Why salvage radiation is bad.

Many of us have heard urologists say "if surgery fails, you can always do salvage radiation." This makes it sound like salvage radiation is a walk in the park. It's not - as PDA, 142, and many others can painfully attest. Sometimes it's unavoidable - like when you go into surgery thinking it's well contained but later find out it isn't. Sometimes it is avoidable -like when you go into surgery knowing surgery won't get it all (Stage T3a or T3b). I know I sound like a broken record when I rail against surgery in such cases, but I have never seen anything to disprove that.

I was writing an article on new salvage radiation techniques, and I wrote a section on why salvage radiation is different from primary radiation. I thought I'd share it here (slightly edited) because this subject has come up several times on HW lately.There are several considerations that arise more in the salvage radiation therapy setting than in the primary therapy setting:

• The bladder and rectum are no longer shielded by an intact prostate, so they are potentially exposed to greater spillover radiation. The prostate bed without the prostate is highly deformable, and rectal distension can change its shape markedly within seconds during the treatment. This increases the amount of toxic radiation absorbed by healthy tissues.

• Blasting the anastomosis (the place where the urethra has been cut and re-attached, and where most recurrences occur) with unshielded, high intensity X-rays may be too much for the fragile tissue.The scar tissue of the anastomosis may become inflamed, leading to a higher risk of urinary retention, tissue destruction, or fistulas.

• The bladder neck, which may be spared during primary radiation and surgery, receives a full dose during salvage radiation therapy, increasing the probability of bladder neck contracture, urethral strictures, pain and incontinence.

• The neurovascular bundles play a large part in erectile function. The nerves are already cut or in shock from the surgery, and may take a long time, if ever, to recover. Radiation, which may cause fibrosis in blood vessels, may further impair erectile function, which is probably already impaired from the surgery. Neurovascular bundles, if spared by surgery, are far more exposed during salvage radiation. These deleterious effects are further aggravated if hormone therapy is given along with the salvage radiation because tissues (nerves, blood vessels, erectile tissues) that are not used may not recover and tend to atrophy.

Salvage treatment is bad - period. That's as true of salvage after radiation as it is of salvage after surgery. A man should never go into any treatment thinking he can just have salvage later. One should choose the treatment that has the best odds of getting it done right the first time with whatever side effects one is willing to tolerate.

- Allen

Finally justification on my decision to flatly resfuse SRT after my "failed" surgery. I've always felt the risks out weighed the gains.

Ch Evers, Doug

Billy, got my nuts cut out and replaced!

Cheers, Doug

Billy, mets were confirmed 11 Dec surgery 22 Dec., didn't see any point in waiting.

Cheers, Doug

Very useful info. (I hope to never need it!)

I think this post should be in the "Newly Diagnosed with PC?" section. People should understand salvage radiation issues before choosing their primary treatment.

-Gedman

Pratoman-

You may have misunderstood me. What I said was, "Sometimes it's unavoidable - like when you go into surgery thinking it's well contained but later find out it isn't."

- Allen

Ok, so what you are saying is basically, assuming the rise in PSA is presumed due to local recurrence, then after surgery, SRT is the answer for another shot at cure, but it's not as easy and "fun n games" as most people think, and if you need it, it will have turned out that some form of RT might have been a better option than surgery for primary treatment..(in hindsight)

Just came across this---and thought it was an interesting read---somewhat relating to this discussion:)


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Metastatic and Advanced Prostate Cancer
Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS more...

Updated: Dec 3, 2014

An indication for immediate bilateral orchiectomy is spinal cord compression, and surgical intervention for weight-bearing bones involved in pathologic fractures is mandatory.

Radical prostatectomy for clinical stage T3 prostate cancer at initial presentation has not historically been considered beneficial, because of the increased probability of incomplete resection of the cancer, likelihood of micrometastatic disease, and increased morbidity.

A retrospective review of approximately 840 men with stage cT3 prostate cancer who underwent radical prostatectomy at the Mayo Clinic (median follow-up, 10.3y) reported outcomes similar to those with organ-confined disease (stage T2c) during the same period at this institution. Pathologic stage, Gleason grade, positive surgical margin, and nondiploid chromatin were found to be independently associated with increased progression of disease.[41]

In another Mayo Clinic study, in which the long-term survival of patients with high-risk prostate cancer was compared after radical prostatectomy (RRP) and after external beam radiation therapy (EBRT), RRP alone and EBRT plus ADT provided similar long-term cancer control.[42] However, the risk of all-cause mortality was greater after EBRT plus ADT than after RRP.

In the study, RRP was used in 1238 men, and EBRT was used in 609 men (344 received EBRT plus ADT, and 265 received EBRT alone). The 10-year cancer-specific survival rates in the study were 92%, 92%, and 88% after RRP, EBRT plus ADT, and EBRT alone, respectively, with a median follow-up of 6-10 years.

Previous Next Section: Prognosis

I'm two weeks into SRT, and naturally find this discussion of great interest. I'm in the camp of those who had every reason to believe surgery would take care of my PC, and the pathology report confirmed that. But I was surprised to read the recent article on just how frequent recurrence is, much more common than the nomograms suggest, it seems. That knowledge might have swayed me toward radiation as the initial treatment. As the RO I got a second opinion from said, "Why put yourself through surgery, when you might have to do salvage radiation anyway?" In the end, I would have chosen radiation if it wasn't for the accompanying hormone treatments, which would have been for two years according to the RO who would have worked on me if I'd chosen that route. Now, apparently, they are less likely to advocate hormones along with radiation for low-intermediate numbers like mine were originally. Unless I get lucky with the SRT (1/3 chance, according to the RO), I will end up going through the full gamut of treatments, with all the SEs that go with those, and be at the same place as if I had just let the disease progress until the mets could be seen and dealt with then. I commend Tall Allen for all he does to keep this forum informed with the latest information. He's a treasure and has undoubtedly helped many of us as we try to navigate the bizarre maze of dealing with our PC.

@ashleynfld101-

The study referred to is this one:

Radical prostatectomy for clinically advanced (cT3) prostate cancer since the advent of prostate-specific antigen testing: 15-year outcome.

The point the authors are making is not that surgery is as good as RT for clinically diagnosed Stage T3 prostate cancer, but that in the 1987-1997 period "Significantly many patients with cT3 prostate cancer [were] overstaged." Furthermore, they make the point that "most men with pT3 disease (78%) received adjuvant therapy."

Arguably, staging has gotten much better since then. Certainly, MRIs are more accurate, especially with 3 Tesla MRIs becoming more prevalent. I don't know what percent of men who are now clinically staged as cT3 are later downstaged to pT2 on final pathology, but I'd be willing to bet that upstaging far exceeds downstaging. Who would go into surgery based on the likelihood that their PC will be downstaged on final pathology?

Their other point is that with multimodal therapy, that is, with RP+adjuvant RT+ADT, that the oncological outcomes are almost as good as among men clinically diagnosed with cancer confined to the prostate (cT2). That probably stills holds true and is not in dispute. So, for example, with about 50% of T3 patients with biochemical recurrences, and about half of those cured by adjuvant radiation+ADT, that gives about a 75% cure rate, which is probably about the same as for men with high risk, cT2 treated with RP.

The other study they quote - on 15 year outcomes - is irrelevant. Dose escalation in the modern era has dramatically improved outcomes of RT, and multi-modal RT seems to have even better outcomes than dose-escalated EBRT. Also, "all cause mortality" is always worse for RT because men who get RT are, on the average, 10 years older than men who receive RP, so of course they die sooner of some cause after therapy.

But none of that addresses the point of my post, which is that the potential side effects of adjuvant/salvage RT are bad, and it is not a good idea to opt for that at the time the original treatment decision is made.

- Allen

Tall Allen said...
Sometimes it is avoidable -like when you go into surgery knowing surgery won't get it all (Stage T3a or T3b). .

- Allen

Allen...

Why would anyone do this??

Shaba.Doug said...
Billy, got my nuts cut out and replaced!

Cheers, Doug

F'it Doug, You are my hero ...
.

I'm not reading an RT as primary treatment bias here. If I was, I would not have made the earlier comments.

I believe that surgery is a good and valid choice, if there is reason to believe that the cancer is contained, or if there is a need to debulk the tumor.

RT is valid if the cancer is clearly escaped, or if the patient could not support the stress of surgery.

In my case, I had a lot of radiation exposure in my work, so RT as a first choice would have needed a resounding reason. In my case, the two ROs I consulted were less than optimistic about their cure possibilities.

I elected surgery for my reasons.

I feel like TA has offered food for thought, none of which I can disagree with.