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EBM verdict
Early salvage versus adjuvant therapy for treatment of prostate cancer following prostatectomy
  1. Meera Garriga1,
  2. Felix Y Feng2,
  3. W Robert Lee3,
  4. Julian C Hong2,4
  1. 1 School of Medicine, University of California San Francisco, San Francisco, California, USA
  2. 2 Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
  3. 3 Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
  4. 4 Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Dr Julian C Hong, Radiation Oncology, University of California San Francisco, San Francisco, CA 94143, USA; julian.hong{at}ucsf.edu

https://doi.org/10.1136/bmjebm-2020-111592

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    The prospective adaptive meta-analysis by the ARTISTIC collaboration did not demonstrate that adjuvant radiotherapy following radical prostatectomy improves event-free survival over early salvage radiotherapy. Early salvage is preferred over adjuvant therapy to reduce overtreatment and associated side effects.

    In patients with localised prostate cancer, the goal of radical prostatectomy is to remove the entire primary tumour. This goal is reached in some patients, but in others, cancerous tissue may be left behind. To protect against local recurrence in high-risk patients, the prostate bed is commonly irradiated after radical prostatectomy. However, the optimal timing of radiotherapy—whether immediately postprostatectomy (adjuvant) or after early biochemical evidence of recurrence (early salvage)—has been the subject of ongoing debate. Recent guidelines1 2 recommend that adjuvant radiotherapy be offered to patients with adverse pathological findings at prostatectomy, although adjuvant radiotherapy is uncommonly used in practice.3

    Randomised trials conducted between 1988 and 2004 showed that in men with high-risk prostate cancer, adjuvant radiotherapy significantly reduced the risk of biochemical progression (identified by prostate-specific antigen (PSA)) compared with prostatectomy alone.4–6 However, the trials did not show a consistent increase in overall survival, and most men in the non-adjuvant groups never received salvage radiotherapy. Given these limitations and the …

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    Footnotes

    • Twitter @julian_hong

    • Contributors MG and JH drafted the manuscript and all authors provided critical revisions. All authors provided final approval of the manuscript and agree to be accountable for all aspects of the work.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests JH is coinventor on a pending patent unrelated to this manuscript. FYF has paid consultant/advisory board relationships with Janssen, Sanofi, Astellas, Bayer, Genentech, EMD Serono, Clovis and Celgene, and an unpaid consultant/advisory board relationship with PFS Genomics.

    • Provenance and peer review Commissioned; internally peer reviewed.