New guideline for prostate cancer introduced at AUA2024
Salvage Therapy for Prostate Cancer: AUA/ASTRO/SUO Guideline (2024) focuses on new management recommendations for patients with biochemical recurrence following prostatectomy or other curative treatment.
The new Salvage Therapy for Prostate Cancer: AUA/ASTRO/SUO Guideline (2024) was unveiled during the morning Plenary on Friday. This is not a revision or an update of the prior 2013 guideline; rather, it is a new consensus document built from the ground up, said Guideline Committee Chair Todd Morgan, MD, chief of urologic oncology and the Jack Lapides, MD, Research Professor at the University of Michigan in Ann Arbor.
“There has a been a huge number of new trials in this area in the past 10 years,” Dr. Morgan said. “The science and evidence around prostate cancer and salvage therapy for prostate cancer have advanced dramatically since the last guideline on adjuvant and salvage radiotherapy after prostatectomy was published. We had no recourse to PET imaging and molecular markers five years ago, and molecular markers play an important role in the new guideline we developed with ASTRO (American Society for Radiation Oncology) and SUO (Society of Urologic Oncology).”
The guideline focuses on management recommendations for patients with biochemical recurrence (BCR) following prostatectomy or other curative treatment. Trials have brought new recommendations for the timing and delivery of salvage therapy, risk stratification, use of ADT, quality of life, molecular imaging and metastasis-directed therapy.
The 2013 guideline, for example, recommended offering salvage therapy to patients with BCR, noting that earlier is better. However, it was not possible to provide guidance on the potential use of androgen deprivation therapy due to lack of data.
Most patients should now receive salvage radiation therapy (RT) when PSA is still ≤0.5 ng/mL. Patients at high risk for clinical progression can start RT when PSA is <0.2 ng/mL.
Advanced imaging is now standard of care. When considering salvage RT for BCR following prostatectomy, the new guideline states that clinicians should perform next-generation molecular PET imaging.
There is also a call for ADT in addition to salvage RT after prostatectomy for patients with BCR and any high-risk features. RT alone may be appropriate for patients without high-risk features.
Patients with no evidence of metastatic disease who are candidates for local salvage therapy should have a prostate biopsy before treatment. For patients with biopsy-documented recurrence, clinicians should offer prostatectomy, cryoablation, high intensity focused ultrasound or re-irradiation as part of a shared decision-making approach.
“We will undoubtedly see updates with continued refinement of adjuvant systemic therapy with RT and improved understanding of how PSMA PET should be used in treatment decisions in the BCR setting,” Dr. Morgan said, “and we can appreciate that the results of EMBARK (enzalutamide plus leuprolide in nonmetastatic prostate cancer) will be incorporated.”
