This paper should be of interest to any patient who had RT after his prostatectomy or is considering it now. It was of special interest to me, as I pushed for and got adjuvant IMRT at just 3 months after my RALP surgery. (Rather that the 6-month wait-period that was common at that time.) My push for advancing RT was due to having chanced on "ASTRO's Guideline on Adjuvant and Salvage RT after Prostatectomy" in the recovery period after surgery. That paper had just gone through its 5-year update and I was to later find that my newly-assigned RO had been on the document's peer-review committee.
I discovered the guideline paper just prior to my initial post-RALP review of my final biopsy pathology report with my surgeon. It lists four major negatives that can be presented in a "final" biopsy" of the prostate; i.e., the one that is done from any tissues removed during the prostatectomy surgery. For any people unacquainted with those negative findings, they are: 1) Non- confined disease, 2) Extra-capsular extension, 3) seminal vesicle invasion, & 4) lymph node invasion. At the time of my surgery in 2013, the numerical order was reflective of the risk of recurrence, with the exception that seminal vesicle invasion often predicted a worse prognosis than did lymph nodes. My pathology was positive for 3 of the 4, with the 5 lymph nodes biopsied as negative for PCa, but positive for CLL, my blood cancer.
When I sat down with my surgeon for the review, I pulled out a copy of the paper and said something to the effect of ~"Hey, Doc, I see from this document that I have 3 of the 4 negatives in the final biopsy pathology report, so it seems that doing adjuvant RT is a 'no-brainer'". He replied on the order of ~" I wouldn't disagree". We discussed the risk for ED and incontinence and I confirmed that I would rather accept those risks rather than give the cancer a wider zero-treatment berth to spread. I even chose to temporarily locate to a treatment center-related housing facility to do the 8 weeks of IMRT treatments under the direction of my center vs a more-convenient one near my home.
Were I to do that RT today, I expect the recommendation would be to add ADT (at least for the period of the RT treatments), boost the total RT dosage, and expand the field beyond just the prostate bed; i.e., to include the pelvic lymph nodes. In reality, I'm pretty sure the extent of the cancer at the time of surgery was indicative of metastatic disease beyond being localized and oligomeastatic.
This a paper is a good guide for anyone considering RT after a prostatectomy , and i expect it will be used to update the ASTRO document as it is due for it's five-year revision.
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Postprostatectomy Radiotherapy Timing and Long-Term Health-Related Quality of Life, JAMA Network Open, Original Investigation, Oncology. October 24, 2024
Sagar A. Patel, MD, MSc1,2; Dattatraya Patil, MBBS, MPH2; Joseph Smith, MD3; et al Christopher S. Saigal, MD, MPH4; Mark S. Litwin, MD, MPH4; Jim C. Hu, MD, MPH5; Matthew R. Cooperberg, MD, MPH6; Peter R. Carroll, MD, MPH6; Eric A. Klein, MD7; Adam S. Kibel, MD8; Gerald L. Andriole, MD9; Misop Han, MD9; Jeff M. Michalski, MD10; David P. Wood, MD11; Larry A. Hembroff, PhD12; Daniel E. Spratt, MD13; John T. Wei, MD, MS14; Howard M. Sandler, MD15; Daniel A. Hamstra, MD, PhD16; Louis Pisters, MD17; Deborah Kuban, MD18; Meredith M. Regan, ScD19; Andrew Wagner, MD20; Catrina M. Crociani, MPH20; Irving Kaplan, MD21; Martin G. Sanda, MD2; Peter Chang, MD, MPH20; for the PROST-QA/RP2 Consortium
Article Information:
JAMA Netw Open. 2024;7(10):e2440747. doi:10.1001/jamanetworkopen.2024.40747
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Key Points
Question Is radiotherapy timing after radical prostatectomy associated with long-term patient-reported health-related quality-of-life (HRQOL) in men with prostate cancer?
Findings In this cohort study of 1203 men with localized prostate cancer undergoing initial prostatectomy, receipt of postprostatectomy radiotherapy was associated with statistically significant long-term decrements in patient-reported urinary incontinence, urinary irritation, bowel, and sexual HRQOL. However, long-term HRQOL did not significantly differ between men receiving early (<12 months) vs late (≥12 months) radiotherapy after prostatectomy.
Meaning The findings of this study suggest that receipt of early vs late radiotherapy following radical prostatectomy may result in similar long-term patient-reported outcomes.
Abstract
Importance The association between radiotherapy (RT) timing after radical prostatectomy and long-term patient-reported health-related quality of life (HRQOL) in men with prostate cancer is unknown.
Objective To measure long-term HRQOL in men with prostate cancer up to 15 years after prostatectomy with or without RT and examine whether early vs late postprostatectomy RT is associated with differences in sexual, urinary, and bowel HRQOL.
Design, Setting, and Participants A prospective, multicenter, longitudinal cohort analysis using HRQOL data from the PROST-QA (2003-2006) and RP2 consortium (2010-2013) studies was conducted. Men with localized prostate cancer undergoing radical prostatectomy were included. Data were analyzed between May 8, 2023, and March 1, 2024. The study was conducted in 12 high-volume academic medical centers in the US.
Exposures Men were stratified based on receipt and timing of postprostatectomy RT: prostatectomy only, early RT (<12 months), and late RT (≥12 months).
Main Outcomes and Measures Longitudinal sexual, incontinence, urinary irritation, bowel, and hormonal/vitality HRQOL were measured via the Expanded Prostate Cancer Index Composite at baseline; months 2, 6, and 12; and annually thereafter. Treatment groups were compared using multivariable linear mixed-effects models of change in longitudinal domain scores. Pad use for incontinence was measured longitudinally among men receiving postprostatectomy RT.
Results A total of 1203 men were included in the study: prostatectomy only (n = 1082), early RT (n = 57), and late RT (n = 64). Median age for the entire cohort was 60.5 (range, 38.8-79.7) years, and 1075 men (92.0%) were White. Median follow-up was 85.6 (IQR, 35.8-117.2) months. Compared with men receiving prostatectomy alone, those receiving postprostatectomy RT had significantly greater decreases in sexual, incontinence, and urinary irritation HRQOL. However, timing of postprostatectomy RT, specifically early vs late, was not associated with a long-term decrease in any HRQOL domain. There was evidence of improved recovery of sexual, continence, and urinary irritation scores among men receiving early RT compared with those receiving late RT after prostatectomy. Before the start of postprostatectomy RT, 39.3% of men in the early RT cohort and 73.4% of men in the late RT cohort were pad-free. By the sixth visit post-RT, 67.4% in the early RT cohort and 47.6% in the late RT cohort were pad-free.
Conclusions and Relevance In this multicenter, prospective analysis, postprostatectomy RT appeared to be negatively associated with long-term HRQOL across all domains. However, receipt of early vs late postprostatectomy RT may result in similar long-term HRQOL outcomes.
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This is a JAMA Network Open paper, so full report can be found here - w/ much detail in it that is worth reading:
Postprostatectomy Radiotherapy Timing and Long-Term Health-Related Quality of Life, JAMA Network Open, Original Investigation, Oncology. October 24, 2024
jamanetwork.com/journals/ja...
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BTW, for anyone interested in the current ASTRO document mentioned above here is a link for a PFD download:
ASTRO's guideline on adjuvant and salvage RT after prostatectomy, Published Update: April 2019
astro.org/patient-care-and-...
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Stay S&W, Ciao - cujoe
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