The American Society for Radiation Oncology (ASTRO) and the American Urological Association (AUA) have set forth several recommendations and clinical principles on the topic of radiation therapy after prostatectomy for patients with and without evidence of prostate cancer recurrence in a joint document, Adjuvant and Salvage Radiotherapy After Prostatectomy: ASTRO/AUA Guideline. The guideline has been published in ASTRO’s International Journal of Radiation Oncology, Biology, Physics (2013;86:822-828) and in AUA’s The Journal of Urology (2013;190:441-449).
Based on their comprehensive review of 324 research articles published from January 1990 through mid-December 2012, the guideline authors recommend that candidates for radical prostatectomy as a treatment for localized prostate cancer be informed of the potential for adverse pathologic findings that portend a higher risk for cancer recurrence. Patients with adverse pathologic findings at prostatectomy (seminal vesicle invasion, positive surgical margins, extraprostatic extension) should be offered adjuvant radiotherapy and should be informed that, compared with radical prostatectomy alone, adjuvant radiation therapy reduces the risk for biochemical recurrence (prostate-specific antigen, or PSA), local recurrence, and clinical progression of cancer. Salvage radiotherapy should be offered to patients with PSA or local recurrence after prostatectomy in whom there is no evidence of distant metastatic disease.
The guideline states that clinicians should define biochemical recurrence as a detectable or rising PSA value after surgery that is at least 0.2 ng/mL, with a second confirmatory level of at least 0.2 ng/mL. Patients should be told that a PSA recurrence after surgery is associated with a higher risk for metastatic prostate cancer or death from the disease. These men should also be made aware that radiation therapy for PSA recurrence is most effective when administered for lower levels of PSA. A restaging evaluation in patients with a PSA recurrence may be considered.
The decision to administer radiotherapy should be made by the patient and the multidisciplinary treatment team, according to the guideline. The patient’s history, values, preferences, quality of life, and functional status should all be factors in the decision-making process. Men who are considering undergoing this treatment should be informed of its possible short-term and long-term urinary, bowel, and sexual side effects as well as the potential benefits of preventing cancer recurrence.