Radiation Therapy After Radical Prostatectomy

With the current advances in screening, earlier detection of prostate cancer, and improved techniques for performing radical prostatectomy, a larger number of patients are being surgically treated. However, on pathologic examination of their prostate, these patients might not have organ confined disease. The pathologic features which predict failure in those cases are unknown prior to surgery. This includes patients with seminal vesicle invasion, positive surgical margins, and high Gleason scores. Patients at high risk for local recurrence are candidates for further therapy to control the local disease. These patients represent a large proportion of surgically treated patients. In spite of 58% of patients having clinically localized disease at presentation, over one-half will likely be T3 disease. 1 This is despite all the advances in screening. Adjuvant radiotherapy and/or various methods of androgen deprivation are available for this group of patients. A Mayo Clinic study found that 5-year local recurrence-free survival rates were >95% among prostatectomy patients who had either radiation or orchiectomy compared with 84% for patients who received no adjuvant therapy. 2 However, no advantage for adjuvant therapy was found in overall or cause-specific mortality. One recent study reported the efficacy of adjuvant radiation after radical prostatectomy, but only among patients found with pT3 who had an undetectable PSA after surgery. 3 Postoperative radiation therapy can be given as adjuvant or salvage irradiation. Adjuvant radiation therapy can be used postoperatively for patients with high risk of recurrence. Radiation used as salvage therapy is usually associated with biochemical failure, whether it is associated with a palpable local or biopsy-detected lesion or not. The questions that we need to answer are: • Does radiation therapy following surgery offer any advantage in local control? • Does radiation therapy in this setting have any influence on survival and mortality? • What predicts patients prognosis after radical prostatectomy? • What should our indications be to use radiation therapy in the postoperative setting? • How can radiation therapy be used most effectively -- salvage or adjuvant?