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Prostate cancer salvage therapy guideline incorporates PSMA-PET imaging


"A key piece of the guideline is that we need to offer radiation at a PSA of 0.5 ng/mL or lower and maybe even, for some patients, a PSA lower than 0.2 ng/mL," says Todd M. Morgan, MD.

In this video, Todd M. Morgan, MD, shares some key points from the AUA/ASTRO/SUO guideline for salvage therapy for prostate cancer, which was recently published in the Journal of Urology. Morgan is chief of urologic oncology, the Jack Lapides M.D. Research Professor and professor of urology at the University of Michigan, Ann Arbor.


What are some key points from the AUA/ASTRO/SUO guideline on salvage therapy for prostate cancer?

One of the important spaces is what do we do with a patient who undergoes prostatectomy and then has a biochemical recurrence? A key piece of the guideline is that we need to offer radiation at a PSA of 0.5 ng/mL or lower and maybe even, for some patients, a PSA lower than 0.2 ng/mL. There are some ways of what we call risk stratifying patients, so saying, of course, everybody is different. But it extends beyond just our clinical intuition to some tangible clinical factors that we can use to help inform our decisions, which patients might need earlier radiation treatment, or if patients who underwent initial radiation, which of those patients are at highest risk for recurrence, and then when we're thinking about patients who get salvage radiation, which of those patients may need hormone therapy with that radiation and for how long that hormone therapy is given. So these are all really key pieces of the guideline. But there's a single table that I think is really important and I hope that people take a second to look at and think about, because it's a table that goes through some of the main prognostic factors that inform all of these risk stratification decisions. And some of those factors are high Gleason grade, high stage, the presence of node-positive disease, a shorter PSA doubling time, a shorter time to PSA recurrence—a patient who has their PSA rising, say, 3 months or 6 months after prostatectomy has a higher risk disease than that patient who has that PSA recurrence 4 or 5 or 6 years after surgery. There's also PET imaging findings. That's another really key part of this guideline. PSMA-PET is really new in our field. This is another reason why this guideline is so topical and really something that is different than the prior guideline is that patients with biochemical recurrence now have the opportunity to undergo an imaging modality that can find that cancer in many, many cases. And so whereas 5 years ago, we were only using CT scans and bone scans and maybe MRI to try to localize disease early not very successfully. Now, PSMA-PET is showing us cancer and lymph nodes that are in the prostate bed, or maybe even a distant site like a spinal metastasis that we just cannot see on a CT scanner or bone scan that totally changes our thinking. Now, we still have a long way to go to have robust clinical trial data that tell us definitively what the best approaches are in each of these little nuanced scenarios. But there are data to start to inform the guideline statements, and there are guidelines statements that we have put together that suggest using PSMA-PET or other molecular imaging modalities in patients with biochemical recurrence, and then targeting those sites of disease when there are a limited number of sites; using for example, radiation or what we call metastasis-directed therapy to targetthose particular sites, and it really does seem to help patients in terms of at least delaying further progression of their disease.

This transcription was edited for clarity.

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