Marieke van Son

182 CHAPTER 10 val to biochemical failure >18 months and an initial ISUP grade <4 into the “low-risk” group, raising awareness that not all patients with biochemical recurrence have similar outcomes or should be offered salvage treatment. To aid individualized treatment decisions in the salvage setting, research should be aimed at finding a combination of clinical features that allows for stratification of patients into prognostic groups predicting high or low risk of focal salvage treatment failure, similar to the risk groups in the primary treatment setting. From the current available literature on both focal and whole-gland salvage treatments, including sev- eral modalities, it seems that initial ISUP grade, interval to biochemical failure, PSA at relapse, PSA doubling time at relapse, T-stage at relapse and prostatic volume all seem to have predictive value(39-43). Common denominators between studies are interval to biochemical failure, PSA-level and PSA doubling time. If left untreated, localized radiorecurrent disease may disseminate, potentially requir- ing systemic ADT in a later phase. Taking into account its time-limited effectiveness and the frequent severe side-effects associated with hormonal suppression, ADT seems most beneficial in the setting of metastatic disease, rather than for the treatment of localized radiorecurrent disease. However, the most optimal timing of ADT initiation remains under debate. The EAU guidelines currently recommend a deferred treatment strategy, offering ADT only to patients with symptoms of advanced disease or patients with an increased risk of spinal cord compression, pathological fractures or urethral obstruction. Early ADT should be reserved for those at highest risk of disease pro- gression, defined mainly by a short PSA doubling time (<6-12 months) or a high initial ISUP grade (>3)(44). As compared to a deferred ADT strategy, it would be interesting to assess the amount of ADT-free time that is gained by offering salvage treatment when the recurrent disease is still at a localized stage. Translation into clinic In contrast to the primary setting, the EAU has no strong recommendations regarding the use of focal salvage treatments for localized radiorecurrent prostate cancer(44). Awaiting prediction models based on long-term oncological outcome data from focal salvage series, adequate patient selection remains a challenge. Based on the available data, focal salvage treatment seems most beneficial for patients with a reasonable in- terval to recurrence and with favorable PSA kinetics. Treatment benefit should however be weighed against the potentially mild natural course of locally recurrent disease with favorable characteristics. With the other treatment option being (deferred) ADT, focal salvage treatment seems especially suitable for patients who are reluctant to start ADT or anxious to await the need for ADT in the longer term.