Predicting outcomes after early salvage radiation therapy for locally recurrent disease

A international, collaborative research group has but together a new nomogram designed to project outcomes at 5 years after early salvage radiation therapy (eSRT) for men with local disease recurrence after first-line surgery for localized prostate cancer. The research team included contributors from the Mayo Clinic (in Rochester, MN), the San Raffaele Scientific Institute (in Milan, Italy), and seven other institutions in Canada and across Europe.

The nomogram is based on data from 472 patients, all with lymph node-negative prostate cancer (pTxN0M0), who demonstrated local biochemical recurrence after their initial surgery. All patients received local eSRT to the prostate fossa while their PSA level was still ≤ 0.5 ng/ml, but had had two consecutive PSA values ≥ 0.2 ng/ml.

Here are the other relevant data provided by Briganti et al. in the abstract of their paper:

  • Average (mean) patient follow-up was 58 months.
  • After eSRT, the 5-year biochemical recurrence-free survival rate was 73.4 percent.
  • Pre-eSRT PSA level, pathologic stage, pathologic Gleason score, and the presence/absence of positive surgical margins were all associated with risk for biochemical recurrence after eSRT.
  • The new nomogram (the first to be able to predict outcomes after eSRT) had a discrimination rate of 0.74.

The accuracy of this new nomogram probably needs to be validated against data from an independent set of patients who meet similar management criteria (i.e., progression after surgery, TxN0M0 disease, and eSRT while PSA levels are ≤ 0.5 ng/ml). While one would obviously like to see a nomogram that could project 10-year outcomes in patients of this type, the data on which to model such a nomogram may be hard to find at this point in time.

We have contacted the lead author to try to find out whether there is any intent to make this nomogram accessible on line for physicians and patients.

5 Responses

  1. It will be interesting to see further reports from this group. It would also be interesting to know the kinds of radiation technology, including imaging and patient positioning/targeting, and related dosing that were provided.

  2. Would be also interesting to know if a percentage of patients received ADT.

  3. I don’t think that any of these patients did get ADT. They all had early salvage for localized recurrence. There would have been no good reason to give them ADT. If I had been constrcuting this nomogram, patients who had received ADT in conjunction with their radiation therapy would have been excluded as potentially ineligible.

  4. Glad I wasn’t one of their patients. Waiting until the PSA hits 0.2 is way too late; and allowing it to approach 0.5 is hopeless. That’s not “early.” Evidence is growing that salvage radiation therapy should be done before the PSA hits 0.1, and preferably before 0.05, especially with higher Gleason scores and positive margins. This is the one place that the ultra-sensitive PSA test is vital.

  5. Dear Tom:

    Men with higher Gleason scores and some men with positive margins are probably more appropriately treated with adjuvant radiation therapy as opposed to salvage radiation (regardless of their PSA level). Furthermore, a very great deal depends on individual patient factors, such as PSA kinetics and what the patient himself does or doesn’t want to do. I couldn’t possibly agree with you that every man whose PSA rises above 0.2 ng/ml post-surgery needs to have immediate radiation therapy. In some men (for example) that rise could have taken 5 years! And the patient may only have a life expectancy of another 5 years for reasons that have nothing to do with prostate cancer.

    There are no “absolutes” here. There are even men like Terry Herbert (the founder of the Yananow web site) who “broke all the rules” by not having treatment for clinically significant, localized prostate cancer in his late 40s nearly 20 years ago now and who, although he has had to take a few shots of an LHRH agonist along the way, are living a happy retirement without ever having to go through surgery or radiation therapy.

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