AUA and ASTRO Issue Joint Guidelines for Postsurgery Radiotherapy

Nick Mulcahy

May 10, 2013

For the first time ever, the 2 medical organizations most responsible for the treatment of prostate cancer in the United States have issued a joint guideline.

The American Society for Radiation Oncology (ASTRO) and the American Urological Association (AUA) announced the publication of a guideline on radiation therapy after prostatectomy (both adjuvant and salvage) at the AUA 2013 Annual Scientific Meeting held in San Diego, California.

"The purpose of this guideline is to provide a clinical framework for the use of radiotherapy after prostatectomy in patients with and without evidence of prostate cancer recurrence," write the guideline authors, led by ASTRO's Richard K. Valicenti, MD, from the University of California Davis Comprehensive Cancer Center in Sacramento, and the AUA's Ian M. Thompson, MD, from the Cancer Therapy and Research Center at the University of Texas Health Science Center at San Antonio.

"We hope the guidelines will facilitate discussion between physicians and patients about the use of radiation therapy," Dr. Valicenti told Medscape Medical News in an interview. He said that the discussion should include the benefits, adverse events, and quality of life associated with the treatment.

The data-dense document considered 324 research articles and is the fruit of the Radiotherapy After Prostatectomy Panel, a collaboration that was created in 2011 by the 2 groups. Only studies in which prostate-specific antigen (PSA) data were provided for at least 75% of patients were included in the guideline.

The recommended strategies and approaches are derived from evidence-based and consensus-based processes in the reviewed articles. "This document constitutes a clinical strategy and is not intended to be interpreted rigidly," write the guideline authors.

The literature that undergirds the guideline has a "major limitation" — the "lack of a large number of randomized controlled trials to guide decision-making in patients with and without evidence of recurrence," they note.

There was a similar data problem regarding the appropriate use of androgen-deprivation therapies (ADT), so the guidelines include no instructions about ADT.

The lack of top-flight data means that the guideline has only 1 statement with an evidence strength of grade A (high quality, high certainty). In short, the guideline's statements are based mostly on less stellar quality/certainty data or on expert opinion.

The guideline document offers 9 major statements, which fall into different categories — clinical principles (wide agreement by urologists), recommendations (grade C; low-quality and certainty evidence), standards (grade A or B; high/moderate-quality and certainty evidence), and options (nondirectives).

Nine Guideline Statements

1 Inform patients undergoing radical prostatectomy for localized prostate cancer of the potential for adverse pathologic findings that portend a higher risk for cancer recurrence (clinical principle).
2 Inform patients with adverse pathologic findings (including seminal vesicle invasion, positive surgical margins, and extraprostatic extension) that adjuvant radiation therapy reduces the risk for biochemical (PSA) recurrence, local recurrence, and clinical progression of cancer, compared with radical prostatectomy alone (clinical principle).
3 Offer adjuvant radiation therapy to patients with adverse pathologic findings at the time of prostatectomy because of the above-stated benefits (standard; evidence strength, grade A).
4 Inform patients that PSA recurrence after surgery is associated with a higher risk for the development of metastatic prostate cancer or death from the disease (clinical principle).
5 Define biochemical recurrence as a detectable or rising PSA value after surgery that is at least 0.2 ng/mL, with a second confirmatory level that is at least 0.2 ng/mL (recommendation; evidence strength, grade C).
6 Consider a restaging evaluation in the patient with a PSA recurrence (option; evidence strength, grade C).
7 Offer salvage radiation therapy to patients with PSA or local recurrence after radical prostatectomy in whom there is no evidence of distant metastatic disease (recommendation; evidence strength, grade C).
8 Inform patients that the effectiveness of radiation therapy for PSA recurrence is greatest when given at lower levels of PSA (clinical principle).
9 Inform patients of the possible short-term and long-term urinary, bowel, and sexual adverse effects of radiation therapy, as well as the potential benefits of controlling disease recurrence (clinical principle).


"This guideline provides a very practical approach for the clinician to help guide in patient decision-making that will result in the very best patient outcomes." Dr. Thompson said in a press statement.

The new guideline will be published in the August 1 print issue of the International Journal of Radiation Oncology * Biology * Physics, the official scientific journal of ASTRO, and in the August print issue of The Journal of Urology, the official journal of the AUA.


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