Approximately 15-25% of men who undergo radical
prostatectomy for localized
prostate cancer will experience a PSA-defined biochemical recurrence (BCR) of their
cancer--men with poorly differentiated
cancer, non-organ-confined disease, and
positive surgical margins are at the highest risk. Accumulating evidence indicates that postoperative
radiation therapy to the prostate bed favorably influences the course of disease in men with pathological features of poor prognosis. Three phase III randomized trials of
adjuvant radiotherapy versus observation have reported improved freedom from BCR, and one study has reported improved
metastasis-free survival and overall survival. Similar evidence from randomized trials for salvage
radiotherapy is lacking; however, several observational studies have reported durable responses to salvage
radiotherapy and reduced
cancer-specific mortality in a substantial proportion of high-risk patients, provided that it is administered at the earliest evidence of BCR. The appeal of salvage
radiotherapy is that a substantial proportion of patients with non-organ-confined
cancer or
positive surgical margins are cured after radical
prostatectomy alone, thereby limiting the adverse effects of postoperative
radiotherapy--which include urinary and bowel dysfunction, sexual dysfunction and secondary pelvic
malignancies--to only those whose
cancer was not cured by surgery. In the absence of data from randomized trials demonstrating the superiority of
adjuvant radiotherapy over a surveillance strategy (with planned salvage
radiotherapy at the earliest evidence of BCR), we advocate shared decision making between physicians and patients, based on the relative advantages and disadvantages of each approach.