Adjuvant radiotherapy after radical prostatectomy: evidence and analysis

Although surgery provides excellent control for localized prostate cancer, pathologic examination of more than one-third of specimens will reveal positive surgical margins, seminal vesicle invasion, and/or extracapsular extension, thus putting these patients at increased risk of cancer recurrence. "Adjuvant" radiotherapy (ART) refers to treatment of patients with an undetectable PSA that is delivered after surgery (usually less than 12-16 weeks from the time of surgery). Currently, there are no standardized guidelines for the use of ART and the bulk of patients are solely monitored for signs of recurrence after prostatectomy. In this article, we review the evidence for ART from three randomized clinical trials. Although radiation therapy in the adjuvant setting has generally been well tolerated, we also examine the complication data associated with treatment. In addition, we discuss the technical aspects of treatment, including dose escalation and treatment target volume. The ability to increase dose and limit target volume would likely result in higher cure rates and decreased side effects, thus ensuring a better clinical outcome and increasing quality of life. Finally, we discuss the cost-effectiveness of ART, in the context of other medical interventions.