Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Oncol. Jan 24, 2020; 11(1): 1-10
Published online Jan 24, 2020. doi: 10.5306/wjco.v11.i1.1
Are all prostate cancer patients "fit" for salvage radiotherapy?
Carmen González-San Segundo, Alfonso Gómez-Iturriaga, Felipe Couñago
Carmen González-San Segundo, Department of Radiation Oncology, HGU Gregorio Marañon, Complutense University, Madrid 28007, Spain
Alfonso Gómez-Iturriaga, Biocruces Health Research Institute, Cruces University Hospital, Barakaldo 48903, Spain
Felipe Couñago, Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Madrid 28003, Spain
Author contributions: All authors contributed to this manuscript.
Conflict-of-interest statement: Authors declare no conflict of interests for this article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Carmen González-San Segundo, MD, PhD, Professor, Department of Radiation Oncology, HGU Gregorio Marañon, Complutense University, C/Doctor Esquerdo 46, Madrid 28007, Spain. cglezss@gmail.com
Received: July 5, 2019
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.

Keywords: Prostate cancer, Salvage radiotherapy, Comorbidity, Fit, Androgen deprivation therapy

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.