Abstract
Adjuvant radiotherapy (ART) after prostatectomy for patients with high-risk features [extracapsular extension (ECE), seminal vesicle invasion (SVI), and positive margin] has been shown to be associated with improved biochemical disease-free survival in three large randomized trials and with improved overall survival in one. Similarly, salvage radiotherapy (SRT) can effectively achieve biochemical control in a significant proportion of patients with a rising PSA after surgery. Nonetheless, both approaches of postoperative RT remain highly underutilized. This might be partly due to concerns with overtreatment inherent to adjuvant approaches, and/or hesitance about causing radiation toxicities and their subsequent effects on the patient’s quality of life. Herein, we review the literature lending evidence to these arguments. We show recent series of ART/SRT and their low rates of acute and long-term toxicities, translating only in transient decline in quality-of-life (QoL) outcomes. We conclude that concerns with side effects should not preclude the recommendation of an effective and curative-intent therapy for men with prostate cancer initially treated with radical surgery.
Highlights
ROLE OF ADJUVANT AND SALVAGE RADIOTHERAPY AFTER PROSTATECTOMY AND THE UNDERUTILIZATION PROBLEMThere were approximately 220,800 new cases of prostate cancer (PCa) diagnosed only in the US in 2015, with 27,540 patients dying from the disease [1]
We show recent series of Adjuvant radiotherapy (ART)/salvage radiotherapy (SRT) and their low rates of acute and long-term toxicities, translating only in transient decline in quality-of-life (QoL) outcomes
According to a recent analysis based on SEER data, 90% of prostate cancer cases in the US are diagnosed in localized stages, and 40% of these are treated with radical prostatectomy [2]
Summary
ROLE OF ADJUVANT AND SALVAGE RADIOTHERAPY AFTER PROSTATECTOMY AND THE UNDERUTILIZATION PROBLEM. Three randomized trials from cooperative groups (SWOG-8794, EORTC 22911, and ARO 96-02) have demonstrated significant biochemical disease-free survival improvement with adjuvant radiotherapy for patients with high-risk features [8,9,10,11] One of these trials showed superior overall survival in the radiation arm [11]. During the last decade, the absolute utilization rates have not significantly changed despite the publication of the three large ART randomized trials [21, 24, 26], notwithstanding the fact that recommendation for the use of adjuvant radiation has increased [25] This discrepancy between evidence and practice is more pronounced in older patients, plausibly due to the uncertainty about treatment benefits in the context of a shorter life span and/ or higher comorbidities [21]. The evidence presented here could serve to guide treatment individualization and shared decision-making between physicians and patients regarding curative-intent adjuvant and salvage radiotherapy after radical prostatectomy
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