A review of salvage treatment options for disease progression after radiation therapy for localized prostate cancer

Abstract

Recurrence of prostate cancer after initial treatment with radiation therapy is highly dependent on pretreatment risk group and unfortunately, a proportion of patients fail primary treatment. The treatment of recurrence after primary radiation is rapidly changing with advances in imaging and it is important to distinguish those with a local failure from those with distant failure. If disease remains locally confined, salvage treatment with a variety of techniques can still provide a potential cure. Patients with distant failure are often treated with androgen deprivation, or in those with a shorter life expectancy, conservative management. In patients with a higher burden of metastatic disease, there is emerging evidence that chemotherapy and advanced androgen therapy can improve survival. We review the relevant literature on available salvage treatment options and appropriate patient selection for patients with recurrent prostate cancer after radiation therapy. We report on the efficacy and adverse effects of the currently available local salvage modalities including salvage radical prostatectomy, high dose rate and low dose rate brachytherapy, cryotherapy, high intensity focused ultrasound, and stereotactic body radiation therapy. We additionally discuss diagnosis of oligometastatic disease on imaging and current approaches to treatment with either radiation or surgery. While a full review of chemotherapy and advanced androgen therapies is beyond the scope of this article we briefly discuss their use in the treatment of newly diagnosed recurrence after radiation.

Functional Outcomes after Local Salvage Therapies for Radiation-Recurrent Prostate Cancer Patients: A Systematic Review

“…Biochemical recurrence is estimated to affect 32–57% in control-dose RT and 16–43% in escalated dose RT after 10-years follow-up [ 10 , 11 ]. BCR is, in fact, a robust surrogate of clinical disease recurrence, including local recurrence and distant metastasis [ 12 , 13 , 14 ].…”

“…Nonetheless, when local recurrence is detected, patients may benefit from local salvage therapies, including salvage RT, cryoablation, high-intensity focal ultrasound (HIFU), and RP [ 12 ]. However, salvage therapies are underutilized due to the limited high-quality data, unclear survival benefits, and treatment-related adverse effects [ 18 , 19 , 20 ].…”

Efficacy and toxicity outcomes for patients treated with focal salvage high dose rate brachytherapy for locally recurrent prostate cancer

“…In our study, where the use of and duration of ADT was at clinician discretion, 74% of patients received ADT and this was for 6 months in most cases. ADT was used in many previous studies of whole gland salvage brachytherapy but it was not used in several studies of focal salvage HDR and LDR brachytherapy [7,10,13,14,39,40]. The rationale for this approach could be that salvage brachytherapy might avoid/delay the need to commence ADT and its associated toxicities and impact on quality of life [10].…”

“…Most patients with recurrent PCa are treated with palliative androgen deprivation therapy (ADT) [5]. However, for patients with confirmed isolated local disease, salvage therapies including low dose rate (LDR) and high dose rate (HDR) brachytherapy, high-intensity focussed ultrasound (HIFU), cryoablation and RP represent a radical alternative with the aim of local disease control and preventing development of metastases [6,7].…”

Focal salvage treatment for radiorecurrent prostate cancer: A magnetic resonance-guided stereotactic body radiotherapy versus high-dose-rate brachytherapy planning study

“…In more than half of the patients with a recurrence detected on imaging, the recurrence is confined to the prostate and/or seminal vesicles [3] . A treatment option for local radiorecurrent prostate cancer is magnetic resonance imaging (MRI)-guided focal salvage high-dose-rate brachytherapy (FS-HDR-BT) [4] , [5] . With FS-HDR-BT, patients are treated in a single treatment session with a dose of 19 Gy to the clinical target volume (CTV).…”