The American Urological Association (AUA), in partnership with the American Society for Radiation Oncology and Society of Urologic Oncology, released in February 2024 a clinical guideline focusing on salvage therapy for recurrent prostate cancer. This three-part series guideline is designed to assist clinicians in making informed care decisions for patients who experience cancer recurrence following initial treatment with curative intent.
Part I covers decision-making strategies at the time of suspected BCR after radical prostatectomy (RP). Part II focuses on treatment delivery for non-metastatic BCR after RP. Part III addresses the evaluation and management of non-metastatic recurrence after radiotherapy (RT) and focal therapy, regional recurrence, and metastatic recurrence identified through molecular imaging, as well as future treatment directions. Links to each part are available below for further reading.
Key Takeaways from the 2024 Guidelines:
- Guiding Treatment Choices for Suspected Biochemical Recurrence Following Primary Radical Prostatectomy
- For patients with detectable PSA after radical prostatectomy (RP), salvage radiation therapy is more effective at lower PSA levels, ideally ≤0.5 ng/mL, and may be considered for values <0.2 ng/mL in high-risk cases. Clinicians should discuss the potential risks to urinary, erectile, and bowel functions, and use prognostic factors to assess progression risk. Ultrasensitive PSA testing and advanced imaging, such as PSMA-PET and next-generation molecular PET, can aid in evaluation and treatment planning. Finally, treatment decisions should consider PSA trends and incorporate findings from imaging studies without withholding radiation based on negative PET/CT results.
- Strategies for Delivering Treatment for Non-Metastatic Biochemical Recurrence After Radical Prostatectomy
- For non-metastatic biochemical recurrence after primary radical prostatectomy, clinicians should consider adding androgen deprivation therapy (ADT) to salvage radiation therapy (RT) for patients with high-risk features. For those without high-risk features, radiation alone may be sufficient. ADT should typically last four to six months, potentially extending to 18-24 months for high-risk patients. Including regional lymph nodes in the radiation field may be considered but can increase side effects. The addition of docetaxel is not recommended, and intensified androgen receptor suppression should be limited to clinical trials for pN0 patients. Discussions with patients should address potential side effects and comorbidities.
- Approaches to Evaluating and Managing Non-Metastatic Recurrence Post-Radiation Therapy
- For patients with biochemical recurrence (BCR) following primary radiation therapy (RT) or ablative treatment who show no signs of metastatic disease and are eligible for local salvage options, a prostate biopsy is recommended to assess for local recurrence. If a biopsy confirms recurrence and local salvage therapy is appropriate, options such as radical prostatectomy (RP), cryoablation, high-intensity focused ultrasound (HIFU), or reirradiation should be discussed in a shared decision-making approach.
- Assessment and Treatment of Non-Metastatic Recurrence After Focal Therapy
- For patients considering salvage local therapy after focal ablation, clinicians should recommend whole gland treatment options such as radical prostatectomy (RP) or radiation therapy (RT).
- Managing Regional Recurrence
- For patients with pelvic nodal recurrence after primary radical prostatectomy (RP), clinicians should provide androgen deprivation therapy (ADT) alongside salvage radiation therapy (RT) to both the prostate bed and pelvic lymph nodes. For those with pelvic nodal recurrence after primary RT who did not previously receive pelvic nodal RT, salvage pelvic nodal RT combined with ADT is recommended. Salvage pelvic lymphadenectomy may be considered for patients with evidence of pelvic lymph node recurrence after RP or RT, though the oncologic benefit of surgery in this context remains uncertain and should be discussed with patients.
- Handling Metastatic Recurrence Identified Through Molecular Imaging
- For patients with regional or metastatic oligo recurrence detected after primary therapy (RP or RT), clinicians may consider stereotactic ablative radiotherapy (SABR) or metastasis-directed therapy (MDT), weighing the potential benefits against the risk of toxicity. For patients with biochemical recurrence (BCR) and non-regional disease identified on PET/CT but not visible on conventional imaging, salvage radiation therapy to the prostate bed may be omitted, and the uncertain role of systemic therapy should be discussed.
In conclusion, the 2024 AUA guidelines offer clear, evidence-based strategies for managing recurrent prostate cancer, focusing on tailored treatment based on individual risk, PSA levels, and imaging results. As the field continues to evolve with advancements in imaging and treatment technologies, these guidelines serve as a valuable resource for ensuring informed, patient-centered care.
Sign up for alerts and stay informed on the latest published guidelines and articles.
Copyright © 2024 Guideline Central, all rights reserved.