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Purpose: Current salvage treatments for recurrent prostate cancer after primary radiation therapy include radical prostatectomy, cryosurgery and brachytherapy. Because toxicity and failure rates are considerable, salvage treatments are not commonly performed. As most centers perform only one preferred salvage technique, the literature only describes single-center outcomes from a single salvage technique with a limited number of patients. In this overview, five high-volume Dutch centers describe their toxicity and outcome data using different salvage techniques. This provides a view on how salvage is performed in clinical practice in the Netherlands. Methods: A total of 129 patients from five different centers in the Netherlands were retrospectively analyzed. Biochemical failure (BF) was defined as PSA >0.1 ng/ml for the salvage prostatectomy group ( n = 44) and PSA nadir + 2.0 ng/ml (Phoenix definition) for the salvage cryosurgery ( n = 54) and salvage brachytherapy group ( n = 31). Toxicity was scored according to the Common Toxicity Criteria for Adverse events (CTCAE v3.0). Results: BF occurred in 25 (81 %) patients in the brachytherapy group (mean follow-up 29 ± 24 months), 29 (66 %) patients in the prostatectomy group (mean follow-up 22 ± 25 months) and 33 (61 %) patients in the cryosurgery group (mean follow-up 14 ± 11 months). Severe (grade >3) genitourinary and gastrointestinal toxicity was observed in up to 30 % of patients in all three groups. Conclusion: This overview shows clinical practice of prostate cancer salvage. Significant failure and toxicity rates are observed, regardless of salvage technique. Patients should be selected with great care before offering these salvage treatment strategies. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Many patients are eligible for more than one treatment option for prostate cancer. In usual care, urologists have a large influence on the treatment choice. Decision aids, providing balanced information on the pros and cons of different treatment options, improve the match between patient preferences and treatment received., In men eligible for both surgery and external beam radiotherapy, treatment choice differed by hospital. Across the participating hospitals, the decision aid consistently led to fewer patients remaining undecided on their treatment preference and more patients choosing brachytherapy., Objectives To examine the treatment choice for localized prostate cancer in selected men who were eligible for both prostatectomy and radiotherapy., To examine whether increased patient participation, using a decision aid, affected the treatment choice., Patients and Methods From 2008 to 2011, 240 patients with localized prostate cancer were enrolled from three separate hospitals., They were selected to be eligible for both prostatectomy and external beam radiotherapy. Brachytherapy was a third option for about half of the patients., In this randomized controlled trial, patients were randomized to a group which only discussed their treatment with their specialist (usual care group) and a group which received additional information from a decision aid presented by a researcher (decision aid group). The decision aid was based on a literature review., Predictors of treatment choice were examined., Results Treatment choice was affected by the decision aid ( P = 0.03) and by the hospital of intake ( P < 0.001)., The decision aid led to more patients choosing brachytherapy ( P = 0.02) and fewer patients remaining undecided ( P < 0.05)., Prostatectomy remained the most frequently preferred treatment., Age, tumour characteristics or pretreatment urinary, bowel or erectile functioning did not affect the choice in this selected group., Patients choosing brachytherapy assigned more weight to convenience of the procedure and to maintaining erectile function., Conclusions Traditionally, patient characteristics differ between surgery and radiotherapy groups, but not in this selected group of patients., Men eligible for both prostatectomy and radiotherapy mostly preferred prostatectomy, and the treatment choice was influenced by the hospital they visited., Giving patients evidence-based information, by means of a decision aid, led to an increase in brachytherapy. [ABSTRACT FROM AUTHOR]

Abstract: Context: Cryosurgery is an evolving treatment for localized prostate cancer in European centers. Modern cryotechnology is associated with a low complication rate, but its definitive role in the spectrum of different treatment modalities remains to be determined. Objective: The primary objective of this review is to analyze the oncological results and complication rates of modern cryosurgery for prostate cancer. Secondarily, the impact of patient selection and the criteria for treatment success are discussed. Evidence acquisition: A structured literature review was performed by an online Pubmed search for data of primary and salvage cryosurgery of the prostate. Papers with relevant information on clinical outcome and complication rates were selected. Evidence synthesis: The introduction of gas-based third-generation cryotechnology has significantly decreased side effects with similar oncological results compared to older techniques. The occurrence of severe complications like rectourethral fistulas (<1%) has almost been eradicated, but the rates of erectile dysfunction remain high (90%). With salvage cryosurgery more side effects can be expected with an average incontinence rate of 8% and fistulas up to 3.4%. Nevertheless, this minimal invasive treatment remains an option for radiorecurrent prostate cancer. Focal cryosurgery is considered experimental, but is an interesting new development in cryosurgery. The intermediate-term biochemical disease free survival rates of 60%–90% are comparable to the results of other treatment modalities. However, the current data of cryosurgery in literature are of low-level evidence which should be discussed when counselling patients. Conclusions: Modern cryosurgery is reliable and results are promising with minimal morbidity. Focal cryosurgery in selected patients aims to reduce side effects, but is currently experimental treatment. Randomized trials comparing the outcomes of the different treatment modalities and long-term follow-up data are needed to define the ultimate role of cryosurgery in the treatment of localized prostate cancer. [Copyright &y& Elsevier]

Abstract: Background: Overdiagnosis and subsequent overtreatment are important side effects of screening for, and early detection of, prostate cancer (PCa). Active surveillance (AS) is of growing interest as an alternative to radical treatment of low-risk PCa. Objective: To update our experience in the largest worldwide prospective AS cohort. Design, setting, and participants: Eligible patients had clinical stage T1/T2 PCa, prostate-specific antigen (PSA) ≤10 ng/ml, PSA density <0.2 ng/ml per milliliter, one or two positive biopsy cores, and Gleason score ≤6. PSA was measured every 3–6 mo, and volume-based repeat biopsies were scheduled after 1, 4, and 7 yr. Reclassification was defined as more than two positive cores or Gleason >6 at repeat biopsy. Recommendation for treatment was triggered in case of PSA doubling time <3 yr or reclassification. Outcome measurements and statistical analysis: Multivariate regression analysis was used to evaluate predictors for reclassification at repeat biopsy. Active therapy–free survival (ATFS) was assessed with a Kaplan-Meier analysis, and Cox regression was used to evaluate the association of clinical characteristics with active therapy over time. Results and limitations: In total, 2494 patients were included and followed for a median of 1.6 yr. One or more repeat biopsies were performed in 1480 men, of whom 415 men (28%) showed reclassification. Compliance with the first repeat biopsy was estimated to be 81%. During follow-up, 527 patients (21.1%) underwent active therapy. ATFS at 2 yr was 77.3%. The strongest predictors for reclassification and switching to deferred treatment were the number of positive cores (two cores compared with one core) and PSA density. The disease-specific survival rate was 100%. Follow-up was too short to draw definitive conclusions about the safety of AS. Conclusions: Our short-term data support AS as a feasible strategy to reduce overtreatment. Clinical characteristics and PSA kinetics during follow-up can be used for risk stratification. Strict monitoring is even more essential in men with high-risk features to enable timely recognition of potentially aggressive disease and offer curative intervention. Limitations of using surrogate end points and markers in AS should be recognized. Trial registration: The current program is registered at the Dutch Trial Register with ID NTR1718 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1718). [Copyright &y& Elsevier]

Abstract: Background and purpose: Goals of this study are to report the outcomes and tolerance of salvage radiotherapy (SRT) after prostatectomy, to identify risk factors for failure after SRT and to evaluate how these results compare with published results of immediate post-operative adjuvant radiotherapy (ART). Material and methods: Men receiving SRT for elevated PSA levels after radical prostatectomy (RP) were included. Biochemical progression-free survival (bPFS), overall survival (OS) and disease-specific survival (DSS) were estimated. Risk factors for biochemical failure and death were evaluated. Late toxicity and quality of life were evaluated. Secondary bPFS (defined as bPFS from prostatectomy until progression after radiotherapy) was calculated for high-risk patients (pT3 and/or positive surgical margins) in order to compare SRT outcomes with ART. Results: 197 Men were included. Five-year bPFS after SRT was 59% (95% CI 49–69%). Five-year OS and DSS were 90% (85–96%) and 97% (93–100%), respectively. Capsular perforation (pT⩾T3), negative surgical margins and serum PSA>1ng/ml at the start of RT were significant predictors of lower bPFS. Patients without any negative factors had a 5-year bPFS of 89%. No severe late toxicity was reported. Five-year secondary bPFS for SRT in high-risk patients was 78% and comparable with published results for ART. Conclusions: Salvage radiotherapy for patients with organ-confined prostate cancer was effective and well tolerated. SRT outcomes were comparable with published ART results for high-risk patients. Initially monitoring serum PSA and considering early SRT for these patients are not harmful and might be a valuable alternative for immediate ART. [Copyright &y& Elsevier]