Despite the stage migration and concomitant improvements in prostate cancer–specific survival (PCSS) associated with widespread prostate-specific antigen (PSA) screening, approximately 1 in 3 men with clinically localized disease will develop a detectable PSA after radical prostatectomy (RP) in contemporary series.1 The natural history of prostate cancer with biochemical failure after RP can be variable; however, approximately two thirds of these men will develop metastatic disease if left untreated and most will die of prostate cancer.2 The argument for postoperative radiotherapy (RT) is predicated on the assumption that some patients may have residual local disease of a potentially lethal phenotype after surgery and that the delivery of secondary local therapy may interrupt the natural history of disease and prevent progression to systemic disease. A basic question in this context is the extent to which this sequence of events—versus the presence of occult metastases at surgery—characterizes the natural history of recurrent and progressive disease.
An emerging body of literature showing efficacy for secondary RT suggests that residual local disease after surgery may represent a much more important avenue of prostate cancer progression than previously appreciated. For patients with high-risk features at RP or who experience biochemical recurrence after RP, solid evidence now shows that secondary RT provides benefit. Reflecting this, the most recent update of the NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer states “new evidence supports offering adjuvant/salvage RT in all men with adverse pathologic features or detectable PSA”3 (to view the most recent version of these guidelines, visit the NCCN Web site at www.NCCN.org). In 2010, the dilemma is not in the question of whether postprostatectomy adjuvant or salvage RT are effective among high-risk patients as a group, but rather which individual patients ought to receive it and when.
Against this backdrop, this article attempts to synthesize salient recent studies in this field to address several important questions relevant to counseling patients regarding the use of postoperative RT. The first section reviews the evidence base showing benefit for postoperative RT in the adjuvant and salvage settings. The next section discusses insights from the data underscoring the heterogeneity of disease recurrence and response to RT among subgroups of patients in different treatment settings. The final section reviews the risks of postoperative RT and highlights important ongoing clinical trials addressing gaps in current understanding.
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. Wiegel T Bottke D Steiner U Phase III postoperative adjuvant radiotherapy after radical prostatectomy compared with radical prostatectomy alone in pT3 prostate cancer with postoperative undetectable prostate-specific antigen: ARO 96-02/AUO AP 09/95. J Clin Oncol 2009; 27: 2924– 2930.
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. Wiegel T Lohm G Bottke D Achieving an undetectable PSA after radiotherapy for biochemical progression after radical prostatectomy is an independent predictor of biochemical outcome--results of a retrospective study. Int J Radiat Oncol Biol Phys 2009; 73: 1009– 1016.
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