With no definitive efficacy data to guide them, surgeons must consider a number of factors when deciding whether salvage prostatectomy or salvage cryotherapy is the optimal treatment for patients who experience recurrence of prostate cancer (PCa) following primary radiation therapy for the disease.
Currently, the decision to perform robotic-assisted laparoscopic prostatectomy (RALP) or cryotherapy is based in large measure on a patient’s preferences and tumor characteristics, as well as age and comorbidities, according to Gerald L. Andriole, MD, chief of urologic surgery and vice-chair of the department of surgery at Washington University School of Medicine and the Siteman Cancer Center, St. Louis, Missouri. “Generally, the youngest, healthiest men would seem to benefit most from surgery to remove the prostate,” Dr Andriole said.
Prostate removal, either by open, laparoscopic, or robotic-assisted approaches, is apt to provide better local control and cancer outcomes than cryotherapy, he said. “This is likely as cryotherapy may be incomplete and some residual tumor may be left within the prostate,” Dr Andriole told Renal & Urology News. “Also, prostate removal may identify and control small amounts of cancer that are outside of the prostate, such as in lymph nodes and or the seminal vesicles.” This generally is not possible with cryotherapy, he added.
Level One comparative data are lacking for salvage therapies, with no clear winner at this point, said Kristen R. Scarpato, MD, MPH, assistant professor of urologic surgery at Vanderbilt University Medical Center in Nashville, Tennessee. Retrospective data and single institution series indicate that both modalities are generally safe and oncologically effective.
Physician experience a factor
“Treatment needs to be individualized to the patient considering his comorbidities, disease parameters, and preferences,” Dr Scarpato said. “Choice also largely depends on physician experience. Currently, I think that risks are limited and benefits are maximized by carefully selecting appropriate patients and limiting salvage procedures to experienced centers of excellence.” Dr Scarpato said.
Salvage RALP offers excellent visualization of the posterior plane between the rectum and the prostate, where the normal tissue planes have often been obliterated by radiation, she said. “Data suggest reasonable oncologic efficacy and minimal blood loss and hospital stay, with an acceptable risk profile,” Dr Scarpato said. “Furthermore, pathologic data are obtained at the time of prostatectomy. Salvage cryotherapy has also been shown to be safe and efficacious and has the advantage of being less invasive.”
Cryotherapy has improved
Aaron Katz, MD, chairman of urology at New York University Winthrop University Hospital in Mineola, New York, said that with respect to overall cancer control, no study has ever demonstrated that salvage prostatectomy provides a better outcome. Salvage cryotherapy, however, may significantly delay the use of androgen-deprivation therapy, he said.
“I’ve done salvage cryotherapy for over 20 years,” Dr Katz said. “The technology has improved. There is no doubt that the quality of life [of patients who undergo] salvage cryotherapy is significantly better than those patients who have salvage prostatectomy.”
Salvage cryotherapy only takes about an hour, and it does not result in blood loss or need for transfusions, he said. In select patients, salvage prostatectomy may be beneficial, but, overall, in patients who fail radiotherapy without evidence of metastatic disease, salvage cryotherapy is the optimal therapy, Dr Katz said.
Julio Pow-Sang, MD, chair of genitourinary oncology at Moffitt Cancer Center in Tampa, Florida, commented that a major benefit of salvage RALP is that patients are cured if their tumors are localized. A disadvantage of the procedure is that it is a more complicated procedure than cryotherapy, he said. “Few centers around the country perform it. We do,” Dr Pow-Sang said.
Salvage cryotherapy is associated with a lower rate of urinary incontinence than RALP: about 5% versus 10%, Dr Pow-Sang said. Additionally, salvage cryotherapy is minimally invasive and usually does not require a hospital stay. A disadvantage with salvage cryotherapy is that prostate tissue remains, and there is a “risk of another recurrence within of about 50%,” Dr Pow-Sang said.
Kristen R. Scarpato, MD, MPH, is assistant professor of urologic surgery at Vanderbilt University Medical Center in Nashville, Tennessee.
Aaron Katz, MD, is chairman of urology at New York University Winthrop University Hospital in Mineola, New York,
Gerald L. Andriole, MD, chief of urologic surgery and vice-chair of the department of surgery at Washington University School of Medicine and the Siteman Cancer Center, St. Louis, Missouri.