Immediate adjuvant radiation therapy in the pT3 patient post-surgery

In March 2009, Thompson et al. published data from the SWOG 8794 trial showing that adjuvant radiation therapy immediately post-surgery significantly improved the oncologic outcomes of men with pathologic T3N0M0 prostate cancer compared to later salvage radiation, but it is also well understood that immediate adjuvant radiation comes with a cost in terms of increased risks for complications and impact on quality of life.

Ghia et al. have just reported new data that add to our understanding of the historic management of pT3 prostate cancer by performing a retrospective patterns of care analysis using data from the Surveillance, Epidemiology and End Results (SEER) Program.

They initially identified men with localized prostate cancer treated with radical prostatectomy (RP) in 2004 or 2005 and who were found to have pathologic extracapsular extension (ECE) with positive surgical margins (i.e., pT3a disease). They then sought out data related to use of immediate adjuvant radiation therapy in these patients.

The results of their analysis showed the following:

  • 1,427 patients had pT3a disease with positive surgical margins.
  • 95.8 percent of these patients were clinical stage T1 or T2 before surgery.
  • According to the D’Amico criteria, prior to surgery,
    • 52.0 percent were high risk.
    • 39.7 percent  were intermediate risk
    • Only 8.3 percent were low risk.
  • 260/1,427 patients (18.2 percent) received immediate adjuvant radiation therapy; 1,167/1,427 patients (81.8 percent) did not.
  • The patients who received immediate adjuvant radiation therapy had worse prognostic factors, including a greater likelihood of
    • A Gleason score >7 (38.5 vs 24.8 percent; P < 0.0001).
    • A PSA level >10 ng/ml (44.6 vs 35.2 percent; P = 0.0045).
    • Positive lymph nodes (11.5 vs 6.4 percent; P = 0.006).
    • High-risk disease (66.8 vs 48.7 percent; P < 0.0001).
  • There was significant variation in the use of immediate adjuvant radiation therapy based on geographic region (range, 8.3 to 34.2 percent).

These data cover the period immediately preceding publication of data showing an oncologic benefit for immediate adjuvant radiation therapy compared to salvage therapy. According to these data, less than 20 percent of patients with pT3 disease and positive surgical margins received adjuvant radiation therapy in the study period just before the publication of the data by Thompson et al. It is the largest analysis of patterns of care data available to date in patients with margin-positive pT3 prostate cancer.

The appropriate use of immediate adjuvant radiation therapy in men with pT3 disease and positive surgical margins is still a controversial issue. Many men with positive surgical margins do extremely well after surgery, and have no need for any further therapy. Others, however, can progress quickly — and some will do so whether they have immediate adjuvant radiation treatment or not.

The “New” Prostate Cancer InfoLink believes the following factors are probably highly important to the decision whether to have (or not to have) immediate adjuvant radiation therapy for patients with pT3a disease and positive surgical margins post-surgery:

  • The number and extent (area) of the surgical margins
  • The Gleason pattern of the cancerous tissue associated with the surgical margin
  • The patient’s PSA level pre-surgery
  • The patient’s PSA level taken as soon as possible post-surgery and prior to radiation

But these are unlikely to be the only factors. Others might include genetics, race/ethnicity, age, degree of perineural invasion, volume of cancer in the prostatectomy specimen compared to total prostate volume, etc. We are only beginning to appreciate all of the possible drivers of more aggressive forms of apparently localized disease.

At present, the decision as to whether to implement immediate adjuvant radiation therapy in patients with T3 disease and positive surgical margins can only be made on a patient by patient basis. There are no good data that allow for strong guidelines on this issue.

Just as an example, for a young (say 47-year-old) patient who has an excellent surgical outcome with immediate return of potency and continence despite Gleason 8 disease and a single, relatively small, positive surgical margin of Gleason pattern 3, and whose first post-operative PSA is < 0.003 ng/ml, it may be a better choice to refrain from immediate adjuvant radiation if the patient is strongly driven to retain sexual functionality. Radiation therapy at any point in time is going to affect this patient’s erectile function, and he and his partner may be willing to risk later problems for the benefit of current sexual satisfaction. The converse argument can be made for the same patient if he is more strongly driven by the idea of extended survival, with the full recognition that this may come with an earlier loss of sexual function.

We should also add that implementation of adjuvant radiation therapy post-surgery should — to whatever extent possible — be deferred until a patient has recovered continence and erectile function, since radiation therapy has a tendency to “freeze” recovery of these capabilities.

4 Responses

  1. I was 44 when the decision had to be made on whether to add additional therapies. Surgery had me at T3b with extraprostatic extension and positive margin. But I also was at an undetectable PSA. With 35 years of life expectancy, I chose adjuvant radiation a month after beginning hormonal therapy that lasted 28 months.

    3.5 years later I have never had an increase in PSA (knock on wood). Oh and everything works fine!

  2. Which accurately goes to prove that there is no good advice that applies accurately to everyone!

  3. But how long was it between your surgery and beginning hormonal therapy?

  4. I completed surgery on February 16, 2007. I started HT on May 18, 2007. I started IMRT radiation about 30 days later. I completed IMRT on August 3, 2007, and stopped HT in October 2009. I am currently not on any therapy for prostate cancer.

    My blog is at

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