The role of androgen ablation in patients with biochemical or local failure after definitive radiation therapy: a survey of practice patterns of urologists and radiation oncologists in the United States

Decision-making Processes among Prostate Cancer Survivors with Rising PSA Levels: Results from a Qualitative Analysis

BACKGROUND

Prostate cancer survivors with a rising prostate-specific antigen (PSA) level have few treatment options, experience a heightened state of uncertainty about their disease trajectory that might include the possibility of cancer metastasis and death, and often experience elevated levels of distress as they have to deal with a disease they thought they had conquered. Guided by self-regulation theory, the present study examined the cognitive and affective processes involved in shared decision making between physicians and patients who experience a rising PSA after definitive treatment for prostate cancer.

METHODS

In-depth interviews were conducted with 34 prostate cancer survivors who had been diagnosed with a rising PSA (i.e., biochemical failure) within the past 12 months. Survivors were asked about their experiences and affective responses after being diagnosed with a rising PSA and while weighing potential treatment options. In addition, patients were asked about their decision-making process for the initial prostate cancer treatment.

RESULTS

Compared with the initial diagnosis, survivors with a rising PSA reported increased negative affect following their diagnosis, concern about the treatability of their disease, increased planning and health behavior change, heightened levels of worry preceding doctor appointments (especially prior to the discussion of PSA testing results), and a strong reliance on physicians' treatment recommendations.

CONCLUSIONS

Prostate cancer survivors' decision-making processes for the treatment of a rising PSA are markedly different from those of the initial diagnosis of prostate cancer. Because patients experience heightened distress and rely more heavily on their physicians' recommendations with a rising PSA, interactions with the health care provider provide an excellent opportunity to address and assist patients with managing the uncertainty and distress inherent with rising PSA levels.

RapidArc, intensity modulated photon and proton techniques for recurrent prostate cancer in previously irradiated patients: a treatment planning comparison study

Background

A study was performed comparing volumetric modulated arcs (RA) and intensity modulation (with photons, IMRT, or protons, IMPT) radiation therapy (RT) for patients with recurrent prostate cancer after RT.

Methods

Plans for RA, IMRT and IMPT were optimized for 7 patients. Prescribed dose was 56 Gy in 14 fractions. The recurrent gross tumor volume (GTV) was defined on ¹⁸F-fluorocholine PET/CT scans. Plans aimed to cover at least 95% of the planning target volume with a dose > 50.4 Gy. A maximum dose (D_Max) of 61.6 Gy was allowed to 5% of the GTV. For the urethra, D_Max was constrained to 37 Gy. Rectal D_Median was < 17 Gy. Results were analyzed using Dose-Volume Histogram and conformity index (CI₉₀) parameters.

Results

Tumor coverage (GTV and PTV) was improved with RA (V_95% 92.6 ± 7.9 and 83.7 ± 3.3%), when compared to IMRT (V_95% 88.6 ± 10.8 and 77.2 ± 2.2%). The corresponding values for IMPT were intermediate for the GTV (V_95% 88.9 ± 10.5%) and better for the PTV (V_95%85.6 ± 5.0%). The percentages of rectal and urethral volumes receiving intermediate doses (35 Gy) were significantly decreased with RA (5.1 ± 3.0 and 38.0 ± 25.3%) and IMPT (3.9 ± 2.7 and 25.1 ± 21.1%), when compared to IMRT (9.8 ± 5.3 and 60.7 ± 41.7%). CI₉₀ was 1.3 ± 0.1 for photons and 1.6 ± 0.2 for protons. Integral Dose was 1.1 ± 0.5 Gy*cm³ *10⁵ for IMPT and about a factor three higher for all photon's techniques.

Conclusion

RA and IMPT showed improvements in conformal avoidance relative to fixed beam IMRT for 7 patients with recurrent prostate cancer. IMPT showed further sparing of organs at risk.

Current salvage methods for recurrent prostate cancer after failure of primary radiotherapy

We reviewed the current salvage methods for patients with local recurrent prostate cancer after primary radiotherapy (RT), using a search of relevant Medline/PubMed articles published from 1982 to 2008, with the following search terms: 'radiorecurrent prostate cancer, local salvage treatment, salvage radical prostatectomy (RP), salvage cryoablation, salvage brachytherapy, salvage high-intensity focused ultrasound (HIFU)', and permutations of the above. Only articles written in English were included. The objectives of this review were to analyse the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method. There are four whole-gland re-treatment options (salvage RP, salvage cryoablation, salvage brachytherapy, salvage HIFU) for RT failure, although others might be in development or investigations. Salvage RP has the longest follow-up with acceptable oncological results, but it is a challenging technique with a high complication rate. Salvage cryoablation is a feasible option, especially using third-generation technology, whereby the average biochemical disease-free survival rate is 50-70% and there are fewer occurrences of severe complications such as recto-urethral fistula. Salvage brachytherapy, with short-term cancer control, is comparable to other salvage methods but depends on cumulative dosage limitation to target tissues. HIFU is a relatively recent option in the salvage setting. Both salvage brachytherapy and HIFU require more detailed studies with intermediate and long-term follow-up. As these are not prospective, randomized studies and the definitions of biochemical failure varied, there are limited comparisons among these different salvage methods, including efficacy. In the focal therapy salvage setting, the increased use of thermoablative methods for eligible patients might contribute to reducing complications and maintaining quality of life. The problem to effectively salvage patients with locally recurrent disease after RT is the lack of diagnostic examinations with sufficient sensitivity and specificity to detect local recurrence at an early curable stage. Therefore, a more strict definition of biochemical failure, improved imaging techniques, and accurate specimen mapping are needed as diagnostic tools. Furthermore, universal selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological efficacy and least comorbidity.

[PSA and follow-up after treatment of prostate cancer]

A first serum total PSA assay is recommended during the first three months after treatment. When PSA is detectable, PSA assay should be repeated three months later to confirm this elevation and to estimate the PSA doubling time (PSADT). In the absence of residual cancer, PSA becomes undetectable by the first month after total prostatectomy: less than 0.1 ng/ml (or less than 0.07 ng/ml) for the ultrasensitive assay method and less than 0.2 ng/ml for the other methods. In the presence of residual cancer, PSA either does not become undetectable or increases after an initial undetectable period. A consensus has been reached to define recurrence as PSA greater than 0.2 ng/ml confirmed on two successive assays. After external beam radiotherapy, PSA can decrease after a mean interval of one to two years to a value less than 1 ng/ml (predictive of recurrence-free survival). Biochemical recurrence after radiotherapy is defined by an increase of PSA by 2 ng or more above the PSA nadir, whether or not it is associated with endocrine therapy. After endocrine therapy, the PSA nadir is correlated with recurrence-free survival. PSA is decreased for a mean of 18 to 24 months followed by a rise in PSA, corresponding to hormone-independence. The time to recurrence or the time to reach the nadir and the PSA doubling time after local therapy with surgery or radiotherapy have a diagnostic value in terms of the site of recurrence, local or metastatic and a prognostic value for survival and response to complementary radiotherapy or endocrine therapy. A PSADT less than eight to 12 months is correlated with a high risk of metastatic recurrence and 10-year mortality. The histological and biochemical characteristics in favour of local recurrence are Gleason score less or equal to seven (3+4), elevation of PSA after a period greater than 12 months and PSADT greater than 10 months. In other cases, recurrence is predominantly metastatic. The risk of demonstrating metastasis in the case of biochemical recurrence after total prostatectomy and before endocrine therapy depends on the PSA level and the PSADT. No consensus has been reached concerning the indication for complementary investigations by bone scan and abdominopelvic CT in patients with biochemical recurrence after treatment of localized cancer without endocrine therapy. However, when PSADT greater than six months, the risk of metastasis is less than 3% even for PSA greater than 30 ng/ml. When PSADT less than six months and PSA greater than 10 ng/ml, the risk of metastasis is close to 50%.

Management of asymptomatic rise in prostatic-specific antigen in patients with prostate cancer

Biochemical failure after curative-intent therapies is an increasingly common dilemma confronting patients and physicians. No definition of biochemical failure exists that can be applied to all forms of treatment and that is not to some degree affected by the follow-up interval, pretreatment prognostic factors, or the frequency of prostatic-specific antigen (PSA) testing. Available imaging techniques lack sensitivity in detection of occult micrometastases. Prognostic factors such as tumor characteristics and PSA kinetics should be considered when recommending second-line therapies. For those patients with suspected localized recurrence, second-line treatment with salvage therapies may provide long-term disease control. Hormonal therapy, although most commonly employed for PSA recurrence, is of palliative benefit only. Currently, the most appropriate therapeutic intervention for asymptomatic patients with evidence of biochemical failure remains undefined.

Locally ablative therapies for primary radiation failures: a review and critical assessment of the efficacy

A significant number of men with prostate cancer will experience biochemical failure following treatment with primary radiation therapy. For patients with biopsy-proven recurrent cancer confined to the prostate, local salvage therapy may be a potentially curative treatment option. Most men, however, do not undergo local salvage therapy owing to difficulties in diagnosis as well as concerns over treatment-related complications in the salvage setting. Recently, improvements in technique and technology have substantially reduced the morbidity associated with locally ablative therapies, resulting in an increased interest in the use of minimally invasive therapies such as brachytherapy, cryotherapy, and high-intensity focused ultrasound in the salvage setting. Although these treatments are well tolerated, concerns remain over incomplete and inadequate treatment with locally ablative therapies. Future studies are required to appropriately select candidates for salvage ablative therapies and to determine the long-term oncologic efficacy of these treatments.

Survival benefit for early hormone ablation in biochemically recurrent prostate cancer

PURPOSE

To determine whether early initiation of androgen ablation in patients with biochemically recurrent prostate cancer, but without clinically evident metastases, is associated with improved overall or disease-specific survival. To describe subgroups, based on PSA kinetics, which are most likely to benefit from early androgen ablation.

MATERIALS AND METHODS

A retrospective cohort of 124 patients, who were definitively treated by external beam radiotherapy between 1988 and 1999, and subsequently received androgen ablation for biochemical (92 patients) or clinically metastatic (32 patients) failure, was reviewed. Median follow-up time was 6.2 years. Overall survival, disease-specific survival, and hormonal control were examined and compared for patients whose hormone ablation was started early (prostate-specific antigen [PSA] <or=15 ng/ml or PSA doubling time >7 months) or late in the course of their biochemical failure.

RESULTS

All patients had biochemical response to hormone initiation, with a median PSA nadir of 0.05 ng/ml. Early initiation of hormone ablation resulted in statistically significant improvement in all outcome measures. Multivariate analysis indicated that PSA doubling time at hormone initiation was the most consistent predictor of outcome. The 5-year overall survival was 78% for patients whose androgen ablation was initiated at doubling time <or=7 months and 93% for patients when initiated at doubling time >7 months. Mean survival improved from 84.9 +/- 4.6 (doubling time <or=7) to 115.3 +/- 8.4 months (doubling time >7). Survival for patients started on hormones with doubling time <5 months was similar to that of patients with clinical metastases.

CONCLUSIONS

This survival benefit justifies the use of androgen ablation in patients whose doubling time approaches 7 months. A randomized trial is needed to confirm these findings, investigate potential benefit for patients with longer doubling times, and gather data on the morbidity of early hormone ablation, including quality of life issues.

The anatomical and pathological characteristics of irradiated prostate cancers may influence the oncological efficacy of salvage ablative therapies

PURPOSE

Recurrent or radioresistant prostate cancer occurs in approximately 30% of men receiving primary radiotherapy. For men who are candidates for local salvage therapy, the oncological efficacy of ablative therapies may be affected by the anatomical and pathological features of cancers within irradiated prostate glands. We characterized and mapped the prostate cancers in our series of whole mount salvage radical prostatectomy specimens.

MATERIALS AND METHODS

A total of 47 salvage radical prostatectomies were performed at our institution between 2000 and 2004. Detailed pathological data, including the anatomical distribution of cancers, were obtained from 46 whole mount salvage radical prostatectomy specimens.

RESULTS

A total of 70 cancer foci were identified in 46 specimens. Of the specimens 93% had cancer foci at the apex. The median minimum cancer-to-urethra distance was smallest at the apex (4.1 mm) and greatest at the base (13.8 mm). More than 65% of patients had cancer 5 mm or less from the urethra and 7% of patients had cancer directly involving the urethra. Nearly half of all patients had evidence of extraprostatic disease.

CONCLUSIONS

The anatomical and pathological features in our study demonstrate that a significant portion of irradiated cancers are pathologically advanced and distributed in regions of the prostate (apical and periurethral) which are at risk for undertreatment using current ablative therapies. Our findings raise serious concerns regarding the oncological efficacy of such treatment modalities. Long-term studies without the use of hormonal therapy are needed to determine the oncological efficacy of salvage ablative therapies in patients with radiorecurrent or resistant prostate cancer.

Feasibility of high-dose-rate brachytherapy salvage for local prostate cancer recurrence after radiotherapy: The University of California–San Francisco experience

PURPOSE

The aim of this study was to evaluate the feasibility and safety of salvage high-dose-rate (HDR) brachytherapy for locally recurrent prostate cancer after external beam radiotherapy (EBRT).

METHODS AND MATERIALS

We retrospectively analyzed 21 consecutively accrued patients undergoing salvage HDR brachytherapy for locally recurrent prostate cancer after EBRT between November 1998 and December 2005. After pathologic confirmation of locally recurrent disease, all patients were treated with 36 Gy in six fractions using two transrectal ultrasound-guided HDR prostate implants, separated by 1 week. Eleven patients received neoadjuvant hormonal therapy immediately presalvage, whereas none received adjuvant hormonal therapy postsalvage. Median follow-up time from recurrence was 18.7 months (range, 6-84 months). Determination of subsequent biochemical failure after brachytherapy was based on the definition by the American Society for Therapeutic Radiology and Oncology.

RESULTS

Based on the Common Terminology Criteria for Adverse Events (CTCAE version 3), 18 patients reported Grade 1 to 2 genitourinary symptoms by 3 months postsalvage. Three patients developed Grade 3 genitourinary toxicity. Maximum observed gastrointestinal toxicity was Grade 2; all cases spontaneously resolved. The 2-year Kaplan-Meier estimate of biochemical control after recurrence was 89%. Thirteen patients have achieved a PSA nadir < or =0.1 ng/ml, but at the time of writing this endpoint has not yet been reached for all patients. All patients are alive; however 2 have experienced biochemical failure, both with PSA nadirs > or =1, and have subsequently been found to have distant metastases.

CONCLUSIONS

Salvage HDR prostate brachytherapy appears to be feasible and effective.

Quality of life 2 years after salvage cryosurgery for the treatment of local recurrence of prostate cancer after radiotherapy

PURPOSE

Previous research has raised concerns that although salvage cryosurgery may be an effective treatment to prevent the progression of prostate cancer after radiotherapy failure, the quality of life cost many be so severe as to prevent its acceptance as a viable treatment. The present study's purpose was to further the understanding of the quality of life outcomes of salvage cryosurgery.

MATERIALS AND METHODS

A total of 46 men with locally recurrent prostate cancer after radiotherapy were recruited to participate in a prospective Phase II clinical trial using salvage cryosurgery. There were 2 questionnaires (i.e., the European Organization of Research and Treatment of Cancer QLQ C30 and the Prostate Cancer Index) administered before cryosurgery, and at 1.5, 3, 6, 12, 18, and 24 months after treatment.

RESULTS

Quality of life returned to preoperative levels by 24 months after cryosurgery in all domains, with the exception of urinary and sexual functioning. At 24 months, 29% of men reported urinary bother as a moderate-to-big problem, and 56% reported sexual bother as a moderate-to-big problem.

CONCLUSIONS

To our knowledge, this is the first study to evaluate prospectively men's quality of life for 2 years after salvage cryosurgery for locally recurrent prostate cancer after radiotherapy. Long-term impairments in quality of life appear to be limited to the sexual and urinary function domains. Overall quality of life appears to be high. These results support salvage cryosurgery as a viable treatment option.

Update on cryotherapy for prostate cancer in 2006

PURPOSE OF REVIEW

With the recent introduction of novel, minimally invasive procedures for the treatment of prostate cancer, cryotherapy has become a feasible option as a viable alternative to traditional radical surgery and radiation therapy. In this review we update recent data concerning the basic science of cryobiology, technical trends, oncologic results and complications of this procedure.

RECENT FINDINGS

As a result of better understanding of tumor cryodestruction at a molecular level, refinements in cryotechniques and improved patient selection, the results of cryotherapy are becoming more promising. Furthermore, the dramatic decrease in the number of complications after modern cryotherapy leads to a better quality of life, which may be a preferable option, especially for elderly patients with comorbidities. Current trends towards nerve-sparing and focal cryoablation are also discussed. Recent advances in cryobiology open up new opportunities to apply cryotherapy in combination with chemotherapy or radiotherapy for patients with intermediate or high-risk cancers.

SUMMARY

Potential directions for future developments in cryosurgery include concepts to reduce side effects such as minimizing cryodamage of the neurovascular bundles (nerve-sparing procedure), and focal ablation of a specific tumor site in patients in whom saturation biopsy supports unifocal prostate cancer.

Salvage prostate cryoablation after primary interstitial brachytherapy failure: a feasible approach

Salvage treatment for recurrent prostate cancer remains a very difficult and challenging field in urologic oncology. The introduction of minimally invasive surgical procedures such a targeted cryoablation brings some hope with its feasibility and efficacy to become a potentially curable treatment. We present the case of a 75-year-old male with prostate cancer treated primarily by brachytherapy, who developed late locally recurrent disease that was successfully treated with targeted salvage cryoablation.

Long-term oncologic results of salvage radical prostatectomy for locally recurrent prostate cancer after radiotherapy

PURPOSE

Salvage radical prostatectomy (RP) may potentially cure patients who have isolated local prostate cancer recurrence after radiotherapy (RT). We report the long-term cancer control associated with salvage RP in a consecutive cohort of patients and identify the variables associated with disease progression and cancer survival.

METHODS AND MATERIALS

A total of 100 consecutive patients underwent salvage RP with curative intent for biopsy-confirmed, locally recurrent, prostate cancer after RT. Disease progression after salvage RP was defined as a prostate-specific antigen (PSA) level of > or =0.2 ng/mL or by initiation of androgen deprivation therapy. Cancer-specific mortality was defined as active clinical disease progression despite castration. Cox regression analysis was used to evaluate these endpoints. The median follow-up from RT was 10 years (range, 3-27 years) and from salvage RP was 5 years (range, 1-20 years).

RESULTS

Overall, the 5-year progression-free probability was 55% (95% confidence interval, 46-64%), and the median progression-free interval was 6.4 years. The preoperative PSA level was the only significant pretreatment predictor of disease progression in the multivariate analysis (p = 0.01). The 5-year progression-free probability for patients with a preoperative PSA level of <4, 4-10, and >10 ng/mL was 86%, 55%, and 37%, respectively. The 10-year and 15-year cancer-specific mortality after salvage RP was 27% and 40%, respectively. The median time from disease progression to cancer-specific death was 10.3 years (95% confidence interval, 7.6-12.9). After multivariate analysis, the preoperative serum PSA level and seminal vesicle or lymph node status correlated independently with disease progression.

CONCLUSIONS

Greater preoperative PSA levels are associated with disease progression and cancer-specific death. Long-term control of locally recurrent prostate cancer after definitive RT is possible when salvage RP is performed early in the course of recurrent disease.

Intervention after PSA failure: examination of intervention time and subsequent outcomes from a prospective patient database

PURPOSE

To investigate timing of intervention for solitary biochemical relapse following external beam radiation therapy (EBRT) for localized prostate cancer, and to assess the impact on survival.

METHODS AND MATERIALS

Of 1499 men treated with EBRT from 1994 to 2000, 544 men had prostate-specific antigen (PSA) relapse by the Vancouver Criteria. Patients with near-simultaneous clinical relapse (n = 79) were excluded, leaving 465 for analysis. Pretreatment prognostic factors, the time that biochemical relapse was realized (trigger PSA time), and postrelapse doubling time (PSAdt) were examined for effect on the timing of intervention and cause-specific survival (CSS).

RESULTS

Median actuarial time from trigger-PSA time to intervention was 30 months. The only factor associated with early intervention on multivariate analysis (MVA) was faster PSAdt (p < 0.0001). Not significant were initial PSA, Gleason score, T stage, or adjuvant androgen ablation use or duration. Seventy-five percent of interventions occurred with PSAdt faster than 12 months. The 5-year CSS was 89%. Faster PSAdt (p = 0.0007), higher Gleason score (p = 0.018), and earlier intervention (p = 0.0006) were significantly associated with increased prostate cancer death on MVA. The 5-year CSS is 19% where the PSAdt was <3 months, 84% where 3-6 months, 93% where 6-12 months, and 98% where >12 months (p < 0.0001).

CONCLUSIONS

Men with a biochemical relapse post-EBRT with PSAdt >1 year had excellent 5-year CSS (98%). Rapid PSAdt is associated with increased mortality on MVA. The association of earlier intervention with increased mortality may be due to the selection of those with occult metastasis for early intervention.

Salvage therapy for locally recurrent prostate cancer after external beam radiotherapy

The greatest obstacle in the cure of patients with locally recurrent prostate cancer after radiation therapy is the lack of early detection markers. The majority of patients who are candidates for local salvage therapy have locally advanced disease, precluding successful salvage therapy. A low pretreatment prostate specific antigen (PSA) has shown to be a favorable prognostic variable for disease progression, regardless of the specific local salvage therapy used. Of all the local salvage treatment options for these patients, we believe that salvage radical prostatectomy (RP) offers patients the greatest likelihood of a cure. The salvage RP results approach those achieved with standard RP for patients of similar pathologic stage. When patients are treated early in the course of recurrent disease (preoperative PSA < 10 ng/mL), an estimated two-thirds of patients will be disease-free 5 years after salvage RP alone. With better patient selection and continued technical modifications, the morbidity associated with salvage RP has substantially improved. Perioperative complications approach those observed with standard RP and approximately two-thirds of patients will recover urinary continence. Select patients may also recover functional erections when nerve-sparing techniques are used. Salvage cryotherapy and brachytherapy are minimally invasive alternatives to salvage RP. The cancer control results of these procedures appear to be inferior to results achieved with salvage RP. Each of these procedures is associated with significant morbidity and do not appear to provide a clear advantage over salvage RP in terms of posttreatment complications, urinary continence, and erectile function. A long-term cure is possible for patients with locally recurrent prostate cancer after radiation therapy. Local salvage therapy must be instituted early to be successful in the course of progressive disease.

Recurrent prostate cancer following external beam radiotherapy

All patients who undergo curative therapy for prostate cancer should be followed for a prolonged period of time to determine tumor control and treatment toxicity for quality assurance purposes. Follow-up duties may be reasonably shared between the oncologist and the family doctor or urologist: however, it is probable that some follow-up information specific to the irradiated patient will be lost unless the oncologist maintains regular contact with the patient, especially in the first 5 years of follow-up when late radiation effects are most likely to appear. There is no strong evidence that patients stop being at risk for recurrence at any time after treatment, and because PSA testing is an accurate, simple, and inexpensive method of determining post-RT tumor status, it is recommended that periodic PSA measurements be continued for life. In the absence of a rising PSA, all other tests and visits are unnecessary to determine post-RT tumor control. Because DRE has been shown to be of limited utility in follow-up of irradiated patients, it should be possible to effectively follow patients remotely. This could be done by asking patients to have PSA tests done, forward the results to their physicians, and report treatment toxicity when it occurs. Only abnormal results would trigger an office visit. This strategy is being evaluated in clinical trials. The alternative is to delegate the follow-up to the primary-care physician with guidelines as to when referral back is required. Follow-up frequency, and the most beneficial follow-up investigations vary from scenario to scenario, and are influenced by the likelihood of relapse, time to relapse, and planned intervention. These decisions are influenced in turn by the initial presentation--either with high or low risk factors--and by the patient's general state of health at completion of EBRT. Effective follow-up also requires active patient cooperation that only can be achieved after discussion of the goals of follow-up with the patient and with the patient's full understanding of the process. The follow-up strategy proposed in Fig. 1 is most suitable for a fit patient with low or intermediate risk factors who wishes to consider all salvage options should he relapse, or for the high-risk individual in situations in which the probability of systemic relapse is of major concern. Young patients with very adverse risk factors may benefit from even closer follow-up in the early years after EBRT and the elderly or frail may require only occasional visits to record or treat treatment toxicity and to ensure clinical non-progression.

Selecting a secondary treatment

There is compelling evidence that early hormonal therapy prolongs life in many stages of prostate cancer. Large-scale trials to answer this question have not yet been conducted in surgically treated patients or in patients with PSA-only relapse. Thus, many physicians and patients use early hormone therapy in PSA-only relapse. Many unique new agents are being tested in this population and may offer benefits. Patients and physicians are encouraged to participate in such trials, with hormone therapy reserved for subsequent use. Following failure of primary hormone therapy, a standard algorithm of care exists: antiandrogen withdrawal, use of alternative or first-line anti-androgens. ketoconazole. and chemotherapy. At each interval, clinical trials should be offered since none of these maneuvers are proven to prolong life.

What to do for prostate cancer patients with a rising PSA?--A survey of Australian practice

PURPOSE

To document current Australian management of asymptomatic prostate cancer patients with prostate-specific antigen (PSA) relapse after radical treatment or considered unsuitable for radical treatment.

MATERIALS AND METHODS

Four case scenarios-postprostatectomy PSA relapse, postradiotherapy (RT) with a slow or a rapidly rising PSA level, or no radical treatment-were presented. Management preferences, including (where relevant) RT, androgen ablation either immediate or delayed until a PSA rise or symptomatic progression, and other approaches, were identified. The preferred methods of androgen ablation were noted.

RESULTS

One hundred eighteen informative replies out of 324 e-mailed surveys were received. For postprostatectomy PSA relapse, 59% of respondents favored salvage RT. For post-RT with a slow or a rapidly rising PSA level and treatment of nonradical patients, there was no clear consensus of opinion, with respondents divided among the different options. A diverse range of PSA levels was cited for delayed intervention, with values ranging from 0.8 to 100 ng/mL. PSA doubling time proved a more consistent criterion for determining intervention. Most respondents favored the use of a luteinizing hormone-releasing hormone agonist as first-line androgen ablation, although patient choice was recognized as important in all decision making.

CONCLUSIONS

A lack of available evidence underlies the diversity of opinion regarding the management of asymptomatic prostate cancer patients with a rising PSA. The need for randomized controlled trials in this area is highlighted.

Impact of target volume coverage with Radiation Therapy Oncology Group (RTOG) 98-05 guidelines for transrectal ultrasound guided permanent Iodine-125 prostate implants

PURPOSE

Despite the wide use of permanent prostate implants for the treatment of early stage prostate cancer, there is no consensus for optimal pre-implant planning guidelines that results in maximal post-implant target coverage. The purpose of this study was to compare post-implant target volume coverage and dosimetry between patients treated before and after Radiation Therapy Oncology Group (RTOG) 98-05 guidelines were adopted using several dosimetric endpoints.

MATERIALS AND METHODS

Ten consecutively treated patients before the adoption of the RTOG 98-05 planning guidelines were compared with ten consecutively treated patients after implementation of the guidelines. Pre-implant planning for patients treated pre-RTOG was based on the clinical target volume (CTV) defined by the pre-implant TRUS definition of the prostate. The CTV was expanded in each dimension according to RTOG 98-05 and defined as the planning target volume. The evaluation target volume was defined as the post-implant computed tomography definition of the prostate based on RTOG 98-05 protocol recommendations. Implant quality indicators included V(100), V(90), V(100), and Coverage Index (CI).

RESULTS

The pre-RTOG median V(100), V(90), D(90), and CI values were 82.8, 88.9%, 126.5 Gy, and 17.1, respectively. The median post-RTOG V(100), V(90), D(90), and CI values were 96.0, 97.8%, 169.2 Gy, and 4.0, respectively. These differences were all statistically significant.

CONCLUSIONS

Implementation of the RTOG 98-05 implant planning guidelines has increased coverage of the prostate by the prescription isodose lines compared with our previous technique, as indicated by post-implant dosimetry indices such as V(100), V(90), D(90). The CI was also improved significantly with the protocol guidelines. Our data confirms the validity of the RTOG 98-05 implant guidelines for pre-implant planning as it relates to enlargement of the CTV to ensure adequate margin between the CTV and the prescription isodose lines.

Controversies in the systemic management of patients with evidence of biochemical failure following radical prostatectomy

The management of patients with evidence of a detectable prostate-specific antigen (PSA) following prostatectomy is an increasingly common and difficult issue for patients and clinicians alike. In the setting in which biochemical failure is believed representative of early systemic failure, therapeutic options primarily involve the use of hormonal therapy. Extrapolating results of early vs. delayed hormonal therapy from studies of patients with more advanced prostate cancer is problematic. Antiandrogen monotherapy and intermittent androgen deprivation are increasingly popular approaches, although their ultimate utility remains unproven. This patient subset is an optimal one in which to conduct clinical trials to both define the role of hormonal therapy and to investigate novel, non-hormonal approaches. The most appropriate therapeutic intervention for patients with evidence of biochemical failure following radical prostatectomy remains undefined.