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Radiation therapy for prostate cancer after prostatectomy: adjuvant or salvage?

Nature Reviews Urology volume 8, pages 385–392 (2011)Cite this article

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Abstract

Approximately 15–25% of men who undergo radical prostatectomy for localized prostate cancer will experience a PSA-defined biochemical recurrence (BCR) of their cancer—men with poorly differentiated cancer, non-organ-confined disease, and positive surgical margins are at the highest risk. Accumulating evidence indicates that postoperative radiation therapy to the prostate bed favorably influences the course of disease in men with pathological features of poor prognosis. Three phase III randomized trials of adjuvant radiotherapy versus observation have reported improved freedom from BCR, and one study has reported improved metastasis-free survival and overall survival. Similar evidence from randomized trials for salvage radiotherapy is lacking; however, several observational studies have reported durable responses to salvage radiotherapy and reduced cancer-specific mortality in a substantial proportion of high-risk patients, provided that it is administered at the earliest evidence of BCR. The appeal of salvage radiotherapy is that a substantial proportion of patients with non-organ-confined cancer or positive surgical margins are cured after radical prostatectomy alone, thereby limiting the adverse effects of postoperative radiotherapy—which include urinary and bowel dysfunction, sexual dysfunction and secondary pelvic malignancies—to only those whose cancer was not cured by surgery. In the absence of data from randomized trials demonstrating the superiority of adjuvant radiotherapy over a surveillance strategy (with planned salvage radiotherapy at the earliest evidence of BCR), we advocate shared decision making between physicians and patients, based on the relative advantages and disadvantages of each approach.

Key Points

  • The predominant pattern of treatment failure in men with a rising PSA level after radical prostatectomy is locoregional

  • Postoperative radiotherapy (as adjuvant or salvage therapy) can reduce the risk of PSA progression and distant metastasis and improve overall and cancer-specific survival

  • Adjuvant radiotherapy for men with positive surgical margins, extraprostatic extension, or seminal vesicle invasion is supported by evidence from three large randomized trials

  • Salvage radiotherapy can have similar outcomes to immediate adjuvant radiotherapy if it is administered at the earliest evidence of biochemical recurrence

  • We advocate shared decision making with patients based on the advantages and disadvantages of adjuvant radiotherapy over a surveillance strategy, with planned salvage radiotherapy at the earliest evidence of recurrence

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Figure 1: Hypothetical timeline of cancer recurrence after local therapy to metastasis progression for prostate cancer compared with breast cancer.

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Acknowledgements

C. P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape, LLC-accredited continuing medical education activity associated with this article.

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  1. Center for Urologic Oncology, Glickman Urological & Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195-0001, OH, USA

    Amit R. Patel & Andrew J. Stephenson

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Both authors contributed equally to researching data for the manuscript, writing, and editing of this article before submission.

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Correspondence to Andrew J. Stephenson.

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Patel, A., Stephenson, A. Radiation therapy for prostate cancer after prostatectomy: adjuvant or salvage?. Nat Rev Urol 8, 385–392 (2011). https://doi.org/10.1038/nrurol.2011.80

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