There is a role for adjuvant therapy after surgery for prostate cancer

Ofer Yossepowitch, M.D. Rabin Medical Center

Petah Tikva, Israel

Adjuvant XRT Salvage XRT

Chris, you should really consider exercising more frequently…..

Level I evidence : adjuvant RT following radical prostatectomy in men with high risk pathological features (ECE, SVI, PSM) is associated with superior clinical outcomes compared to watchful waiting :

improves BCR free rates (SWOG, EORTC, ARO)

clinical progression free survival (SWOG, EORTC)

overall survival (SWOG)

No level I evidence : salvage RT = adjuvant RT

… Physicians should offer adjuvant RT to patients with adverse pathological findings at prostatectomy, including seminal vesicle invasion, positive surgical margins or extra prostatic extension, because of demonstrated reduction in BCR, LR and clinical progression…

Ref: Freedland et al, J Clin Oncol, 2014

Thompson et al, JAMA, 11/2006 - aRT reduces BCR rates

Thompson et al, J Urol, 2009 – aRT improves survival

Bolla et al, Lancet, 2005 – aRT reduces BCR rates

Bolla et al, Lancet, 2012 – aRT reduces LR rates

Low use of immediate postoperative RT

aRT

sRT

Ref: Maurice et al, J urol, 2015; Sineshaw et al Eur Urol 2015

NCDB - 57,448 PCa patients diagnosed with pT3 and/or PSM

4136 (7.5%) – aRT ; 1637 (2.8%) - sRT

NCDB - Between 2005 and 2011, receipt of postoperative RT

decreased steadily from 9.1% to 7.3% (ptrend < 0.001).

Fox Chase : No increase in the proportion of patients treated with

aRT from 2003-2011 (Martin JM et al, J Natl Comp Can Netw 2015)

Underutilization of adjuvant RT

Harvard : aRT recommendations increased (13.5% 15.8%) after

the reporting of a survival benefit in 2009, BUT, its overall

utilization remains low (Mahal B et al, Clin Genitourinary Can 2015)

1. Some men with adverse pathological features are likely to be cured left untreated …particularly if I was the surgeon..

2. Salvage RT at the earliest onset of PSA relapse is a legitimate equal alternative…

Urologists “beliefs” :

Ref: Kim et al, Urology 2013

Variation in treatment recommendation of aRT by physician specialty

Adjusted odds ratios in the recommendation of aRT from Rad Oncol

(ref – urologists)

Can we identify those who might derive the highest benefit from aRT ?

1. Some men with adverse pathological features are likely to be cured left untreated …particularly if I was the surgeon..

2. Salvage RT at the earliest onset of PSA relapse is a legitimate equal alternative…

Urologists “beliefs” :

Younger patients

High Gleason score (8-10)

Extensively involved surgical margins (high GS @ PSM site)

Higher number of risk factors

Reference: Van der qwast, JCO, 2007; Freedland, JCO, 2014; Herranz-Amo, Actas Urol Esp, 2016; Savdie, BJU, 2012; Bolla, Lancet, 2012

aRT will provide the highest clinical benefit in :

Louis C.K.

OF COURSE - adjuvant RT is the most appropriate clinical approach to men with high risk pathological features

BUT MAY BE ….

1. Some men with adverse pathological features may be

cured left untreated …

2. Salvage RT at the earliest onset of PSA relapse is a legitimate alternative…