Just out: the 2013 salvage radiation guidelines by which doctors treat us

[I.P. Freely]

Adjuvant and Salvage Radiotherapy after Prostatectomy: ASTRO/AUA Guideline

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.

Methods

A systematic review of the literature using the Pubmed, Embase and
Cochrane databases (search dates 1/1/90 to 12/15/12) was conducted to
identify peer-reviewed publications relevant to the use of radiotherapy
after prostatectomy. The review yielded an evidence base of 294 articles
after the application of inclusion/exclusion criteria. These
publications were used to create the guideline statements. If sufficient
evidence existed, then the body of evidence for a particular treatment
was assigned a strength rating of A (high quality evidence; high
certainty), B (moderate quality evidence; moderate certainty) or C (low
quality evidence; low certainty) and evidence-based statements of
Standard, Recommendation or Option were developed. Additional
information is provided as Clinical Principles and Expert Opinion when
insufficient evidence existed.

This guideline's purpose is to provide direction to clinicians and
patients regarding the use of radiotherapy (RT) after prostatectomy in
patients with and without evidence of prostate cancer recurrence. The
strategies and approaches recommended in this document were derived from
evidence-based and consensus-based processes. This document constitutes
a clinical strategy and is not intended to be interpreted rigidly. The
most effective approach for a particular patient is best determined by
discussions among the multidisciplinary team of physicians, the patient,
and his family.

Guideline Statements

Guideline Statement 1. Patients who are being considered for management
of localized prostate cancer with radical prostatectomy should be
informed of the potential for adverse pathologic findings that portend a
higher risk of cancer recurrence and that these findings may suggest a
potential benefit of additional therapy after surgery. (Clinical Principle)

Guideline Statement 2. Patients with adverse pathologic findings
including seminal vesicle invasion, positive surgical margins, and
extraprostatic extension should be informed that adjuvant radiotherapy,
compared to radical prostatectomy only, reduces the risk of biochemical
(PSA) recurrence, local recurrence, and clinical progression of cancer.
They should also be informed that the impact of adjuvant radiotherapy on
subsequent metastases and overall survival is less clear; one of two
randomized controlled trials that addressed these outcomes indicated a
benefit but the other trial did not demonstrate a benefit. However, the
other trial was not powered to test the benefit regarding metastases and
overall survival. (Clinical Principle)

Guideline Statement 3. Physicians should offer adjuvant radiotherapy to
patients with adverse pathologic findings at prostatectomy including
seminal vesicle invasion, positive surgical margins, or extraprostatic
extension because of demonstrated reductions in biochemical recurrence,
local recurrence, and clinical progression. (Standard; Evidence
Strength: Grade A)

Guideline Statement 4. Patients should be informed that the development
of a PSA recurrence after surgery is associated with a higher risk of
development of metastatic prostate cancer or death from the disease.
Congruent with this clinical principle, physicians should regularly
monitor PSA after radical prostatectomy to enable early administration
of salvage therapies if appropriate. (Clinical Principle)

Guideline Statement 5. Clinicians should define biochemical recurrence
as a detectable or rising PSA value after surgery that is ≥ 0.2 ng/ml
with a second confirmatory level ≥ 0.2 ng/ml. (Recommendation; Evidence
Strength: Grade C)

And on and on and on, for four more Guideline Statements and *MANY*
pages of discussion. It's written for patients, not statisticians and
oncologists, and is thus understandable by any of us. Some sentences and
concepts must be read a few times to grasp the nuances, but it's worded
carefully enough to warrant study of sections pertaining to one's own
situation.

It's at
http://www.auanet.org/education/guidelines/radiation-after-prostatectomy.cfm

I.P.