My understanding of these terms as applied to RP is as follows. Adjuvant can be decided relatively soon after surgery, but is often delayed for several months to allow healing and return of as much potency and continence as possible. Some say the heading
adjuvant is applicable even up to a year after surgery if the PSA is still basically undetectable or very low.
Adjuvant means added to, or to help the primary treatment. (If something is given before the primary treatment, it is
neoadjuvant).
If there is persistent PSA after surgery or the PSA starts to rise at any time (even decades) after RP, therapy is termed salvage. "Official" BCR (biochemical recurrence) is still defined by the AUA as a PSA of 0.2 and confirmed as rising. Studies refer to salvage at 0.2 and a bit higher (I've seen 0.4) as "early." Not all men with BCR go on to clinical recurrence (the detection of lesions), but most men choose to treat and not run the risk, unless at an advanced age. In other words, many men will be knowingly overtreated. The confounder in all this is that some men will have a PSA that rises, but then plateaus.
There has been a move toward very early salvage therapy (below 0.2). I have seen Forum Brothers treat as low as 0.03 after being undetectable. One study said that uros tend to wait for higher values, and ROs are about
evenly divided into those siding with uro's and those advocating very early salvage.
There is much uncertainty in study results as to exactly who benefits from adjuvant vs. early vs. very early salvage. This is a big topic. Some important results are coming out this year. Currently many are advocating what you mentioned, that all the factors be weighed for deciding at what PSA to start salvage treatment, such as, Gleason score, path report adverse findings (number, type, and extent), genomic testing for met potential, potency and urinary recovery, PSA nadir, PSA level, time from RP to start of PSA rise (the longer, the better), PSA velocity (the slower the rate of rise, the better), and perhaps imaging. It's not easy to determine how low one should start, but many high-risk guys (high G scores, adverse RP features, high-risk Decipher test scores) appear not to wait for anything much higher than 0.10 to begin salvage.
As I mentioned, advanced scans are proving useful for identifying the type of salvage therapy based on recurrence
location. Unfortunately, the lower the PSA, the less sensitive the scan for detecting lesions.
These definitions are really not all that important. What counts is that someone gets the right treatment at the right time. Confusing the picture is that the term "undetectable" usually refers to a PSA of <0.1. But with ultrasensitive testing, more and more men have low, but still detectable, levels and the meaning of the term is blurred. These more sensitive tests allow high-risk men to start salvage treatment with a smaller PSA rise and at smaller values.
I hope others will check and correct me and add their thoughts.
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There are a several issues complicating comparisons of adjuvant and. salvage studies. Most of the studies are retrospective and not the gold standard of randomized prospective. Studies have different criteria for selection and treatment, so they are rarely apple-to-apple comparisons. BCR rates are often used as the endpoint, but lower BCR rates do not always translate to better rates of overall or PCa-specific survival.
Djin
Post Edited (DjinTonic) : 3/2/2020 4:26:01 AM (GMT-7)