Radiation therapy after radical prostatectomy: why patience is a virtue! The case for salvage radiation therapy

Without reliable clinical or pathologic predictors of local recurrence, selection of patients for adjuvant radiotherapy based on any combination of clinical or pathological parameters is bound to lead to the unnecessary treatment of significant numbers of patients whose disease might not have ultimately recurred or who might have been destined to have recurrence with extrapelvic metastatic disease, for which pelvic radiation would be ineffective. Furthermore, new ultrasensitive prostate-specific antigen (PSA) assays can identify patients actually failing surgery with a detectable and rising PSA earlier than ever, when disease volume is low and still amenable to salvage radiation therapy, and can allow the calculation of the PSA doubling time, which is gaining widespread acceptance as a proven predictor of response to salvage radiation therapy in this setting. Therefore, the rationale for preemptive adjuvant radiation therapy after radical prostatectomy is weaker than ever.