Dr. Ian Thompson, UTHSCSA discussed the benefits of adjuvant radiotherapy for a localized recurrence of prostate cancer (CaP). He cited the data from the EORTC trial where patients with positive surgical margins or seminal vesicle invasion had improved survival if given adjuvant radiotherapy. He also reviewed his data on 473 men primarily with stage pT3 CaP. With adjuvant radiotherapy they showed a 30-40% improvement in recurrence-free survival with adjuvant radiotherapy. There was also a 60% decrease in disease recurrence. Complications were higher in the patients undergoing adjuvant radiotherapy and worse bowel and urinary function were noted in the first 2 years, but not thereafter. Erectile function was not different. However, no significant difference was found regarding metastasis free or overall survival.

Dr. Kevin Slawin, Baylor College of Medicine presented the case for salvage as opposed to adjuvant radiotherapy. His primary message was to agree that adjuvant radiotherapy decreases biochemical recurrence, but early identification of recurrence and initiation of salvage therapy may be equally effective. He described a wide resection of the bladder neck and seminal vesicles in patients at risk for pT3b disease. Application of this surgical technique with extended lymph node dissection can decrease the risk for recurrence, argued Dr. Slawin. Dr. Slawin also discussed that up to 50% of patients with a positive surgical margin at radical prostatectomy will never experience a clinical recurrence. As such, half of patients will be receiving treatment unnecessarily. If monitored, a rising PSA can prompt salvage radiotherapy and if given before the PSA rises to >1ng/ml, outcomes may be similar to the adjuvant setting. At Baylor, patients are followed with the ultrasensitive PSA test for early detection and determination of doubling time, which has narrowed the window between adjuvant and salvage therapies. Furthermore, no trial has randomized men at risk for recurrence following radical prostatectomy to adjuvant vs. salvage radiotherapy. The EORTC data published did not divide patients with a positive surgical margin to focal or gross. However, their presentation of the data at the winter SUO meeting did not show a benefit for those with a focal positive surgical margin.

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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