New Clinical Practice Guideline Provides Overview on Salvage Therapy’s Role in Prostate Cancer

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The 2024 clinical practice guideline regarding salvage therapy for the treatment of patients with prostate cancer, which features 30 recommendations, has been released by the American Urological Association (AUA) in partnership with the American Society for Radiation Oncology (ASTRO) and the Society of Urologic Oncology.¹

The Salvage Therapy for Prostate Cancer Panel created the guideline for patients with clinically localized disease who experienced biochemical recurrence following initial definitive local therapy and highlighted that the guideline is for all patient populations with a prostate gland.² In the guideline statements, recommendations were categorized as clinical principle or expert opinion by the Panel when evidence was lacking. Otherwise, the recommendations were categorized as either strong, moderate, or conditional, with evidence levels ranging from grade A to C.³

“With a focus on evidence-based approaches and a commitment to patient-centered care, this guideline will make a real difference for patients dealing with recurrence of their prostate cancer following initial treatment,” Todd Morgan, MD, chair of the Guideline Panel, and chief of the Division of Urologic Oncology at Michigan Medicine in Ann Arbor, said in a press release.1 “Thanks to the incredible expertise of the entire Panel, this guideline helps provide a roadmap that combines the latest advancements with thoughtful recommendations, empowering patients and clinicians alike.”

The guidelines encompass 6 topics: treatment decision-making at the time of suspected biochemical recurrence after primary radical prostatectomy; treatment delivery for non-metastatic biochemical recurrence after primary radical prostatectomy; evaluation and management of suspected non-metastatic recurrence after radiation therapy; evaluation and management of suspected non-metastatic recurrence after focal therapy; evaluation and management of regional recurrence; and management for molecular imaging metastatic recurrence.¹

Of the 30 guideline recommendations, 8 were in the form of expert opinion and 6 were clinical principles.³ Additionally, The Journal of Urology released a 3-part series detailing the nuances of the recommendations, noting the significant advancements that have occurred since the original AUA/ASTRO guideline on adjuvant and salvage radiotherapy was released in 2013. Advancements include the introduction of PET/CT imaging and androgen deprivation therapy for patients with biochemical recurrence, among others.²

“Clinical trials involving large numbers of men show that radiation as a salvage therapy after radical prostatectomy can improve survival outcomes, delay cancer progression and potentially offer a second chance at cure for many patients,” Ronald C. Chen, MD, MPH, FASTRO, vice chair of the Guideline Panel and professor/chair of Radiation Oncology at the University of Kansas Medical Center in Kansas City, said in the press release.1 “This guideline provides a framework for multidisciplinary teams to personalize treatments based on best practices developed through decades of research.”

Of the recommendations in the guideline, there were only 2 strong recommendations, both with an evidence grade level of B. The first notes that if biochemical recurrence after primary radical prostatectomy is suspected, clinicians should inform patients that salvage radiation for a detectable prostate-specific antigen (PSA) after radical prostatectomy is more effective when given at lower levels of PSA. Additionally, the second strong recommendation advised that clinicians should not recommend adding docetaxel to treatment for patients with non-metastatic biochemical recurrence after primary radical prostatectomy who are undergoing salvage radiation therapy and androgen deprivation therapy.³

The AUA noted that the systematic review which informed the guideline was based on searches conducted in Ovid MEDLINE from 1946 to July 21, 2022, and in the Cochrane Central Register of Controlled Trials as well as the Cochrane Database of Systematic Reviews through August 2022. On July 26, 2023, update searches also occurred.²

References

1. American urological association releases salvage therapy for prostate cancer guideline. Press Release. American Urological Association. February 29, 2024. Accessed March 1, 2024. https://www.auanet.org/about-us/media-center/press-center/american-urological-association-releases-salvage-therapy-for-prostate-cancer-guideline
2. Morgan TM, Boorjian SA, Buyyounouski MK, et al. 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. J Urol. Published online February 19, 2024.doi:10.1097/JU.0000000000003892
3. American Urological Association. Salvage therapy for prostate cancer: AUA/ASTRO/SUO guideline (2024). Accessed March 1, 2024. https://www.auanet.org/guidelines-and-quality/guidelines/salvage-therapy-for-prostate-cancer