Letter to the editor in response to Hopper et al, "Salvage image guided radiation therapy to the prostate after cryotherapy failure".

We read with great interest the article by Hopper et al on salvage image guided radiation therapy after failure of cryotherapy among 8 patients with prostate cancer with no acute grade 2 toxicities.

As the authors note, radiation therapy for salvage of a local recurrence after cryotherapy yields acceptable disease control rates and relatively low toxicity or additional morbidity. However, even though salvage radiation therapy may provide minimal increased toxicity, cryotherapy followed by radiation therapy can result in more toxicity and worse disease control than upfront curative-intent radiation therapy.

In our experience, patients who received upfront cryotherapy suffered higher rates of grade 3 toxicities that were directly attributable to the cryosurgical procedure and lower rates of biochemical control compared with patients who received upfront radiation therapy. Among >1000 men with prostate cancer who were treated with upfront radiation therapy at our institution, the cumulative incidence for all grade 3 toxicities was 5%, compared with a toxicity rate approaching 17% in patients who had received either cryosurgery or high-intensity focal ultrasound before image guided radiation therapy.3, 4

Rather than debate or focus on the role of advancing technology, we should consider the toxicities that result from cryotherapy in addition to those after radiation therapy. Although salvage radiation therapy provides acceptable biochemical control rates and minimal additional toxicity, it is important to remember that primary radiation therapy provides excellent oncologic control without the morbidity associated with cyrotherapy.