Postoperative radiotherapy for men who have persistently elevated PSA levels following radical prostatectomy (RP) for prostate cancer is associated with improved survival among patients with adverse pathologic characteristics, according to a new study.

In addition, persistently elevated PSA after RP is not always associated with a poor prognosis.

Giorgio Gandaglia, MD, of IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University in Milan, Italy, and colleagues studied 496 men who underwent RP and lymph node dissection at 2 referral centers from 1994 to 2014 and had persistently elevated PSA (0.1 to 2 ng/mL at 6 to 8 weeks after RP. The group consisted of 251 men who underwent postoperative radiotherapy and 245 who did not.

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The median follow-up for survivors was 110 months, the investigators reported in a paper published online ahead of print in European Urology. In all, 49 patients died from prostate cancer.

The 10-year CSM-free survival was 88%. Receipt of postoperative radiotherapy was associated with a survival benefit only among patients with a CSM risk of 30% or higher. Patients with a CSM risk less than 30% should be initially managed expectantly, according to the researchers.

Among the 245 patients who did not receive postoperative radiotherapy, those in pathologic grade group 4 or higher had a nearly 7-fold higher risk of CSM than those in pathologic grade 3 or lower.

Pathologic grade group and pathologic stage independently predicted CSM. In multivariable analysis, a pathologic grade group of 4 or higher was associated with a significant 2.7-fold higher risk of CSM compared with a pathologic grade group of 3 or less. A pathologic tumor stage of T3b/4 versus T2-pT3a was associated with a significant 2.3-fold higher risk of CSM.

The association between CSM-free survival and PSA at 6 to 8 weeks differed by the baseline risk of CSM, as defined by pathologic characteristics. The effect of increasing PSA was evident only in patients with a CSM risk of 10% or more.  “Increasing PSA levels should be considered as predictor of mortality exclusively in men with worse pathologic characteristics,” the investigators concluded.

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Gandaglia G, Boorjian SA, Parker WP, et al. Impact of postoperative radiotherapy in men with persistently elevated prostate-specific antigen after radical prostatectomy for prostate cancer: A long-term survival analysis. Eur Urol 2017; published online ahead of print.