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PROSCA 2019 - case 4

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Your case challenge

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You answered: B
You answered: B
A) "Do not panic: your PSA doubling time is so low that you do not need any treatment"
B) "As your PSA is rising with a confirmed value above 0.2 ng/ml you need salvage irradiation"
C) "As your PSA is rising with a confirmed value above 0.2 ng/ml you need salvage irradiation and ADT for 6 months"
D) "As your PSA is rising with a confirmed value above 0.2 ng/ml you need a PSMA PET to detect where it is produced"

What would Alberto Bossi do?


Based on the updated results from GETUG-AFU-16, presented at ASCO, I would choose option C (salvage RT + 6 months of ADT).

A rising PSA after radical prostatectomy is not a rare event and urologists should discuss this possibility when proposing surgery for men diagnosed with PCa. Traditionally, a rising PSA after radical prostatectomy for PCa is defined a “biochemical relapse” and for levels above 0.2 ng/ml, has prompted a salvage irradiation of the prostatic bed. So said, not all patients presenting with a biochemical relapse after surgery will invariably have a bad prognosis and the 2019 version of the EAU Guidelines correctly distinguish low versus high-risk patients in this respect. Jean-Michel belongs to the low-risk group but his long life-expectancy (15-20 years?) makes me preferring to propose him a salvage irradiation.

Modern imaging techniques may also be discussed for such patients and PSMA is currently extensively recommended for patients with rising PSA after local treatment. Even if the EAU guidelines mention this possibility, I am still convinced that, for the time being, we do not have solid data to systematically justify this attitude outside clinical trials.

Once a salvage irradiation is proposed, the next question is related to the need of associating an androgen deprivation treatment. A survival advantage with 2 years of bicalutamide 150 mg/d in this setting has been obtained over RT alone in a RTOG RCT published by Shipley but this benefit was only present for patients with a PSA at entry superior to 0.7 ng/ml and this is not the case of Jean-Michel. At the last ASCO meeting, Carrie on behalf of the French GETUG group, presented the updated results of the GETUG-AFU-16 trial: at a median follow-up of 112 months, patients with a rising PSA after surgery and treated with an association of salvage irradiation and 6 months of ADT had a significant better metastatic–free-survival as compared to patients treated with salvage irradiation only and this independent of the PSA at entry. Consequently, irradiation with short ADT (6 months) should be considered the standard of treatment for patients presenting with a rising PSA after radical prostatectomy.

Want to challenge me? I’m happy to discuss these data in more detail during PROSCA on 23-24 October in Paris!
 
 


What would Alberto Bossi do?

Based on the updated results from GETUG-AFU-16, presented at ASCO, I would choose option C (salvage RT + 6 months of ADT).

A rising PSA after radical prostatectomy is not a rare event and urologists should discuss this possibility when proposing surgery for men diagnosed with PCa. Traditionally, a rising PSA after radical prostatectomy for PCa is defined a “biochemical relapse” and for levels above 0.2 ng/ml, has prompted a salvage irradiation of the prostatic bed. So said, not all patients presenting with a biochemical relapse after surgery will invariably have a bad prognosis and the 2019 version of the EAU Guidelines correctly distinguish low versus high-risk patients in this respect. Jean-Michel belongs to the low-risk group but his long life-expectancy (15-20 years?) makes me preferring to propose him a salvage irradiation.

Modern imaging techniques may also be discussed for such patients and PSMA is currently extensively recommended for patients with rising PSA after local treatment. Even if the EAU guidelines mention this possibility, I am still convinced that, for the time being, we do not have solid data to systematically justify this attitude outside clinical trials.

Once a salvage irradiation is proposed, the next question is related to the need of associating an androgen deprivation treatment. A survival advantage with 2 years of bicalutamide 150 mg/d in this setting has been obtained over RT alone in a RTOG RCT published by Shipley but this benefit was only present for patients with a PSA at entry superior to 0.7 ng/ml and this is not the case of Jean-Michel. At the last ASCO meeting, Carrie on behalf of the French GETUG group, presented the updated results of the GETUG-AFU-16 trial: at a median follow-up of 112 months, patients with a rising PSA after surgery and treated with an association of salvage irradiation and 6 months of ADT had a significant better metastatic–free-survival as compared to patients treated with salvage irradiation only and this independent of the PSA at entry. Consequently, irradiation with short ADT (6 months) should be considered the standard of treatment for patients presenting with a rising PSA after radical prostatectomy.


Want to challenge me? I’m happy to discuss these data in more detail during PROSCA on 23-24 October in Paris!

Do you have an interesting case of your own?

Up to 3 case reports will be selected by the scientific committee for discussion in the official programme of PROSCA 2019.
 

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