Adjuvant radiotherapy for patients with locally advanced prostate cancer - A new standard?

Context: After radical prostatectomy (RPE) pathologically advanced disease is detected in 38% to 52% of patients. Retrospective data on the role of postoperative radiotherapy (RT) are controversial. Objectives: To clarify in how far an adjuvant radiation treatment (ART) in cases of locally advanced disease affects outcome, three randomised trials have been started. The available data are critically reviewed. Evidence acquisition: Relevant publications were detected by searching the Medical Literature Analysis and Retrieval System Online (MEDLINE) and the Public/Publisher MEDLINE (PUBMED; National Library of Medicine journal articles database) databases using the medical subject headings "prostatic neoplasms," "radiotherapy," and "adjuvant." A major emphasis was placed on the results of the randomised trials. Evidence synthesis: The European Organization for Research and Treatment of Cancer (EORTC) trial number 22911, Southwest Oncology Group (SWOG) trial number 8794, and German Intergroup trial ARO 96-02/AUO AP 09/95 randomised patients to receive ART with 60 Gray (Gy) and 60-64 Gy (SWOG trial), respectively. The majority of patients had undetectable PSA levels postoperatively. The data concordantly show that ART improves biochemical progression-free survival rates (EORTC trial, progression-free survival rate after 5 yr: 74.0% with ART vs 52.6% without ART; SWOG trial, after S yr: similar to 73% vs similar to 44%, respectively; and ARO 96-02/AUO AP 09/9S trial, after 5 yr: 72% vs 54%, respectively). The EORTC trial shows improved local control of cancer progression (p < 0.0001) for treated patients. The SWOG trial demonstrates an improved freedom from hormonal treatment (5-yr: 21% with ART vs 10% without ART). A statistically significant benefit with regard to metastasis-free survival and overall survival was not seen. Genitourinary and gastrointestinal toxicity was moderate, with late side-effects (>= grade 3) between 3% (in the ARO 96-02 trial) and < 5% (in the EORTC trial). Conclusion: Biochemical progression-free survival and local control are significantly improved by postoperative RT with 60 Gy. Patients should be offered adjuvant treatment when they are at high risk for local relapse (especially with positive surgical margins). (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.