Radiation Therapy After Radical Prostatectomy: What Has Changed Over Time?

Abstract

The role and timing of radiotherapy (RT) in prostate cancer (PCa) patients treated with radical prostatectomy (RP) remains controversial. While recent trials support the oncological safety of early salvage RT (SRT) compared to adjuvant RT (ART) in selected patients, previous randomized studies demonstrated that ART might improve recurrence-free survival in patients at high risk for local recurrence based on adverse pathology. Although ART might improve survival, this approach is characterized by a risk of overtreatment in up to 40% of cases. SRT is defined as the administration of RT to the prostatic bed and to the surrounding tissues in the patient with PSA recurrence after surgery but no evidence of distant metastatic disease. The delivery of salvage therapies exclusively in men who experience biochemical recurrence (BCR) has the potential advantage of reducing the risk of side effects without theoretically compromising outcomes. However, how to select patients at risk of progression who are more likely to benefit from a more aggressive treatment after RP, the exact timing of RT after RP, and the use of hormone therapy and its duration at the time of RT are still open issues. Moreover, what the role of novel imaging techniques and genomic classifiers are in identifying the most optimal post-operative management of PCa patients treated with RP is yet to be clarified. This narrative review summarizes most relevant published data to guide a multidisciplinary team in selecting appropriate candidates for post-prostatectomy radiation therapy.

Characterization of Lymph Node Tumor Burden in Node-Positive Prostate Cancer Patients after Robotic-Assisted Radical Prostatectomy with Extended Pelvic Lymph Node Dissection

“…In addition, many patients with low volume LNI may continue to receive excessive and potentially unnecessary post-operative therapy [26,27]. For example, in 2021 Zattoni et al reported that although adjuvant radiation therapy may improve recurrence-free survival compared to salvage therapy in patients with high risk for local recurrence, up to 40% of patients could be overtreated [28].…”

Joint models for dynamic prediction in localised prostate cancer: a literature review

“…This review focused on radiotherapy, however there are other treatments for prostate cancer including hormone therapy, prostatectomy and combinations therein, though optimal timing of these combinational therapies appears unclear [ 96 , 97 ]. There have been recent advances in using sophisticated machine learning/artificial intelligence (ML/AI) techniques on imaging data to predict whether patients require biopsies, or to predict clinical failure or death under these alternative treatment pathways.…”

Addressing controversial areas in the management of advanced prostate cancer in Canada

“…Histology and risk factors are important in determining PSA levels to initiate salvage radiation therapy. 31,32 Results from the RADICALS trial showed no additional benefit with adjuvant radiation therapy after radical prostatectomy compared with early salvage radiation therapy for PSA biochemical progression. 33 Individual consideration is important before suggesting adjuvant or salvage radiotherapy in prostatectomy patients based on factors such as PSA levels, Gleason score, adverse risk factors, nodal status, and the postoperative clinical condition of the patient.…”