Radiotherapy in the Management of Prostate Cancer After Radical Prostatectomy

Detlef Bartkowiak; Dirk Bottke; Thomas Wiegel

Disclosures

Future Oncol. 2013;9(5):669-679. 

In This Article

Abstract and Introduction

Abstract

The choice of treatment options for prostate cancer patients who have undergone radical prostatectomy depends on their risk profile, which is determined by the tumor node metastasis (TNM) status, histopathologic findings, and the pre- and post-radical prostatectomy PSA characteristics. The results of large clinical studies with a 10-year follow-up or more are the backbone of predictive models for risk estimates that incorporate these criteria and also for guideline recommendations. For low-to-intermediate-risk prostate cancer patients and older patients, observation with – in case of biochemical recurrence – early salvage radiotherapy can be advised after R0 resection, thus, avoiding overtreatment. After R1 resection, adjuvant radiotherapy should be considered. Patients with two or more positive lymph nodes and/or with distant metastasis may benefit from adjuvant hormone deprivation therapy. Beyond this rough outline, detailed analysis of subgroups is still required (and ongoing) to enable individually optimized treatment.

Introduction

Recently, model calculations on prostate cancer (PC)-specific mortality have been published that apply three independent models on Surveillance, Epidemiology and End Results data to understand the progress that has been achieved in tackling this disease since the 1990s. It was concluded that changes in the primary treatment alone can not explain the positive development. Nor does PSA screening for early diagnosis deserve all the credit as "changes in secondary disease management may have been primarily responsible for the early decline in mortality".[1]

A comprehensive review on postprostatectomy radiotherapy (RT) appeared in this journal in 2011.[2] Therefore, in the present paper, we will focus on the most recent publications on this topic. Nonetheless, some basic studies and well-established facts have to be recalled in brief. We will adopt the recently updated recommendations from the German interdisciplinary S3-guideline for the management of PC,[201] which may, in a few aspects, deviate from the various regional or national routines.

Owing to an increased awareness and screening of PSA, PC is now the most frequent male malignancy in developed countries; it ranks third in mortality.[3] Regarding the side effects and quality of life, active surveillance or watchful waiting are options for patients with a low-risk profile/localized disease and/or higher age.[4–9] Alternatively, and for more advanced stages, radical prostatectomy (RP) or RT are primary treatment options.[201,202] Men with organ-confined disease have the best prognosis. Infiltration of the seminal vesicles or positive surgical margins, however, correlate with increased relapse rates and, generally, advanced tumor stage, a high Gleason score and a high pre-RP PSA level are risk factors.[10–16] As might be assumed intuitively, the experience of the operating surgeon is another decisive factor.[17] However, even a favorable pattern of risk parameters does not exclude recurrences; their overall absolute rates in terms of biochemical relapse are 15–30%,[18–21] while with adverse features, figures above 60% (also including cases of clinically manifest local failure and metastasis) have been reported.[22,23]

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