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group. Subgroup analyses showed that patients with
aggressive disease experienced the most benefit from
combination therapy. The most common adverse event
reported was gynecomastia (69.7% in the bicalutamide arm
vs 10.9% in the placebo arm).
Experts’ comments:
The timing and modality for treatment of biochemical recur-
rence after RP are a major challenge for all physicians. Shipley
et al showed that combining sRT with antiandrogen therapy
leads to a significant improvement in outcome. They also
showed that the greatest benefit was achieved in patients
with aggressive disease [1].
There are several aspects of this study that must be
considered. The authors also state that the definition of
biochemical recurrence was complex because of a change in
the lowest detectable PSA level from 0.5 to 0.2 ng/ml during
the enrollment period. This reflects the continuous im-
provement in diagnostic tests and therapeutic strategies
over time. Almost 20 yr ago, when this study was designed,
PSA could be detected at minimum level of 0.5 ng/ml and
highly sensitive imaging modes such as positron emission
tomography scan were not routinely available, possibly
leading in some cases to late detection of recurrence. Early
detection and treatment of biochemical recurrence are
essential for better cancer control [2]. Conversely, the
randomization process and the relative short recruitment
period of 5 yr have probably smoothed this bias. The authors
reported significantly better OS for the bicalutamide arm,
particularly in the subgroup of patients who presented with
PSA >1.5 ng/ml at inclusion, reflecting the magnitude of the
combined treatment in an unfavorable situation. However,
if the same patients had been treated with sRT at a lower
PSA level, would antiandrogen therapy have been neces-
sary? In the era of precision medicine, the one-size-fits-all
approach is certainly not the best one. Diagnostics and risk
stratification models have improved over time, optimizing
the indications for salvage therapy, reducing overtreatment,
and minimizing side effects. Administration of systemic
therapy should probably be considered only for patients
presenting with high-risk features. Another question that
remains open is the duration of hormone therapy. Results
were recently published for the GETUG-AFU 16 study. In
this multicenter randomized controlled trial, addition of
10.8 mg of goserelin to sRT for biochemical recurrence and a
repeat injection after 3 mo led to a significant reduction in
biochemical or clinical progression after 5 yr when
compared to placebo (80% vs 62%, HR 0.5; p < 0 0001)
[3]. It is noteworthy that no difference in OS could be
observed, reflecting the biology of a disease that requires
longer follow-up to correctly assess survival outcomes. The
last issue that should be considered is whether RT should be
salvage or adjuvant, particularly in the population at
intermediate risk. RADICALS is an ongoing phase 3 trial
that will hopefully help shed light on how to manage these
patients [4].
In conclusion, patients with high-risk features and PSA-
only recurrence may experience a survival benefit from
multimodal treatment consisting of sRT and hormonal
therapy. Treatment can be curative in 76.3% of patients. The
biggest challenge remains patient selection for the multi-
modal approach or salvage surgery, specifically among
those who are at intermediate risk of progression. Patient
selection may be improved by new imaging technologies.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
[2]
[3]
[4]
David D’Andrea, [1_TD$DIFF]Shahrokh F. Shariat*[2_TD$DIFF]
Urology Department, Medical University of Vienna, Vienna,
Austria
*Corresponding author. Urology Department, Medical University of
Vienna, Wa¨hringer Gu¨ rtel 18–20, Vienna 1090, Austria.
E-mail address: ([1_TD$DIFF]Shahrokh F. Shariat).
# 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Lower Urinary Tract Symptoms and Incident Falls in
Community Dwelling Older Men: The Concord Health
and Ageing in Men Project
Noguchi N, Chan L, Cumming RG, et al
J Urol 2016;196:1694–9
Experts’ summary:
In the study by Noguchi et al [1], the authors conducted a
prospective cohort study of men above the age of 70 yr of age.
total of 1090 men were selected from the New South Wales
electoral roll. Urinary symptoms were assessed using the
International Prostate Symptom Score and the Incontinence
Consultation on Incontinence Questionnaire. The authors
found increased storage symptoms, with or without urgency
incontinence, were associated with falls.
Experts’ comments:
Male lower urinary tract symptoms (LUTS) is prevalent among
the elderly population with over 40% of those reporting uri-
nary leakage [2]. In addition to a diminished quality of life,
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