COMMENTARY

A Three-Pronged Attack on Recurring Prostate Cancer: Ready for Prime Time?

Gerald Chodak, MD

Disclosures

November 29, 2018

Hello. I'm Dr Gerald Chodak for Medscape. Today's topic is: managing men with a rising prostate-specific antigen (PSA) after radical prostatectomy.

Pollack and coworkers[1] recently presented their 10-year results from a randomized trial involving almost 1800 men. The patients were divided into three groups. One group received radiation to the prostate bed; the second group received radiation to the prostate bed plus 4-6 months of androgen deprivation using an LHRH agonist and an antiandrogen; and the third group received prostate bed radiation, radiation to the pelvic lymph nodes, and the hormone therapy.

The inclusion criteria were the following: At 6 weeks after prostatectomy, the PSA could not be higher than 1 ng/mL; nothing could be palpable in the prostate bed or if [a mass was palpable], it had to be biopsy negative; lymph nodes had to be negative at the time of surgery or less than 1.5 cm in diameter seen on MRI or CT; and the PSA level could reach no higher than 2 ng/mL at entry.

What were the results? At 5 years, the progression-free survival, defined as a rise in PSA of 2 ng/mL from nadir, was significantly better in the men who received the combination therapy of radiation to the pelvis and to the prostate bed, plus the hormone therapy. Progression-free survival was 72% in the men who received the radiation alone; 83% in the men who received radiation to the bed plus the hormones; and 89% in the men who received all three treatments.

What does this mean going forward? First, investigators had results at 8 years that did not reach statistical significance. There was a benefit for the combination therapy, but in the men whose PSAs were 1 ng/mL or less, the benefit disappeared.

So we have to ask ourselves: Are these results sufficient to make recommendations going forward? I don't think so. First, giving radiation to the pelvis of a man whose PSA is low—meaning, less than 1 ng/mL—could result in overtreatment, and the treatment did have a higher risk for side effects. Second, the results have not yet reached statistical significance for metastasis-free survival, and a longer follow-up is needed to see if that does occur. Third, we still have no information about overall survival, and it's still preliminary to conclude that a benefit for metastasis-free survival will definitely translate into a benefit for overall survival.

Nevertheless, going forward, it is reasonable to have a conversation with your patients about these early results. And men whose PSA is higher can be offered the more aggressive therapy, but realizing that the results are not definitive.

I look forward to your comments. Thank you.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....