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JU INSIGHT: Not All Adverse Pathology Features Are Equal: Identifying Optimal Candidates for Adjuvant Radiotherapy Among Patients With Adverse Pathology at Radical Prostatectomy

By: Elio Mazzone, MD; Giorgio Gandaglia, MD; Armando Stabile, MD; Carlo Andrea Bravi, MD; Francesco Barletta, MD; Simone Scuderi, MD; Giuseppe Ottone Cirulli, MD; Nicola Fossati, MD; Vito Cucchiara, MD; Daniele Raggi, MD; Andrea Necchi, MD; Francesco Montorsi, MD, FRCS (Hon); Alberto Briganti, MD, PhD | Posted on: 01 Nov 2022

Mazzone E, Gandaglia G, Stabile A, et al. Not all adverse pathology features are equal: identifying optimal candidates for adjuvant radiotherapy among patients with adverse pathology at radical prostatectomy. J Urol. 2022;208(5):1046-1055.

Study Need and Importance

Early salvage radiotherapy (eSRT) represents a potential curative treatment option for patients affected by PSA rise after radical prostatectomy. In this context, 3 recent randomized clinical trials and a meta-analysis showed comparable outcomes between eSRT and adjuvant radiotherapy (aRT). However, a recent large retrospective analysis reported a potential benefit associated with aRT for patients with adverse pathology features at pathology. We hypothesized that not all the patients with adverse features may benefit from aRT, and therefore observation ± eSRT may still be considered in a subgroup of these patients.

Figure. Novel overall survival risk stratification based on data for patients with adverse pathology features after radical prostatectomy, and treated with adjuvant radiotherapy (RT) or observation with or without early salvage radiotherapy (eSRT).

What We Found

A total of 538 (58%) versus 89 (10%) versus 299 (32%) patients received aRT versus eSRT versus observation. Patients were stratified in 3 risk groups based on pathological T stage, International Society of Urological Pathology grade, and number of positive nodes. After risk stratification and propensity score weighting, survival analyses depicted comparable 10-year overall survival rates in low- and intermediate-risk patients treated with aRT or observation ± eSRT. Conversely, in high-risk patients, aRT was associated with significant improvement in 10-year overall survival compared to observation ± eSRT (76 vs 63%, P = .038; see Figure).

Limitations

We relied on a large retrospective institutional series of patients treated over a wide time span. As such, specific considerations related with radiotherapy technique variation and related toxicity should be considered when interpreting these results. Moreover, the impact of the progressive introduction of new imaging modalities such as prostate-specific membrane antigen-based positron emission tomography/CT scan for detection of recurrence, as well as the use of ultrasensitive methods for post-prostatectomy PSA dosage, was not accounted for in the current analysis.

Interpretation for Patient Care

Our risk stratification defined the exact characteristics of patients with adverse pathology who may really benefit from aRT. The application of this model in clinical practice could optimize the use of aRT by improving survival in selected individuals and avoiding the unnecessary adverse effects of aRT in others.

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