<p><strong> </strong><strong>Clinicians should not routinely recommend adjuvant radiation therapy after radical prostatectomy. <em>(Strong Recommendation; Evidence Level: Grade A)</em></strong></p>
Discussion
Discussion
<p>Three randomized trials (GETUG-AFU 17, RAVES, RADICALS) evaluated adjuvant radiation therapy versus surveillance with early salvage radiation therapy for PSA increase in patients with high-risk localized prostate cancer following radical prostatectomy.<sup>219-221</sup> The criteria for early salvage therapy was a PSA >0.1 ng/mL or >0.2 ng/mL depending on the trial; the proportion of patients in the early salvage therapy groups that received radiation therapy ranged from one third to one half. All three trials demonstrated no significant difference in oncological outcomes between patients who received adjuvant radiation therapy versus patients managed with surveillance and early salvage therapy. Moreover, a prospectively planned systematic review of these trials found no evidence of improvement in event-free survival (pooled HR 0.95, 95% CI 0.75 to 1.21) with receipt of adjuvant therapy and noted that adjuvant radiation was associated with increased risk of genitourinary toxicity.<sup>222</sup> Given these findings, together with the observation that between one third and one half of the patients in the surveillance arm of the trials did not require salvage therapy, the Panel concluded adjuvant radiation therapy should not be routinely recommended, and patients should be initially managed with PSA surveillance after radical prostatectomy. The Panel does recognize the relatively limited number of patients included in the trials with particularly high-risk features (e.g., Gleason 8 to 10 disease with extraprostatic extension, positive lymph nodes) and thereby acknowledges a potential role for adjuvant radiation in such select patients.<sup>223</sup></p>