Optimum treatment modalities in prostate cancer continue to evolve, with debates at each stage of the evolution process, from focal therapy to radical treatment. In this randomised study, Wiegel et al. investigated the role of adjuvant radiotherapy following open radical prostatectomy for confirmed adenocarcincoma of the prostate in those with pT3-4 disease. Postoperatively patients were randomised into either the wait-and-see (WS) arm or adjuvant radiotherapy arm (ART), with prostate specific antigen (PSA) monitoring. The study excluded any patient who failed to achieve undetectable PSA levels postoperatively (these patients were recommended for immediate radiotherapy). Patients were stratified for Gleason score, tumour stage, margin status and neoadjuvant hormone therapy. They were followed up with regular PSA checks and rectal examinations. In total, 307 patients were included (159 WS vs. 148 ART). Primary endpoint was progression free survival (PFS) which was defined as non-occurrence of biochemical progression, local or distant recurrence, or all cause death. Thirty-four patients in the ART arm refused radiotherapy. Median follow-up was 112.2 months. PFS was significantly better in the ART group (10-year Kaplan-Meier estimates 35% vs. 56%). ART did not show significant improvement in the risk of developing metastasis or death, however these results were underpowered. Conversely 21.9% of the ART arm developed ≥ grade 1 adverse effects of the bladder or rectum compared with 3.7% in the WS arm. This study raises an interesting idea for selecting adjuvant therapy in those with higher stage disease. However, longer term follow-up and a bigger patient cohort are needed to fully assess this prior to general recommendation. In a group of potentially elderly patients, the risks of treatment need to be assessed unless there is clear evidence of a survival benefit rather than biochemical response.
Adjuvant radiotherapy versus wait-and-see after radical prostatectomy
Reviewed by Sophia Cashman
Adjuvant radiotherapy versus wait-and-see after radical prostatectomy: 10-year follow-up of the ARO 96–02/AUO AP 09/95 trial.
