A rising prostate specific antigen (PSA) after radical prostatectomy represents a pivotal moment in prostate cancer management, with salvage radiation therapy (RT) the standard intervention. However, the optimal role and duration of androgen deprivation therapy (ADT) alongside RT remain debated. While prior trials suggested mixed outcomes, evolving imaging, biomarkers, and treatment paradigms demand a clearer understanding of who benefits from intensification with ADT. In this issue of European Urology, Burdett et al. present the DADSPORT meta-analysis, pooling five randomised trials with over 4400 men – 96% of all eligible patients. ADT combined with postoperative RT improved metastasis-free survival (HR 0.78) and prostate cancer specific survival (HR 0.61), but the absolute gain in overall survival was modest: 2% at eight years (HR 0.86; p=0.057). Benefits were consistent across short- and long-course ADT, suggesting that using ADT is more important than its duration. Subgroup analyses hinted at greater effects in patients with higher PSA or CAPRA-S scores, but these findings remain exploratory. The study’s limitations reflect its era: neither trials nor the pooled analysis incorporated prostate specific membrane antigen (PSMA) positron emission tomography (PET), now widely used in biochemical recurrence. PSMA PET detects occult metastases in up to 46% of patients deemed non-metastatic by conventional imaging, frequently altering treatment intent and scope. Future trials must integrate this technology to refine patient selection. Beyond imaging, genomic classifiers such as Decipher and artificial intelligence (AI)-based tools like ArteraAI provide individualised prognostic insights and may guide ADT use more precisely. By identifying men with aggressive biology, these strategies could balance ADT’s modest survival benefits against its side effects. Overall, DADSPORT provides the most robust evidence to date supporting ADT with salvage RT, reinforcing its role in improving metastasis-free and disease-specific survival. The future, however, lies in tailoring therapy with advanced imaging and molecular risk stratification to achieve biologically driven, patient specific care.
Refining the role of androgen deprivation therapy after radical prostatectomy
Reviewed by Asif H Ansari
Refining the role of androgen deprivation therapy after radical prostatectomy.
