Refers to article:
Selecting the Optimal Candidate for Adjuvant Radiotherapy After Radical Prostatectomy for Prostate Cancer: A Long-term Survival Analysis
Accepted 18 October 2012
June 2013 (Vol. 63, Issue 6, pages 998 - 1008)
Abdollah et al.  selected, from a cohort of 6357 patients who underwent radical prostatectomy with extended pelvic lymph node dissection in the same institution between 1988 and 2008, a series of 1049 patients with pathologically advanced prostate cancer (PCa). The aim was to evaluate the impact of risk prognostic factors on survival with a regression analysis, and then to evaluate the relationship between adjuvant radiotherapy (ART) and survival according to the number of selected risk factors. The adjuvant treatments were based on the clinical judgment of each treating physician according to clinical and cancer characteristics after discussion with the patient. The following distribution was noted: no treatment (n
Despite the fact that all variables have been included in the multivariable analyses, the methodology is subject to bias, which may lessen the relevance of the results and their potential clinical impact: (1) the absence of a pathologic review, since the Gleason score has changed along time and a Gleason score was a criterion of eligibility for ART and/or ADT; (2) the mixture of pN0 and pN1 patients who do not share the same outcome; (3) the lack of any clinical guidelines to tailor adjuvant treatments; (4) the difference in the choice of the planning target volume, the techniques of external irradiation, and the dose range; (5) the heterogeneity of ADT modalities and the duration of ADT; (6) the absence of a report of morbidity for adjuvant treatments, especially as the authors emphasize the potential morbidity of ART; and (7) the lack of prostate-specific antigen (PSA) values after surgery. Therefore, the comparison with randomized trials devoted to ART after radical prostatectomy with pelvic lymph node dissection , , and  is a challenge, because those trials dealt with pT2 R1 pN0, pT3a–4 R0–1 pN0 patients with irradiation focused on the prostatic bed with conventional doses (60–64
For pN1 patients, although the authors claim a benefit for ART alone, the use of ART remains controversial; the evidence of a benefit from randomized trials is needed, likely from an ART/ADT combination, as in breast cancer . Indeed, Da Pozzo et al.  showed in a cohort of 250 pN1 patients with a median follow-up of 91.2 mo that patients treated with ART/ADT (n
I agree that pT3–4 pN0 patients with Gleason score 8–10 (risk score: 2) do need ART. In the randomized trials that have been mentioned, which consistently show a 50–60% reduction in the risk of PSA progression, the main eligibility criteria was pT3 (pT2R1, pT3–4 for the European Organization for Research and Treatment of Cancer [EORTC] trial). In the Southwest Oncology Group (SWOG) trial  that compared ART with observation in pT3 pN0 patients, ART did improve metastasis-free survival (p
At the current time, the treatment policy for pT3–4 pN0 patients must take into account the PSA value after surgery to separate patients with undetectable PSA from patients with a detectable PSA who are at very high risk of relapse and who require a combined approach , with perhaps a dose escalation.
Nevertheless, no trial has shown so far that immediate RT is better than early salvage RT; thus, for R0 patients with Gleason score <8 and an undetectable PSA, many surgeons prefer to wait for a biochemical relapse and start RT as soon as the patient's PSA concentration reaches 0.2 ng/ml. RT can begin even earlier thanks to ultrasensitive assays that are able to detect a PSA concentration as low as 0.01 ng/ml—the lower the concentration, the better the outlook .
In conclusion, the decision whether to proceed with adjuvant RT for high-risk PCa (pT3–4 pN0–1 M0) after radical prostatectomy or to postpone RT as an early salvage procedure in case of biochemical relapse remains difficult. In daily practice, the urologist should explain to the patient before radical prostatectomy that adjuvant irradiation could be applied if the patient has negative prognostic risk factors. Ultimately, the decision to treat needs a multidisciplinary approach to determine the optimal timing of radiotherapy when used and to provide justification when not used, which will help in the discussion between the referent physician and the patient.
Conflicts of interest
Michel Bolla is a board member of Janssen and has received payment for lectures, including service on speakers bureaus, from Ipsen and Astellas.
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Department of Radiation Oncology, Grenoble University Hospital, Grenoble, France
© 2012 European Association of Urology, Published by Elsevier B.V.