Functional Outcomes after Local Salvage Therapies for Radiation-Recurrent Prostate Cancer Patients: A Systematic Review

SIMPLE SUMMARY: Local salvage therapies are offered to prostate cancer (PCa) patients with recurrent disease following primary radiation therapy with initial curative intent. Favorable oncologic outcome is the primary aim of salvage therapy, but many patients may be left with treatment-related adverse consequences, potentially affecting their quality of living. The aim of this review was to evaluate the rates and severity of various functional outcomes after salvage therapy in patients with radiation recurrent PCa. Local salvage therapies are associated with impaired urinary and sexual functions depending on the specific salvage strategy. However, accurate estimation of the likelihood of these sequalae may be predictable based on the high pre-salvage general and disease specific health status. Despite these adverse consequences and impaired quality of life, oncologic advantage of local salvage treatment post radiation recurrence prostate cancer seems justified in general, but shared decision working with an informed patient is essential. This paper serves as a discussion platform for this process. ABSTRACT: Purpose: To assess the rate and severity of functional outcomes after salvage therapy for radiation recurrent prostate cancer. Methods: This systematic review of the MEDLINE/PubMed database yielded 35 studies, evaluating salvage radical prostatectomy (RP), brachytherapy (BT), high-intensity focal ultrasound (HIFU) and cryotherapy (CT) after failure of primary radiation therapy. Data on pre- and post-salvage rates and severity of functional outcomes (urinary incontinence, erectile dysfunction, and lower urinary tract symptoms) were collected from each study. Results: The rates of severe urinary incontinence ranged from 28–88%, 4.5–42%, 0–6.5%, 2.4–8% post salvage RP, HIFU, CT and BT, respectively. The rates of erectile dysfunction were relatively high reaching as much as 90%, 94.6%, 100%, 62% following RP, HIFU, CT and BT, respectively. Nonetheless, the high pre-salvage rates of ED preclude accurate estimation of the effect of salvage therapy. There was an increase in the median IPSS following salvage HIFU, BT and CT ranging from 2.5–3.4, 3.5–12, and 2, respectively. Extended follow-up showed a return-to-baseline IPSS in a salvage BT study. The reported data suffer from selection, reporting, publication and period of study biases, making inter-study comparisons inappropriate. Conclusions: local salvage therapies for radiation recurrent PCa affect continence, lower urinary tract symptoms and sexual functions. The use of local salvage therapies may be warranted in the setting of local disease control, but each individual decision must be made with the informed patient in a shared decision working process.