Radiation therapy post radical prostatectomy: who, when and why?

Purpose of review: During decades, adjuvant radiotherapy (ART) has been the standard of care after surgery, based on four randomized clinical trials (RCTs). As early salvage radiotherapy (SRT) recently challenged the ART paradigm, the optimal timing to initiate radiotherapy remains a matter of debate.

Recent findings: Three RCTs evaluated ART or SRT for postprostatectomy patients, with pathological risk factors (Gleason score > 8, pT3, positive margins). The ARTISTIC meta-analysis demonstrated similar 5-year biochemical recurrence-free survival for ART and SRT (89 vs. 88%). Lower rates of late genitourinary toxicity were demonstrated within the SRT arm, favouring early SRT in clinical practice.The addition of pelvic lymph node radiotherapy recently demonstrated an improvement in freedom from progression within the randomized RTOG 0534 trial, especially for patients with pretreatment prostate serum antigen (PSA) levels more than 0.35 ng/ml. The most appropriate androgen deprivation therapy duration remains a point of controversy.

Summary: The SRT approach can be favoured for the vast majority of patients, provided close monitoring of PSA and early treatment in the event of biochemical recurrence. Radiotherapy dose and volumes and ADT use might be correlated to SRT timing (early vs. late). Results from trials including genomic tests and metabolic imaging will probably help to refine these criteria.