Adjuvant Radiation With ADT for Men With Lymph Node Metastases After Radical Prostatectomy

[Balsam01]

Interesting OS rate for patients with "adverse pathological features". this is a FYI and the study has design issues.

practiceupdate.com/C/79695/56

[Kamilekamile]

My husband is in the same situation but i can not read it😞

[Balsam01 in reply to Kamilekamile]

I re-posted the entire article below.

[Tub111]

Can you cut and paste the info as not many want to have to subscribe to it?

Sheri (cheerleader for you all now)

[Balsam01 in reply to Tub111]

TAKE-HOME MESSAGE

•Patients with lymph node metastases following prostatectomy may be managed through a variety of ways. The authors of this study accessed the National Cancer Data Base to identify 8704 men who had pN1 disease and evaluated oncologic outcomes associated with different strategies. In all, 6% underwent observation, 25.6% underwent androgen-deprivation therapy (ADT), and 18.8% underwent radiation with ADT. Multivariable analysis demonstrated an overall survival benefit with ADT plus radiation versus observation (HR, 0.77; P = .008) compared with no survival benefit with ADT versus observation. Patients without pT3b disease, Gleason score ≥9, positive margins, or three or more positive nodes did not have an increased survival benefit.

•These data are limited by minimal data on ADT duration and no data on cancer-specific mortality. Nevertheless, they may help identify an optimal treatment plan for men with node-positive disease following prostatectomy.

– Michael H. Johnson, MD

 Urology 

Written by Brian F. Chapin MD, FACS

The benefit of adjuvant therapies post prostatectomy in the occult lymph node–positive (pN+) population is unknown. Some studies have demonstrated benefits of androgen-deprivation therapy (ADT) and others ADT plus external beam radiotherapy (EBRT); however, these options can clearly impact overall quality of life and have the potential for increased urinary toxicity. The potential of these therapies makes clinical sense based on clinical recurrence patterns being pelvic only in up to one-third of pN+ patients.

In this study, the authors demonstrate a survival benefit with ADT plus EBRT versus ADT alone or observation only in a pN+ population. Interestingly, in this study the men receiving adjuvant ADT plus EBRT had worse oncologic features (surgical margins, stage, Gleason score, nodal burden) but still significantly improved survival. The authors further compared treatment approaches in a select cohort, limited to patients without adverse features, and found no difference in overall survival with observation versus ADT plus EBRT, indicating that, in this group, it may be reasonable to consider salvage approaches.

Population-based data, with all the limitations and selection biases, can still provide thought-provoking insight and help to develop hypotheses to test in a prospective fashion. Taken together with the existing data, it seems a multimodal approach in select patients may be advantageous for survival.

abstract

This abstract is available on the publisher's site.

Access this abstract now 

OBJECTIVES

To perform a comparative analysis of three current management strategies for patients with lymph node metastases (LNM; pN1) following radical prostatectomy (RP): observation, androgen-deprivation therapy (ADT), and external beam radiation therapy (EBRT) + ADT.

PATIENTS AND METHODS

Patients with LNM after RP were identified using the National Cancer Database (2004-2013). Exclusion criteria included any use of radiation therapy or ADT before RP, clinical M1 disease, or incomplete follow-up data. Patients were categorised according to postoperative management strategy. The primary outcome was overall survival (OS). Kaplan-Meier curves and adjusted multivariable Cox proportional hazards models were employed. Sub-analyses further evaluated patient risk stratification and time to receipt of adjuvant therapy.

RESULTS

A total of 8 074 patients met the inclusion criteria. Postoperatively, 4 489 (55.6%) received observation, 2 065 (25.6%) ADT, and 1 520 (18.8%) ADT + EBRT. The mean (median; interquartile range) follow-up was 52.3 (48.0; 28.5-73.5) months. Patients receiving ADT or ADT + EBRT had higher pathological Gleason scores, T-stage, positive surgical margin rates, and nodal burden. Adjusted multivariable Cox models showed improved OS for ADT + EBRT vs observation (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.64-0.94; P = 0.008) and vs ADT (HR 0.76, 95% CI: 0.63-0.93; P = 0.007). There was no difference in OS for ADT vs observation (HR 1.01, 95% CI: 0.87-1.18; P = 0.88). Findings were similar when restricting adjuvant cohorts for timing of adjuvant therapy. There was no difference in OS between groups for up to 2 549 (31.6%) patients lacking any of the following adverse features: ≥pT3b disease, Gleason score ≥9, three or more positive nodes, or positive surgical margin.

CONCLUSIONS

For patients with LNM after RP, the use of adjuvant ADT + EBRT improved OS in the majority of patients, especially those with adverse pathological features. Conversely, adjuvant therapy did not confer significant OS benefit in up to 30% of patients without high-risk features, who may be managed with observation and forego the morbidity associated with immediate ADT or radiation.

Topic Alerts

[Tub111 in reply to Balsam01]

Thank you!!!

[Kamilekamile in reply to Balsam01]

Thank you and god bless you!!

[Moespy]

I am post prostatectomy (7.5 years ago) with newly discovered pelvic lymph node involvement. Started ADT immediately and having Pelvic Radiation in 45 days. This study is on my side with my treatment decision since I am Gleason 4+3 with PT2c disease and no positive margins or nodes.

Thanks for the post!

Jim

[tango65]

This is a RCT (SPPORT trial) about treatment of BCR after prostatectomy with radiotherapy :

astro.org/News-and-Publicat...