From the Guidelines
For a male patient with prostate cancer showing extra prostatic extension but with complete resection and negative lymph nodes, adjuvant radiation therapy is the recommended next treatment step. This recommendation is based on the most recent and highest quality evidence available, including the study by Thompson et al 1, which reported improved 10-year biochemical failure-free survival for high-risk patients receiving postprostatectomy adjuvant radiation compared with observation.
Key Considerations
- Adjuvant radiation therapy should ideally begin within 3-6 months after surgery once urinary continence has adequately recovered.
- The treatment typically involves external beam radiation therapy (EBRT) delivered to the prostate bed at doses of 60-66 Gy over 6-7 weeks.
- For patients with additional high-risk features such as Gleason score ≥8 or PSA >20 ng/mL, adjuvant androgen deprivation therapy (ADT) may be added for 4-6 months alongside radiation.
- Regular PSA monitoring should follow treatment, typically every 3-6 months for the first 2 years, then every 6 months thereafter.
Rationale
The presence of extra prostatic extension (pT3 disease) indicates a higher risk of recurrence even with negative surgical margins and lymph nodes, making adjuvant therapy important for improving long-term cancer control and survival outcomes. As noted in the study by Wiegel et al 1, postoperative radiation improved 5-year biochemical progression-free survival compared with observation alone.
Additional Guidance
- The decision to administer radiotherapy should be made by the patient and the multi-disciplinary treatment team with full consideration of the patient’s history, values, preferences, quality of life, and functional status, as recommended by the AUA/ASTRO guideline 1.
- Patients should be informed about the potential benefits and risks of adjuvant radiation therapy, including the risk of erectile dysfunction and other side effects, as discussed in the American Cancer Society prostate cancer survivorship care guidelines 1.
From the Research
Next Treatment Step for Prostate Cancer with Extra Prostatic Extension
- The patient has prostate cancer with extra prostatic extension, completely resected with negative lymph nodes.
- According to the study 2, androgen deprivation therapy (ADT) can be combined with primary therapy to shrink the tumor, reduce margin positivity, and reduce the risk of recurrence in patients with high-risk prostate cancer.
- The study 3 suggests that salvage external beam radiotherapy (RT) with ADT improves survival over RT in men with prostate cancer and rising prostate-specific antigen (PSA) levels after radical prostatectomy.
- The study 4 proposes a novel pT3a subclassification, which may help in determining the prognosis and treatment plan for patients with pT3a disease.
- The study 5 found that the addition of ADT to radiotherapy significantly improved metastasis-free survival, and adjuvant ADT prolongation also improved metastasis-free survival.
- The study 6 found that adjuvant ADT yielded significant reductions in both metastases and prostate cancer-specific mortality for all high-risk definitions.
Treatment Options
- Androgen deprivation therapy (ADT) may be considered as an additional treatment to reduce the risk of recurrence 2, 5, 6.
- Salvage external beam radiotherapy (RT) with ADT may be considered for patients with rising PSA levels after radical prostatectomy 3.
- The treatment plan should be individualized based on the patient's specific characteristics, such as Gleason score, PSA level, and presence of high-risk features 4, 6.
Considerations
- The patient's overall health and potential side effects of treatment should be considered when determining the next treatment step.
- The patient's preferences and values should also be taken into account when making treatment decisions.
- Further discussion with a healthcare provider is necessary to determine the best course of treatment for the patient.