Marieke van Son

70 CHAPTER 4 overall survival. However, the main impact lies in delaying the need for palliative hor- monal treatment, while providing a chance of cure through local control. With this in mind, it is important to consider treatment-related side effects of focal salvage treatments. Although toxicity might be underreported in many current series due to the retrospective nature of data collection, the general trend seems favorable. Severe GU and GI toxicity seem limited to a maximum of 5-10%. Potency preservation (measured with the international index of erectile function [IIEF] or CTCAE) is observed in the majority of patients in many of the series. Treatment effects on patient-reported quality of life was only reported in focal salvage brachytherapy series, revealing no significant changes in most domains, except an increase in urinary symptoms after focal low-dose-rate brachytherapy [78]. Table 1 provides an overview of functional and oncologic outcomes of the different focal salvage treatment modalities. To determine which patients benefit the most from focal salvage treatment, it is import- ant to consider other patient and tumor characteristics, too. In the above mentioned studies, patients with stage T1-T3b recurrent tumors, total Gleason score ≤6-10 and PSA-levels between 0.01 and ≥20 ng/ml were treated. This indicates that a wide range of patients, classified from (very) low-risk to high-risk disease, were included. Most studies did not report on the pre-treatment PSA doubling time (PSADT). In a Delphi consensus study among 18 experts in the field of salvage brachytherapy for radiore- current prostate cancer, 88% of participants indicated that stage T3b should be the maximum tumor classification to be eligible for salvage treatment. A total of 94% agreed that the Gleason score should not be used as a criterion (with over half of participants stating that the Gleason score cannot be determined in case of relapse after primary radiotherapy). In terms of PSA kinetics, a maximum PSA-level of 10 ng/mL and mini- mum PSADT of 6 months was preferred by most participants [88]. A prediction study on factors associated with failure after focal salvage HIFU revealed that the length of the interval between primary treatment and radiologic recurrence, prostatic volume, T-stage, PSA-level, PSADT and primary tumor Gleason score are potential predictors of failure [89]. More research is warranted to better understand which combination of patient and tumor characteristics is best served by (which) focal salvage treatment. The decision-making process before and after focal salvage treatment is displayed in a flow chart in Figure 2.