Immediate adjuvant therapy for men with positive surgical margins after RP

There are no absolute guidelines as to which patients who have positive surgical margins after a radical prostatectomy (RP) are most appropriate for immediate adjuvant radiation therapy (with or without neoadjuvant and/or adjuvant hormone therapy).

Swanson and Lerner have carried out an exhaustive review of the available literature in an attempt to identify specific risk factors that — in combination with the presence of positive surgical margins — would generally suggest the necessity for immediate adjuvant therapy as compared to later salvage therapy.

They made the assumption that patients with a greater than 70 percent risk for biochemical failure after radical prostatectomy were appropriate candidates for immediate adjuvant therapy. Based on that (reasonable) assumption, and based on their careful review, they suggest that the presence of any one of the following factors places patients with positive surgical margins into the > 70 percent risk for biochemical progression category (i.e., at high risk for relatively short-term biochemical progression):

  • Positive lymph nodes
  • Positive seminal vesicles
  • A pre-surgical PSA level of > 20 ng/ml
  • A pathologic Gleason score of > 7

In addition, the authors note the following:

  • Many men with positive surgical margins and a Gleason score of 7 fall into the > 70 percent risk category.
  • All men with positive surgical margins and one of the above criteria should be carefully considered as candidates for immediate adjuvant therapy.
  • There are no “absolutes” regarding who should or shouldn’t be given immediate adjuvant therapy, since clinical experience and judgment (in addition to the patient’s personal wishes) are still critical factors in making such decisions.

3 Responses

  1. The concept of undergoing adjuvant therapies for men with high-risk cases of prostate cancer is waning. At the time I thought I was sort of pioneering when I decided on adjuvant radiation and adjuvant hormone therapy after surgery proved that I had at least two of the above risk factors. A few years later and it seems the controversy is now more about doing nothing after finding those risk factors.

    I had a terrible post-surgical pathology but I have had a terrific response to surgery + adjuvant RT + adjuvant HT. I know many like myself who have had similar results. In fact, I know many men with pT3b disease who have had adjuvant therapies and many who did not; it seems that all the remissions are with the adjuvant therapies. Whether that leads to improved prostate cancer-specific survival or not is another question. But it looks good so far … Most studies I am seeing do support that theory …

  2. Tony:

    I think that a lot of the controversy surrounds the ages and the life expectancies of the individual patients concerned.

    Using a highly aggressive form of therapy (radical surgery with adjuvant RT + HT) in someone like you with pT3b disease, and Gleason 9, in your early to mid 40s seems to come with a great deal more potential for long-term remission (and a greater ability to handle the aggressive treatment) than might be the case for someone with the same pathologic characteristics in their mid 70s with a concomitant — albeit mild — heart condition. This does not mean that older men in general shouldn’t be considering early adjuvant therapy based on the criteria laid out above. What it means is that every patient needs to be carefully considered as an individual and treated in the way that will maximize the likelihood of long-term remission while simultaneously not opening up the patient to unnecessary risks for serious side effects and complications of therapy.

  3. I agree with that. Thus far I am not in the high side effects category but I know that can change down the line. Most of the men I see doing adjuvant therapies are younger like myself. They probably went with the same thoughts that I did in that I did not like the fact that long-term outcomes in the prostate cancer world are not predictable based on short-term study data. At the age of 44 all I could find from studies were 10-year biochemical failure rates. Today I can find some longer studies but the ones I see where the patient does go with adjuvant therapies all seem to point to improved outcomes. But for a man at age 70 when diagnosed ~ clearly adjuvant therapies come with higher risks. But at least this patient has less need for them, too.

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