Published online Jan 24, 2020. doi: 10.5306/wjco.v11.i1.1
Peer-review started: July 17, 2019
First decision: October 14, 2019
Revised: November 13, 2019
Accepted: November 18, 2019
Article in press: November 18, 2019
Published online: January 24, 2020
The indication for salvage radiotherapy (RT) (SRT) in patients with biochemically-recurrent prostate cancer after surgery is based on prostate-specific antigen (PSA) levels at the time of biochemical recurrence. Although there are clear criteria (pT3-pT4 disease and/or positive margins) for the use of adjuvant radiotherapy, no specific clinical or tumour-related criteria have yet been defined for SRT. In retrospective series, 5-year biochemical progression-free survival (PFS) ranges from 35%-85%, depending on the PSA level at the start of RT. Two phase 3 trials have compared SRT with and without androgen deprivation therapy (ADT), finding that combined treatment (SRT+ADT) improves both PFS and overall survival. Similar to adjuvant RT, the indication for ADT is based on tumour-related factors such as PSA levels, tumour stage, and surgical margins. The number of patients referred to radiation oncology departments for SRT continues to rise. In the present article, we define the clinical, therapeutic, and tumour-related factors that we believe should be evaluated before prescribing SRT. In addition, we propose a decision algorithm to determine whether the patient is fit for SRT. This algorithm will help to identify patients in whom radiotherapy is likely to improve survival without significantly worsening quality of life.
Core tip: Salvage radiotherapy (SRT) is an effective treatment for biochemically-recurrent prostate cancer after prostatectomy. Proper patient selection is crucial. While tumour-related factors are important, the indication for SRT should also be based on clinical factors and dosimetric variables. Patients with non-aggressive tumours who have a life expectancy of less than 10 years are unlikely to benefit from radiotherapy and should thus be considered "unfit" for SRT. The development of advanced imaging techniques such Ga-PSMA positron emission tomography/computed tomography, which are capable of localizing the recurrent lesion when prostate-specific antigen ≤ 0.5 ng/mL, has forced clinicians to reconsider whether patients should undergo radiotherapy without locate first the recurrence.