'Immense' change prompts new guideline to address salvage therapy for prostate cancer
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The American Urological Association released a clinical practice guideline pertaining to salvage therapy for men with prostate cancer.
The guideline, issued in collaboration with American Society for Radiation Oncology and Society of Urologic Oncology (SUO), includes 30 recommendations for treating men with localized disease who underwent definitive local therapy and experienced PSA recurrence.
The guidelines address six topics:
- treatment decision-making at the time of suspected biochemical recurrence after primary radical prostatectomy;
- treatment delivery for nonmetastatic biochemical recurrence after primary radical prostatectomy;
- assessment and management of suspected nonmetastatic recurrence after radiation therapy;
- evaluation and management of suspected nonmetastatic recurrence after focal therapy;
- evaluation and management of regional recurrence; and
- management for molecular imaging metastatic recurrence.
The American Urological Association (AUA) Salvage Therapy for Prostate Cancer Panel — chaired by Todd M. Morgan, MD, chief of the division of urologic oncology at Michigan Medicine — drafted the guideline.
“There are a number of studies showing that many patients have PSA recurrence after initial surgery or radiation but don’t undergo salvage therapy, even though these salvage therapies are often curative,” Morgan told Healio. “Sometimes when they do undergo salvage therapy, it’s at a point that is later than what we would recommend. That means we potentially are missing a cure for some of these patients.”
Healio spoke with Morgan about the need for the new guideline, the key recommendations, and the potential implications of this guidance on prostate cancer management and outcomes.
Healio: What prompted the development of this guideline?
Morgan: AUA and ASTRO issued adjuvant and salvage therapy guidelines in 2013, and there has been an immense amount of change in the field since then. Pivotal clinical trials have shown there is really no role for adjuvant therapy after prostatectomy as long as appropriate early salvage therapy is given when indicated. There also have been huge technological developments, such as the availability of prostate-specific membrane antigen (PSMA) PET imaging, which plays a major role in this space. With all the new data, changes in clinical practice and our understanding of what the best standard of care should look like, we needed to develop new guidelines.
Healio: What percentage of men treated for localized disease develop recurrence or metastasis?
Morgan: Roughly 30% to 40% of patients who initially undergo treatment for clinically localized prostate cancer will need some type of salvage therapy due to biochemical recurrence. Part of the reason it’s that high is because we now understand that we don’t need to treat patients with more favorable-risk prostate cancer. Therefore, the risk profile of patients undergoing primary treatment for localized prostate cancer is much higher and there’s a reasonable chance that one form of treatment may not be enough.
Healio: What types of scenarios do these recommendations cover, and can you highlight one or two key recommendations?
Morgan: A good deal of the recommendations address that scenario of the patient who is initially treated with radical prostatectomy and then has biochemical recurrence. Starting from that moment when they have a rising PSA, we talk about the use of PSMA PET imaging and risk stratification in that setting. Patients have a hugely variable risk for progressing to metastatic disease when they have that initial PSA recurrence. It depends on many factors, including stage and grade, as well as the timing of the PSA recurrence and the pace of the PSA change. Those factors are spelled out in the guidelines.
Treatment options obviously are a major part of this guideline. We describe how to use PSMA PET imaging and how that information can help tailor the use of salvage radiation, which is the standard of care in the setting of PSA recurrence after prostatectomy. We address the use of androgen deprivation therapy, both in terms of the duration and timing of that therapy, as well as who should receive it based on some of these clinical risk questions. Additionally, we discuss the use of metastasis-directed therapy. When should we be targeting specific sites of metastasis? How might we do that?
Those are some of the “bread and butter” scenarios that these guidelines speak to.
Another scenario the guidelines address is the patient who undergoes initial radiation therapy with or without hormone therapy. We talk about how we define PSA recurrence after radiation, and how we think about our evaluation and management of patients in that clinical context.
Healio: What impact will this guideline have on prostate cancer management?
Morgan: One of the biggest clinical problems in this space is the underuse of salvage therapy with a biochemical recurrence after initial treatment. Patients with a PSA recurrence typically do need some type of salvage therapy. There are options in different clinical contexts, but the bottom line is that we need to be discussing salvage therapy — specifically early salvage therapy — with these patients and offering it to them. This hopefully will improve survival and reduce rates of metastasis in the long term for patients at the highest risk.
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For more information:
Todd M. Morgan, MD, can be reached at tomorgan@med.umich.edu.
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