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• W4308768071 abstract "In the current issue of BJUI, Swedish researchers report on late toxicity induced by post-prostatectomy radiation (PPR). This late toxicity includes urinary and rectal toxicity and data on induced secondary malignancies [1]. Based on patient and outcome data available in the Prostate Cancer Database Sweden (PCBaSe) the authors compared the toxicity data of patients treated with PPR and patients treated with prostatectomy alone (PRAL). Using 1:2 matching, the data of 2789 patients who received PPR and 5578 patients who underwent PRAL were analysed [1]. Not surprisingly, the largest difference was observed in the incidence of late genitourinary (GU) toxicity. Indeed, urinary tract procedures were more often needed in the PPR group than in the PRAL group. The same applied to haematuria (five times higher rate in the PPR group) and the necessity for urinary diversion (three times higher in the PPR group, but still very low absolute numbers). Added to this increased risk of (severe) urinary toxicity, patients in the PPR group had a significantly higher probability of developing secondary bladder cancer, although the absolute numbers remained low [1]. The authors should be congratulated for performing this huge task. As they correctly state, toxicity data after a very long follow-up in PPR patients are sparse. Nevertheless, there are some constructive remarks to make, which might be of relevance for further research in this area. First, details concerning the irradiated volume and radiation doses are missing. As the patient inclusion covered a time span of nearly 20 years, it is very likely that changes in clinical target volume, planning target volume (these terms refer to the volumes to be treated), beam set-up and radiation technology/dose have occurred. As an example, the term ‘salvage’ radiotherapy may refer both to radiotherapy of the prostatic bed only and to radiotherapy of the prostatic bed and pelvic lymph nodes (whole-pelvis radiotherapy), for which, in turn, several volume definitions have been implemented over time [2]. It is likely that patients treated with whole-pelvis radiotherapy will be more likely to develop more pronounced late GU toxicity [3]. Therefore, it would be of value to know the radiation volumes that were used in the patients included in the PCBaSe, and, if relevant, to know the late GU toxicity rates of whole-pelvis radiotherapy versus prostatic bed radiotherapy. While the median follow-up periods were 4.1 and 5.1 years in the PPR group and PRAL group, respectively, the authors report on late toxicity at 15 years. Although this leads to substantial 95% CIs, as can be concluded from figs 2 and 3, these results confirm well-known and important data. Figure 2 clearly demonstrates the time-dependent increase in (severe) GU toxicity, which is certainly the case for haematuria. In that sense, it is a pity that details concerning the use of anticoagulants are missing. Indeed, the use of anticoagulant/antiplatelet treatment significantly increases the risks of developing severe haematuria and the need for admission to hospital [4]. Figure 3b confirms the time-dependent tendency for secondary bladder cancer to be induced in the PPR group, with an incidence of approximately 3% and 5% at 10 and 15 years, respectively. Without stating it explicitly, the authors hereby stress the importance of strict and lifelong follow-up of PPR patients. Although the advent of intensity-modulated radiation photon techniques has lowered the probability of developing rectal toxicity, this will not be the case for urethral toxicity and the development of secondary tumours, as both are linked to the high-dose regions. In contrast to the volumes receiving intermediate doses, the volume of urethra and bladder receiving a high dose (e.g., >66 Gy) will not be lower using intensity-modulation as they are in the clinical target volume. A more philosophical but also positively intended remark can be made concerning the discussion, which strongly focuses on late toxicity. The reader should realize, however, that salvage radiotherapy (whether combined with temporary administration of androgen deprivation therapy) is the only curative treatment when biochemical recurrence occurs after radical prostatectomy. The best cure rates are observed when PSA level prior to PPR is low [5]. ‘Cure’ means the absence of prostate cancer and eventually metastatic disease and the avoidance of need for palliative lifelong androgen deprivation therapy with its well-known toxicity and impact on quality of life [6]. It would have been interesting to know the percentage of patients who were cured within the present study, and it would have been even more interesting to know the authors' viewpoint on the balance between presence of PPR-induced toxicity and avoidance of ADT-induced toxicity. In fact, the same goes for the comparison between PPR-induced toxicity and toxicity after primary radiotherapy. In conclusion, this paper stresses the importance of late follow-up in patients treated with PPR because late GU toxicity (including development of secondary malignancies) mounts with time. However, the reported late toxicity should not be a ‘gamechanger’ and lead to avoidance of PPR. The author declares no conflicts of interest." @default.
• W4308768071 created "2022-11-15" @default.
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• W4308768071 date "2022-11-10" @default.
• W4308768071 modified "2023-09-26" @default.
• W4308768071 title "Post‐prostatectomy radiotherapy: does late toxicity lead the game?" @default.
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• W4308768071 doi "https://doi.org/10.1111/bju.15875" @default.
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