Latest Salvage Radiation News

 Some recent discoveries in salvage radiation

Early salvage RT after prostatectomy improves outcomes: https://www.cancertherapyadvisor.com/home/news/conference-coverage/american-society-of-clinical-oncology-genitourinary-asco-gu/asco-gu-2022/early-salvage-radiation-after-surgery-improves-mfs-in-recurrent-prostate-cancer/  (Research continues to confirm that earlier is better if you need SRT.)

When to Add ADT to Early or Late Salvage Radiation: https://www.urotoday.com/video-lectures/prostate-cancer-genomic-classifier/video/2269-when-to-add-adt-to-early-or-late-salvage-radiation-dan-spratt.html (I didn't have ADT, otherwise known as hormone therapy, but in higher-risk cases it makes sense)

Salvage Radiotherapy versus Observation for Biochemical Recurrence: https://pubmed.ncbi.nlm.nih.gov/35159007/. (Salvage radiation was associated with better long-term survival, both in terms of being free of metastatic disease and overall survival.)

My History of Prostate Cancer.

A long time ago, in a pelvis far, far away:




Age 38
8 Dec 2000
bothered by frequent urination, went to primary care phys.
PSA 4.5
PCP said prostate was boggy
referred to Urologist
Biopsy Ordered

Jan 2001
Biopsy:  negative for cancer, findings consistent with prostatitis

Age 39
16 Jul 2001
PSA 4.1

20 March 2002
PSA 6.1
START Cipro 500mg daily for 3 wks, Motrin 800 mg daily

Age 40
30 May 2002
PSA 5.7
Free PSA 11.9%
CONTINUE Motrin
Urologist believes probably prostatitis

30 Sep 2002
PSA 7.3
Free PSA 11.3%
START Avodart
STOP Motrin
ORDER Biopsy

November 2002
Biopsy:  negative for cancer, but PIN III found

31 Jan 2003
PSA 2.2
Stop Avodart

Age 41
03 Sep 2003
PSA 4.9
Restart Avodart

23 Jan 2004
PSA 2.2
Continue Avodart

Age 42
24 July 2004
PSA 2.5
Continue Avodart

26 Jan 2005
PSA 3.3
Continue Avodart

29 Apr 2005
PSA 2.9
Continue Avodart

Age 43
11 Jan 2006
PSA 4.8 (on Avodart)
Abnormal DRE
Biopsy ordered

7 Feb 2006
Biopsy finds cancer
PIN also found
No perineural invasion
Gleason 3+4
20% on right
5% on left

Age 44
14 April 2006
SURGERY
Robotic prostatectomy
Positive margin at apex and left lobe
No perineural invasion identified
Extension into capsule, but not through
Gleason 3+4
70% of gland involved
stage t2c NX MX


16 May 2006
PSA less than 0.1

15 Aug 2006
PSA 0.2

14 Dec 2006
PSA 0.6

REFERRED FOR RADIATION

Day before radiation commenced, PSA = 0.7

Radiation Jan-Mar 2007.  PSA quickly fell to less than 0.1 and remains there as of early 2013, now age 51.
No side effects from radiation at this point.

Latest Salvage Radiation News

A small, in-house study from the Graduate School of Medicine in Kyoto, Japan found multiple, independent risk factors for recurrence after salvage radiation (SRT). These were:

• Gleason at or above 8
• PSA nadir (low point) after SRT at or above 0.04 ng/ml
• Negative surgical margins

They found that 77.8% of patients in their study with zero risk factors were free of PSA progression five years later.  50% of patients with one risk factor were progression-free, and only 6.7% of patients with two or three risk factors were progression-free at the 5 year mark. 

In my own case, I was okay on the Gleason and surgical margins, but I don't know my PSA nadir to that level of specificity. 

This was an interesting little study, but I trust Andrew Stephenson's much larger one a lot more.

Kyoto blossoms. Photo: jmurawski  Creative Commons license.

Outcome of salvage radiotherapy for biochemical failure

Outcome of salvage radiotherapy for biochemical failure after radical prostatectomy with or without hormonal therapy.

Not sure how I missed this one--probably because I usually search "radiation" and not "radiotherapy"--but a study from MD Anderson in 2005 reaffirmed the idea that the earlier you start, the better, with salvage. Like Stephenson et al at Cleveland Clinic, they found that the best results were obtained when the man's pre-radiation PSA was 0.5 or less.

The MD Anderson study put men into two groups: favorable and unfavorable. Those in the favorable group had pre-RT PSAs of 0.5 or less, and positive margins. Unfavorable included everyone else. 81.7% of those in the favorable group had no PSA progression 5 years later, compared to 61.7% in the unfavorable.

I'm in the unfavorable group. The 61.7% chance of being progression free at 5 years (which would be spring of 2012 for me) matches up well with other research I've read.
___________________________________________________________

Int J Radiat Oncol Biol Phys. 2005 Sep 1;63(1):134-40.

Outcome of salvage radiotherapy for biochemical failure after radical prostatectomy with or without hormonal therapy.

Cheung R, Kamat AM, de Crevoisier R, Allen PK, Lee AK, Tucker SL, Pisters L, Babaian RJ, Kuban D.

Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA. mrcheung@mdanderson.org

BACKGROUND: This study analyzed the outcome of salvage radiotherapy for biochemical failure after radical prostatectomy (RP). By comparing the outcomes for patients who received RT alone and for those who received combined RT and hormonal therapy, we assessed the potential benefits of hormonal therapy. PATIENTS AND METHODS: This cohort was comprised of 101 patients who received salvage RT between 1990 and 2001 for biochemical failure after RP. Fifty-nine of these patients also received hormone. Margin status (positive vs. negative), extracapsular extension (yes vs. no), seminal vesicle involvement (yes vs. no), pathologic stage, Gleason score, pre-RP PSA, post-RP PSA, pre-RT PSA, hormonal use, radiotherapy dose and technique, RP at M. D. Anderson Cancer Center, and time from RP to salvage RT were analyzed. Statistically significant variables were used to construct prognostic groups. RESULTS: Independent prognostic factors for the RT-alone group were margin status and pre-RT PSA. RP at M. D. Anderson Cancer Center was marginally significant (p = 0.06) in multivariate analysis. Pre-RT PSA was the only significant prognostic factor for the combined-therapy group. We used a combination of margin status and pre-RT PSA to construct a prognostic model for response to the salvage treatment based on the RT group. We identified the favorable group as those patients with positive margin and pre-RT PSA < or =" 0.5" p =" 0.03).">

PMID: 16111581 [PubMed - indexed for MEDLINE]

Predicting the Outcome of Salvage Radiation Therapy

I've been following the work of Dr. Andrew Stephenson, of the Cleveland Clinic, who for several years has been trying to predict the outcome of salvage radiation, like the treatments I had this spring.

He, along with experts in the field like Scardino, Kattan, Slawin, and others, have just published an important paper in the Journal of Clinical Oncology. You can read a summary of the work here.

I obtained the full text of the document (you can too--just go to your nearest public library and tell them you need interlibrary loan). The full title is " Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer after Radical Prostatectomy" from JCO, May 2007, pp. 2035-41.

Stephenson and his colleagues looked at 1,540 patients across 17 medical centers in North America. All of these patients underwent salvage radiation (an attempt to rescue the patient when surgery fails to eradicate prostate cancer). The researchers created a nomogram to predict the outcome of salvage radiation. The nomogram is in the public domain and will be available soon in an easy to use web version at http://www.nomograms.org soon.

In general, Stephenson found as he did in earlier work, that the earlier you can get started with salvage radiation, the better. He writes "The 6-year response to SRT among patients treated at PSA levels of 0.50 n/mL or less appears to be durable because only two progression events were observed after 6 years among 32 patients at risk at 6 years (median follow-up, 90 months)" (p. 2037). Besides the pre-radiation PSA, other important variables are Gleason score, PSA doubling time (PSADT), surgical margins, hormone therapy administered along with or before radiation, and lymph node metastasis. In earlier work, Stephenson had found that of patients at high risk (because of a Gleason >= 8, or rapid PSA doubling time) many could still benefit from radiation, especially if they had positive surgical margins like I did. This new study validated this idea.


In my case, the nomogram shows I have about a 55-57% chance of being progression free at 6 years out from radiation. Those are pretty good odds, I think. The flow chart in the article, which for me goes like this:

Pre-RT PSA <= 2.0, Gleason 4-7, Positive margins, doubling time <=10 months and that comes out to 57% probability of being progression free at 6 years. This study goes back to way before the days of IMRT, though, and the average man in the study got less radiation than I did. So I think my odds are probably better than 57%, since the targeting of radiation and dose escalation are much better these days than was the case for most of the study participants. Of course, if my cancer was already systemic, then the radiation probably didn't do much good. I should get some idea soon--I had blood drawn yesterday and I get the results in one week. So check back, dear reader, on or after June 15--will this blogger get on with his life and career? Or will he start putting affairs in order? ?