What is Salvage Therapy?
Salvage therapy is treatment administered with curative or palliative intent after initial definitive therapy has failed, most commonly applied when patients experience biochemical recurrence (BCR) or disease progression following primary treatment. 1
Core Definition and Intent
Salvage therapy represents a second-line curative approach undertaken after failure of primary definitive treatment. 1 The term is most extensively defined in the context of prostate cancer, where it specifically addresses management of BCR following radical prostatectomy (RP) or radiation therapy (RT). 1
Local salvage therapy is generally undertaken with curative intent, distinguishing it from palliative systemic therapy alone. 1
Clinical Context and Application
After Radical Prostatectomy
- Salvage radiation therapy to the prostate bed is the primary curative-intent salvage treatment for BCR after RP without metastatic disease. 2
- Androgen deprivation therapy (ADT) is added to salvage RT for patients with high-risk features (PSA ≥0.7 ng/mL, Gleason Grade Group 4-5, PSA doubling time ≤6 months, persistently detectable post-operative PSA, or seminal vesicle involvement). 1, 3
- The minimum duration of ADT when combined with salvage RT is 4-6 months, with extension to 18-24 months for patients with multiple high-risk features. 3
After Radiation Therapy or Focal Ablation
- Salvage treatment options include salvage radical prostatectomy, cryoablation, high-intensity focused ultrasound (HIFU), or reirradiation. 1
- Prostate biopsy must be performed before any local salvage therapy to confirm recurrent cancer—treatment should never be based solely on imaging findings due to false-positive rates. 1
- Salvage therapy after RT carries higher risks of treatment-related adverse events affecting urinary, sexual, and bowel function compared to primary treatment. 1
Regional and Oligometastatic Disease
- For pelvic nodal recurrence following RP, salvage RT to the prostate bed and pelvic lymph nodes plus ADT should be offered. 1
- Salvage treatment should be largely reserved for Grade Group 2 and higher recurrences in individuals with life expectancy greater than 5-10 years. 1
Beyond Prostate Cancer
In other malignancies, salvage therapy follows similar principles:
- Lymphomas: High-dose chemotherapy followed by autologous stem cell transplantation serves as salvage therapy after failure of primary chemotherapy regimens. 4, 5
- Germ cell tumors: Salvage chemotherapy (standard dose VIP, TIP, or VeIP) is used for relapse after primary treatment, with surgery playing a role in localized or late relapses. 1
- Testicular seminoma: Chemotherapy is the salvage treatment of choice after radiation failure, though re-irradiation may be considered for localized, small-volume relapse with long intervals. 1
Critical Distinctions
Salvage therapy differs fundamentally from palliative systemic therapy—historically, up to 90% of patients with recurrence after radiation do not receive local salvage therapy and instead are managed with ADT alone, which is not curative. 1
The key distinguishing feature is curative intent: salvage therapy aims to achieve long-term disease control or cure in patients who have failed primary treatment but have not yet developed widespread metastatic disease. 1