Salvage External Beam Radiotherapy for Prostate Cancer After Radical Prostatectomy

Prostate cancer is the second most common cause of cancer death in American men, with 192,289 new cases and 27,360 deaths expected in 2009.[1] While radical prostatectomy provides excellent control for clinically localized disease, approximately one-third of patients undergoing surgery will have positive surgical margins and another 9% will have seminal vesicle invasion.[2-5] Around one-third of patients will also have extracapsular extension.[5] These adverse pathological risk factors, in addition to the Gleason score and initial PSA level, are independent predictors of biochemical recurrence of cancer. Indeed, 40%-50% of high-risk patients have a biochemical recurrence after surgery, and many of those patients eventually develop metastases.[6-11] Currently, the majority of post-surgical patients without high-risk features are observed for signs of disease progression without active treatment. However, recently updated randomized trials have shown a very significant benefit to immediate "adjuvant" radiation therapy for prostate cancer at high risk of recurrence, such as pT3 disease.[12-14] Controversy surrounds the issue of what to do when prostate cancer recurs months or years after initial prostatectomy, and whether the risks and morbidity of radiation therapy in the "salvage" setting outweigh the intended benefits.