A prostatectomy involves the surgical removal of the prostate gland, a common treatment for prostate cancer. Following this procedure, radiation therapy may sometimes be considered to reduce the risk of cancer returning or to treat a recurrence. This additional radiation can be delivered in different scenarios, each with specific timing and goals. Understanding these approaches is important for individuals navigating treatment decisions after prostate surgery.
Adjuvant Radiation Therapy
Adjuvant radiation therapy is a treatment given shortly after a prostatectomy, typically within a few months, before there is clear evidence of cancer returning. The primary goal of this approach is to eliminate any microscopic cancer cells that might have been left behind after surgery, reducing the risk of recurrence. It is usually considered for individuals whose prostate cancer is deemed to be at a higher risk of coming back.
This type of radiation is recommended when certain high-risk features are identified in the prostate tissue removed during surgery. These features include positive surgical margins, where cancer cells are found at the edge of the removed tissue. Other factors include extracapsular extension (cancer growth beyond the prostate capsule) or seminal vesicle invasion (spread to the seminal vesicles). Even if prostate-specific antigen (PSA) levels are undetectable after surgery, these pathological findings can prompt consideration of adjuvant radiation to target residual disease.
Salvage Radiation Therapy
Salvage radiation therapy is administered later than adjuvant therapy, specifically when there is evidence that prostate cancer has returned after a prostatectomy. This recurrence is most commonly indicated by a rising prostate-specific antigen (PSA) level in the blood. A PSA level of 0.2 ng/mL or greater, followed by another increased measurement, is often used as a definition for biochemical recurrence, which triggers consideration for salvage therapy.
The purpose of salvage radiation is to treat cancer cells that have returned or regrown after surgery. This approach directly targets the area where the prostate once was, known as the prostate bed, and sometimes nearby lymph nodes, aiming to eradicate the returning cancer and lower PSA levels. Unlike adjuvant therapy, which is given preventatively, salvage radiation is a reactive treatment initiated in response to biochemical evidence of disease.
Factors Guiding Treatment Decisions
The decision to pursue radiation therapy after a prostatectomy is highly individualized, involving evaluation by the medical team and patient. Pathological findings from the prostatectomy are central. These include the Gleason score (assessing cancer aggressiveness), the pathological stage (spread within or beyond the prostate), surgical margin status, and lymph node involvement. Higher Gleason scores, advanced pathological stages, and positive surgical margins are all indicators that might favor radiation.
Post-operative PSA levels play a significant role, particularly in determining the need for salvage therapy. The nadir (lowest point) of the PSA after surgery and any subsequent rise are carefully monitored. The rate at which PSA levels increase, known as PSA velocity or doubling time, can also influence decisions, with a faster rise suggesting more aggressive disease.
A patient’s overall health and life expectancy are important considerations. This includes co-existing medical conditions and age, which affect tolerance to radiation and its side effects. Radiation therapy can lead to side effects like urinary, bowel, and sexual changes, including increased urinary frequency, burning, diarrhea, or erectile dysfunction. These effects are weighed against the benefits of preventing or treating cancer recurrence.
Patient preferences and quality of life considerations are integral to shared decision-making. Clinical trials and evidence-based guidelines provide a framework for these discussions, outlining effectiveness and risks of different strategies. Ultimately, the choice of whether and when to have radiation therapy after prostatectomy is a collaborative one, tailored to each individual’s situation and values.