Prostate cancer: more effective use of underutilized postoperative radiation therapy

ABSTRACT

Introduction: Adverse pathological features at radical prostatectomy such as extracapsular extension, seminal-vesicle involvement, positive surgical margins and/or lymph node invasion define a particular subgroup of patients that might benefit from additional treatment after surgery, in particular radiation therapy.

Areas covered: Post-prostatectomy radiation is intended as adjuvant, early-salvage or salvage depending on the timing and PSA levels at the treatment. After providing the most used definitions, the high-level evidence supporting adjuvant radiation is reviewed together with the limitations affecting its utilization. In recent years early-salvage radiation was hypothesized to be a non-inferior alternative based on good-quality retrospective data. Recently, preliminary results of ongoing trials provide additional evidence. In light of the need to identify patients that will truly benefit from adjuvant radiation, clinically based and molecular tools available for this purpose are reviewed.

Expert opinion: In order to tailor treatment for the patient after radical prostatectomy, there is a need for a tool that could both improve the oncological outcomes and be cost-effective. To date, genomic testing provides the most promising results that will be reasonably improved in the coming years.

KEYWORDS:

• Adjuvant Radiation Therapy
• biochemical recurrence
• early salvage radiation therapy
• prostate cancer
• radical prostatectomy

Article Highlights

• Four randomized clinical trials show a benefit for adjuvant radiation therapy in high-risk patients after prostatectomy in terms of preventing biochemical recurrence but there is no clear benefit on survival.

• Early salvage radiation therapy (PSA <0.5 ng/ml) is now being considered a safe non-inferior alternative and preliminary results of ongoing trials support the findings of previous retrospective studies.

• To date, there is no consensus on who is the patient that can still benefit from adjuvant radiation.

• In order to provide a personalized treatment and avoid overtreatment, several scores and nomograms have been developed.

• Promising results are emerging from the use of a Genomic Classifier, although prospective results and validation data on this particular setting are still needed.

Declaration of Interest

R Jeffrey Karnes has personal and institutional royalties associated with GenomeDx Biosciences. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper received no funding.