High Risk Prostate cancer- ASCO education book 2020

 

1. High risk is defined ( NCCN) as:

T3a, Gleason 8 or higher, PSA> 20

Very high risk:

T3b, T4

2. Extended PLND: 

-unclear oncologic benefit, recommended if the probability of LN involvement> 2%.

-lymphoceles are more common after PLND

-accurate staging, potentially curative in limited LN involvement

3. Genomic assays in prostate cancer:

Men with unfavorable intermediate- and high-risk disease and life expectancy ≥ 10 years may consider the use of Decipher and Prolaris tumor-based molecular assays. This is in addition to favorable intermediate and low-risk disease.

4. Adjuvant versus salvage RT in high-risk disease after prostatectomy: bottom line is this: salvage is acceptable. Adjuvant XRT did not improve outcomes and resulted in clinically relevant GU toxicities.

Whole pelvis versus prostate only XRT- whole pelvis XRT if the estimated risk of nodal involvement > 15%. Ongoing RTOG study looking at this question along with ADT.

Image and intensity modulate RT are SOC. Brachytherapy results in improved biochemical outcomes, no impact on OS, but more GU toxicity. Hypofractionation i.e fewer fractions, but a higher dose ( 3.4 Gy versus standard of 2 Gy) results in more GI ( not GU toxicity).

5. Systemic therapy for high-risk disease: phase II trials looking at neoadjuvant and adjuvant agents such as abiraterone, enzalutamide, apalutamide have shown increased path CR and 3 yr metastases free survival of 98%. Therefore phase III trials are underway.

6. Neoadjuvant docetaxel in high-risk prostate cancer- PUNCH study. Not statistically significant. A strong signal of improved overall survival in patients receiving systemic therapy (HR, 0.66; 95% CI, 0.42–1.03)