is this guideline is fully aligned to the latest science and provides physicians with a relevant blueprint for the use of radiotherapy after prostatectomy.”
Guideline Statement 9 was updated — with grade A evidence — to incorporate data from two randomized controlled trials, RTOG 9601 and GETUG-AFU 16, that assessed the impact of hormonal therapy on OS as well as biochemical and clinical progression among patients who received salvage radiotherapy after prostatectomy.
These studies provided strong enough evidence to recommend hormonal therapy for patients eligible for salvage radiotherapy. However, clinicians should inform patients about the potential benefits and risks of this treatment, specifically the greater freedom from disease progression observed in both trials, and improvement in OS documented in RTOG 9601.
The panel also added new information about genomic classifiers as potential predictors of treatment efficacy and called for further study in this area.
According to Valicenti, the amended guideline is the culmination of years of study.
“With the current update, this collaborative guideline now reflects nearly 3 decades of multidisciplinary research,” he said. – by Jennifer Byrne
Reference:
Thompson IM, et al. Adjuvant and salvage radiotherapy after prostatectomy: ASTRO/AUA Guideline. Available at: www.auanet.org/guidelines/prostate-cancer-adjuvant-and-salvage-radiotherapy-guideline. Accessed on May 3, 2019.
Disclosures: Thompson reports scientific study/trial support from the NCI-SWOG; consultant roles with the Cancer Prevention and Research Institute of Texas and Ferring (expired); and meeting participant/lecturer roles with American Association for Cancer Research, ASCO, Canary Foundation, Columbia University, Cornell University, Doctors Hospital Renaissance, Ireland Urologic Society, Laredo Medical Center, Texas Urological Society, and Urologic Society of Australia. Valicenti reports no relevant financial disclosures. Please see the guideline for all other authors’ relevant financial disclosures.
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Three randomized controlled trials of adjuvant radiation after radical prostatectomy have all shown that men with adverse pathological features may benefit from radiation therapy with respect to a lower likelihood of a PSA recurrence, local recurrence and clinical progression. The updated guidelines have simply reiterated this benefit based on longer-term outcomes of the two most recent trials.
The new recommendation — also based on long-term results of several randomized trials — is to offer androgen deprivation therapy in conjunction with adjuvant radiation to lower the risks for progression and improve survival, and represents a change in standard practice. Men who choose ADT plus adjuvant radiation are likely to reduce their risk for disease recurrence and progression, and perhaps enjoy a survival advantage, but may experience adverse side effects typical of these therapies, making the choice of adjuvant vs. salvage radiation one that should be individualized for each patient based on a thorough discussion of the potential benefits and risks.