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Optimizing the Timing of Salvage Postprostatectomy Radiotherapy and the Use of Concurrent Hormonal Therapy for Prostate Cancer.

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Publication Date
2018-05-15
ICR Author
Parker, Chris
Author
Kishan, AU
Tendulkar, RD
Tran, PT
Parker, CC
Nguyen, PL
Stephenson, AJ
Carrie, C
Type
Journal Article
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Abstract
<h4>Context</h4>Currently, salvage radiotherapy (SRT) is the only known curative intervention for men with recurrent disease following prostatectomy. Critical issues in the optimal selection and management of men being considered for SRT include the threshold prostate-specific antigen (PSA) value at which to initiate treatment (ie, pre-SRT PSA) and the role of concurrent hormonal therapy (HT).<h4>Objective</h4>To review the published evidence pertaining to the optimal timing for SRT and the role of concurrent HT.<h4>Evidence acquisition</h4>MEDLINE (via PubMed), EMBASE, the Cochrane Central Register of Controlled Trials, and guideline statements from professional organizations were queried from January 1, 2000 through January 10, 2018.<h4>Evidence synthesis</h4>Thirty-three independent reports, including two randomized trials evaluating HT with SRT, were identified. Retrospective data suggest that SRT initiation at lower pre-SRT PSA levels is associated with better clinical outcomes. Prospective data suggest an overall survival benefit with concurrent HT that manifests during long-term follow-up, with the caveat that hypothesis-generating subgroup analyses suggest that this benefit may be limited to patients with higher pre-SRT PSA levels. Patients with adverse risk factors, such as Gleason grade group 4-5 disease, are likely to benefit the most from earlier SRT initiation and/or the use of HT.<h4>Conclusions</h4>Given the limitations of the available data, it is imperative that physicians participate in shared decision-making, with the recommendation tailored for each man's desire to maximize oncologic benefit (with a risk of overtreatment) versus potential quality-of-life optimization (with a risk of undertreatment). Within that framework, a significant body of retrospective data supports initiation of SRT at low pre-SRT PSA values, without an arbitrary absolute threshold. Prospective data suggest a benefit of HT, but this benefit may be greatest in patients with a pre-SRT PSA that is higher than the typical level in most patients receiving "early" SRT. Further research is necessary before absolute recommendations can be made.<h4>Patient summary</h4>Two ways to potentially improve outcomes following salvage radiotherapy for prostate cancer that recurs after prostatectomy are to start treatment at a lower prostate-specific antigen level and to use concurrent hormonal therapy. Our review suggests that the available evidence is imperfect, but highlights that both measures are likely to improve clinical outcomes in general, but perhaps not uniformly and/or consistently for all patients. Physician-patient shared decision-making and further research are critical.
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https://repository.icr.ac.uk/handle/internal/4380
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  • Other ICR Research
Licenseref URL
http://www.rioxx.net/licenses/all-rights-reserved
Version
AM
Version of record
10.1016/j.euo.2018.02.008
Subject
Humans
Prostatic Neoplasms
Neoplasm Recurrence, Local
Kallikreins
Prostate-Specific Antigen
Antineoplastic Agents, Hormonal
Treatment Outcome
Salvage Therapy
Survival Analysis
Physician-Patient Relations
Decision Making
Aged
Middle Aged
Male
Randomized Controlled Trials as Topic
Neoplasm Grading
Chemoradiotherapy
Time-to-Treatment
Language
eng
Date accepted
2018-02-12
License start date
2018-05-15
Citation
European urology oncology, 2018, 1 (1), pp. 3 - 18

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