Salvage Therapy for Prostate Cancer - Introduction and Treatment Decision-Making at the Time of Suspected Biochemical Recurrence after Radical Prostatectomy

Publication Date: February 19, 2024
Last Updated: February 29, 2024

Summary of Recommendations

Clinicians should inform patients that salvage radiation for a detectable prostate-specific antigen (PSA) after RP is more effective when given at lower levels of PSA. (Strong, B)
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For patients with a detectable PSA after RP in whom salvage radiation therapy (RT) is being considered, clinicians should provide salvage radiation when the PSA is ≤0.5 ng/mL. (Moderate, B)
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For patients with a detectable PSA after RP who are at high risk for clinical progression, clinicians may offer salvage radiation when PSA values are <0.2 ng/mL. (Conditional, C)
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Clinicians should inform patients that salvage radiation after RP poses inherent risks to urinary control, erectile function, and bowel function. These risks must be considered in the context of the risks posed by recurrent cancer along with patient life expectancy, comorbidities, and preferences to facilitate a shared decision-making (SDM) approach to management. (Clinical Principle, )
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Clinicians should use prognostic factors (e.g., PSA doubling time [PSADT], Gleason Grade Group, pathologic stage, surgical margin status, validated post-prostatectomy genomic classifier and/or positron emission tomography (PET) imaging results) to counsel patients with a detectable PSA about their risk of clinical progression. (Moderate, B)
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Clinicians may obtain ultrasensitive PSA following RP in patients who are at high risk of recurrence and in whom salvage RT would be considered. (Expert Opinion, )
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For patients who do not meet the AUA definition of biochemical recurrence (BCR) after RP (PSA ≥0.2 ng/mL) yet have a detectable ultrasensitive PSA, clinicians should confirm a rising trend in PSA before proceeding with therapy. (Expert Opinion, )
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In patients with a BCR after local therapy, clinicians may obtain a prostate-specific membrane antigen (PSMA)-PET in lieu of conventional imaging or after negative conventional imaging for further evaluation of clinical recurrence. (Conditional, C)
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For patients with BCR following RP in whom salvage radiation is being considered, the clinician should perform next generation molecular PET imaging. (Moderate, C)
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In patients with BCR following RP with PET/computed tomography (CT) positive pelvic nodal disease, the clinician should incorporate treatment of these positive findings in the radiation plan. (Moderate, C)
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In patients with BCR, clinicians may obtain a pelvic magnetic resonance imaging (MRI) in addition to a PET/CT for evaluation of local recurrence. (Conditional, C)
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In a patient with a BCR following RP, clinicians should not withhold salvage prostate bed RT in the setting of a negative PET/CT. (Expert Opinion, )
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Salvage Therapy for Prostate Cancer - Introduction and Treatment Decision-Making at the Time of Suspected Biochemical Recurrence after Radical Prostatectomy

Authoring Organizations

Publication Month/Year

February 19, 2024

Last Updated Month/Year

March 13, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

The summary presented herein covers recommendations on salvage therapy for recurrent prostate cancer intended to facilitate care decisions and aid clinicians in caring for patients who have experienced a recurrence following prior treatment with curative intent. This is Part I of a three-part series focusing on treatment decision-making at the time of suspected biochemical recurrence (BCR) after radical prostatectomy (RP). Please refer to Part II for discussion of treatment delivery for non-metastatic BCR after RP and Part III for discussion of evaluation and management of recurrence after radiotherapy (RT) and focal therapy, regional recurrence, and oligometastasis.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Keywords

prostate cancer, salvage therapy, Radical Prostatectomy, Biochemical Recurrence, BCR

Source Citation

Morgan, Todd M.*; Boorjian, Stephen A.; Buyyounouski, Mark K.; Chapin, Brian F.; Chen, David Y. T.; Cheng, Heather H.; Chou, Roger; Jacene, Heather A.; Kamran, Sophia C.; Kim, Sennett K.; Kirkby, Erin; Luckenbaugh, Amy N.; Nathanson, Ben J.; Nyame, Yaw A.; Posadas, Edwin M.; Tran, Phuoc T.; Chen, Ronald C. Salvage Therapy for Prostate Cancer: AUA/ASTRO/SUO Guideline Part I: Introduction and Treatment Decision-Making at the Time of Suspected Biochemical Recurrence after Radical Prostatectomy, Journal of Urology:  - Volume 0 - Issue 0 doi: 10.1097/JU.0000000000003892

Methodology

Number of Source Documents
164
Literature Search Start Date
July 21, 2022
Literature Search End Date
July 26, 2023