Salvage Treatments for the Local Recurrence of Prostate Cancer After Radiotherapy - Results of an International Multidisciplinary Survey.

Abstract

PURPOSE/OBJECTIVE(S)\nThe treatment of local recurrences of prostate cancer after radical radiation therapy (RT) varies widely. The aim of this study was to evaluate the international practice patterns and opinions from a multidisciplinary point of view.\n\n\nMATERIALS/METHODS\nA web-based survey was spread between 26 May 2020 and 28 February 2021 through social media and personal contacts, aiming to reach all countries where RT for prostate cancer is delivered. We sought to obtain a balanced feedback from radiation oncologists and urologists (the primary physicians who manage local recurrences after RT) from each country, as well as clinical and medical oncologists. A proportional representation of countries according to the number of RT centers was intended. The survey had a decision tree design, with a total of 45 questions.\n\n\nRESULTS\nWe received 1030 responders from 114 countries. There were 51.1% radiation oncologists, 37.2% urologists, 5.2% clinical oncologists and 5.3 % medical oncologists. Most respondents work in academic centers (56.3%), have more than 20 years experience in treating prostate cancer (56.4%) and at least 10 prostate cancer patients under active treatment/month (53.4%). Almost 17% of the respondents declared not using any salvage treatment in case of a local recurrence after RT. The main reasons of not recommending salvage prostatectomy were: concerns on safety (68%), efficacy (33.7%), local protocols (22.7%), or availability (22.7%). For those who chose to avoid re-irradiation, the reasons were concerns on safety (70.7%), efficacy (43.1%), local protocols (26.9%) or availability (10.8%). In case of cryotherapy and HI-FU, the main issue was availability (71.9%), followed by concerns on efficacy (41.5%), safety (25.7%), local protocols (20.5%) or reimbursement (12.3%). Those not recommending salvage treatments, reported as usually preferred option GnRH agonist (64%), antiandrogens (49%), active surveillance, (32%) chemotherapy (27%), or observation (24%). The most important factors considered as contraindication for salvage therapies mentioned by participants consider this for local recurrence after RT of prostate cancer were: life expectancy < 5 years (71.5%), no biopsy or imaging confirmation (61.1%), rectal late toxicity after first treatment (46.8%), coexisting relapse in the regional lymph nodes (33.8%). The following salvage treatments were used Often , Usually or Always : radical prostatectomy (48.9%), HDR-BT (37%), SBRT (36.6%), IMRT (25.4%), LDR-BT (18.4%), HI-FU (15.4%), proton therapy (12.5%). When making the treatment decision, 73.4% of the participants declared that they Always or Usually present the case in a tumor board.\n\n\nCONCLUSION\nSalvage treatments for recurrent prostate cancer after radical RT are frequently recommended. However, there are significant concerns on efficacy, safety and availability. Radical prostatectomy remains the preferred option, but re-irradiation is often used as an alternative.