There is approximately a 25% risk of cancer coming back after prostatectomy for prostate cancer. The risk is elevated if worrisome features are seen on the pathology report such as positive margins, extracapsular extension, or seminal vesicle invasion. High quality studies have previously indicated a survival benefit with adjuvant radiation, where everyone with these findings receives radiation within 6 months of surgery. However, this means that large numbers of patients will receive radiation (and possible side effects) when they do not need it. A recent randomized study evaluated salvage radiation instead, where radiation was only given to these patients if the PSA rose to 0.2 or higher. Using this strategy 50% of patients were able to avoid radiation all together, and at 5 years, cancer control was similar between adjuvant and salvage radiation with 86% versus 87% of patients with no evidence of PSA progression, respectively. Lastly, the salvage radiation group had significantly reduced side effects/complication rates. Although these findings need to be confirmed in larger studies, I believe that they demonstrate that salvage radiation therapy is a safe and reasonable option that may save large numbers of patient from over treatment.
https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30456-3/fulltext
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