The most common oncologic outcome following radical prostatectomy (RP) for localised prostate cancer is achieving undetectable prostate-specific antigen (PSA) levels (<0.1 ng/ml), indicating an absence of detectable disease. However, the landscape of RP is shifting as active surveillance becomes the preferred approach for low-risk prostate cancer. Consequently, more RP procedures are being performed for intermediate-risk, high-risk, and even advanced or oligometastatic prostate cancer. Alongside the rising incidence of advanced cases, an increasing number of patients are at heightened risk for residual or recurrent disease post-surgery. Traditionally, RP aims to completely eradicate prostate cancer. However, studies show that detectable PSA persists in 5–20% of patients after RP. Furthermore, 15–35% of patients who initially achieve undetectable PSA levels experience biochemical recurrence (BCR) over time. Advances in diagnostic tools, such as ultrasensitive PSA assays, multiparametric MRI, prostate-specific membrane antigen (PSMA) positron emission tomography (PET), and genomic classifiers, are reshaping how clinical states after RP are defined. This evolving understanding, combined with efforts to balance overtreatment and undertreatment, has led to wide variability in clinical practices. Currently, post-RP treatments are categorised as ‘adjuvant’ or ‘salvage’ therapy. Adjuvant therapy targets patients with no detectable disease, while salvage therapy is for those who initially achieve undetectable PSA but later experience recurrence. However, this framework fails to adequately address patients with PSA persistence, a subgroup with higher risks of adverse outcomes compared to those with undetectable PSA or BCR. PSA persistence, defined as a detectable PSA that never becomes undetectable after RP, signals a significantly worse prognosis. For example, studies show that at 15 years post-RP, metastasis-free survival is 53.0% for patients with PSA persistence versus 93.2% for those with initially undetectable PSA. Similarly, overall survival and cancer-specific survival are markedly lower for patients with persistent PSA. These findings underscore the need for upfront treatment in high-risk patients as part of a multimodal strategy. To address this gap, the term ‘consolidative therapy’ is proposed to describe treatment aimed at residual disease that remains detectable after RP. Unlike adjuvant or salvage therapy, consolidative therapy targets persistent disease, recognising the distinct clinical scenario and intent. This terminology better reflects the need for tailored treatment strategies for patients with PSA persistence. Clinical trials such as SWOG 8794, EORTC 22911, and FinnProstate support this distinction. Many patients included in these trials had PSA levels indicative of persistent disease rather than recurrence, suggesting they benefited from what would now be termed consolidative therapy. Early intervention for PSA persistence could improve outcomes, making timely treatment standard practice for this high-risk population. The use of consolidative therapy is becoming increasingly relevant with advanced imaging technologies like PSMA PET, which can detect disease at very low PSA levels. Incorporating this term into clinical practice will enable better alignment of treatment strategies with patient outcomes and facilitate more accurate comparisons in future clinical trials. By adopting this three-tiered framework – undetectable PSA, PSA persistence, and PSA recurrence – alongside corresponding treatment categories (adjuvant, consolidative, and salvage), clinicians can enhance decision-making and optimise care for patients with prostate cancer.
Defining adjuvant, consolidative, and salvage treatment after RP
Reviewed by Asif H Ansari
More than words: defining adjuvant, consolidative, and salvage treatment after radical prostatectomy.
