Extraprostatic extension (EPE) alone is not enough to justify adjuvant radiation

Patrick Walsh and Nathan Laurentschuk wrote an opinion piece in European Urology taking issue with the 2013 AUA/ASTRO recommendation that adjuvant radiation is indicated for men with a pathological finding of extraprostatic extension (EPE, stage pT3a) after surgery, regardless of the surgical margin status. The combination of EPE and negative surgical margins is the most common adverse finding, accounting for 60% of them. Therefore, the AUA/ASTRO guideline would lead to gross overtreatment if it were followed. They believe that it is fortunate that that guideline is increasingly ignored (see this commentary).

They looked at the three randomized clinical trials of adjuvant radiation vs. wait-and-see, for evidence that EPE alone justified adjuvant radiation.

• ·      Although it concludes that all patients with EPE should have adjuvant radiation, SWOG 8794 never looked at that subgroup separately.
• ·      In ARO 96-02, men with EPE and negative margins received no statistically significant benefit in terms of freedom from biochemical failure from adjuvant radiation.
• ·      Not only was there no benefit, but EORTC 22911 found a 78% increased risk of dying among men with EPE and negative margins who received adjuvant radiation.

They conclude with a set of recommendations about adjuvant radiation:

“Who should NOT receive it:

 • Men with extraprostatic extension (capsular penetration) with negative margins

 • Men aged >70 yr unless they are very healthy and have high grade or positive margins

 • Men with bladder neck contractures or significant incontinence who have marginal indications

Who should receive it:

 • Men with Gleason ≥7 with positive surgical margins

Marginal benefit:

 • Men with positive seminal vesicles

In a commentary published in Practice Update, Christopher King, a radiation oncologist at UCLA, takes tissue with their recommendations. He argues that until the findings of randomized clinical trials provide more reliable data, current evidence does not justify adjuvant radiation based only on adverse pathology. Instead, based on several retrospective studies (reviewed on this site), he advocates waiting for some evidence of measurable disease. He believes that early salvage (before PSA rises above 0.2 ng/ml) will have equivalent oncological outcomes to adjuvant radiation, but will avoid the toxicity of overtreatment.