Adjuvant versus salvage radiotherapy for high-risk prostate cancer patients

Radiotherapy (RT) after prostatectomy may potentially eradicate any residual localized microscopic disease in the prostate bed. The current dilemma is whether to deliver adjuvant RT solely on the basis of high-risk pathology (pT3 or positive margins), but in the absence of measurable prostate-specific antigen, or whether early salvage radiotherapy (SRT) would yield equivalent outcomes. Although the results of current randomized trials answering this very question remain years away, the best evidence to date supports early SRT as the better strategy. In terms of SRT, the pooled evidence reveals that one should initiate RT at the lowest prostate-specific antigen possible to maximize results. Similarly, the pooled data suggest that there is a dose-response favoring doses >70 Gy to the prostate bed. The evidence regarding the role of androgen deprivation therapy and the use of elective pelvic nodal RT is weak, and ongoing randomized trials are underway. Several clinical scenarios are presented for discussion.