Postprostatectomy adjuvant versus salvage radiotherapy

Abstract

BACKGROUNDRadiotherapy (RT) has been used with success after radical retropubic prostatectomy (RRP), both in the adjuvant and salvage settings. The purpose of the current investigation was to systematically compare adjuvant versus salvage RT in a manner that incorporates both treatment efficacy and complications.METHODSA literature review was performed of reports of post‐RRP salvage and adjuvant RT, and 12 trials comprising 1060 patients met the appropriate inclusion criteria. The biochemical failure‐free survival in each study/arm was tabulated, and these values were entered into a model to compute an unadjusted number‐needed‐to treat (NNT). RT complications were then considered, accounting for differences in toxicity incidences in the salvage versus adjuvant setting, to compute complication‐adjusted NNTs. In all the trials, the signs and magnitudes of the NNTs obtained were used to compare adjuvant with salvage RT.RESULTSThe absolute NNT analysis showed an advantage of adjuvant compared with salvage RT. After adjustment for RT complications, however, the advantage shifted to salvage RT. This transition point from superiority of adjuvant RT to superiority of salvage RT was sensitive to the estimated incidence and severity of RT side effects.CONCLUSIONSAdjuvant post‐RRP RT was advantageous in comparison to salvage RT if the side effects of RT were estimated to be negligible. However, with moderate incidence/severity of RT side effects, salvage RT was advantageous. The findings herein must be tested in a prospective study in which both health‐related quality of life and cancer control are documented in patients receiving adjuvant versus salvage post‐RRP RT. Further work is needed to better estimate parameters entered into the model to determine the precise transition point between adjuvant and salvage RT with modern RT techniques. Cancer 2005. © 2005 American Cancer Society.

Three Years of Salvage IMRT for Prostate Cancer: Results of the Montpellier Cancer Center

“…It is also questionable whether adjuvant radiotherapy, systematically given to high-risk patients with no known recurrence, is a better cost-effective option than salvage treatment given to relapsing patients. From a clinical point of view, the superiority of one approach over the other will necessarily imply minimizing side effects [25]. The recently updated results of the EORTC 22911 trial presented at ESTRO 29 (Barcelona) and at ASTRO 2010 did not show any overall or metastasis-free survival benefit of adjuvant radiotherapy, possibly due to the use of early salvage therapy in the control arm.…”

Long-term complications in men who have early or late radiotherapy after radical prostatectomy.

“…[10][11][12][13] In one study, adjuvant RT was only found to be beneficial over salvage RT if the side effects were negligible, emphasizing the importance of side effects on treatment timing. 18 In addition, long-term follow-up from the European Organization for Research and Treatment of Cancer (EORTC) trial 22911 has shown that clinical progression-free survival rates previously reported with adjuvant RT were no longer clinically significant; moreover, in patients over 70, adjuvant RT had a detrimental effect on progression-free and overall survival. 2 The decision to treat with adjuvant or salvage RT is perhaps more controversial than ever and should include patient preference, demographics, pathologic features and risk of complications.…”