Adjuvant radiotherapy may improve survival in node-positive prostate cancer

1. In a retrospective cohort of 1107 patients with lymph node invasion following primary prostate cancer treatment, the use of adjuvant radiotherapy was associated with a significant improvement in cancer-specific mortality.

2. Two sub-group of patients: 1) Patients with positive lymph node counts of <2, Gleason score 7-10, pT3b/pT4 stage or positive surgical margins, and 2) Patients with positive lymph node count of 3-4 had significantly improved cancer-specific mortality rates with adjuvant radiotherapy.

 Evidence Rating: 2 (Good)

Study Rundown: Lymph node invasion (LNI) in the setting of prostate cancer following radical prostatectomy is associated with decreased cancer survival outcomes, leading to debate over optimal postoperative management of these patients. The current standard of treatment is adjuvant hormonal therapy (aHT); however, recent studies have demonstrated the potential benefit of adjuvant radiotherapy (aRT) to maximize local control and reduce the risk of local recurrence. The purpose of this study was to identify patient sub-groups most likely to benefit from aRT. This study retrospectively evaluated over 1100 prostate cancer patients with LNI treated with aHT alone or aHT with aRT. At the conclusion of this study, the authors found that the addition of aHT was associated with a significant improvement in cancer-specific mortality. However, on risk stratification, 2 groups of patients actually benefited: 1) patients with positive lymph node (PLN) count of two or less, Gleason 7-10, pT3b/pT4 stage, or positive surgical margins, and 2) patients with PLN count of 3-4. The results from this retrospective study suggests that these specific prostate cancer patient populations may benefit when aRT is added to aHT and provide evidence for future prospective trials with aRT.

Click to read the study in Journal of Clinical Oncology

Relevant Reading: Long-term outcome after radical prostatectomy for patients with lymph node positive prostate cancer in the prostate specific antigen era (The Journal of Urology)

In-Depth [retrospective cohort]: This study included 1107 patients with pN1 prostate cancer treated with either aHT or aHT and aRT from 2 tertiary care centers between 1988 and 2010. All patients underwent aHT and 35% (n = 386) also underwent aRT. Researchers performed regression tree analysis to stratify patients into risk groups based upon tumor characteristics, with the primary outcome of cancer-specific mortality (CSM) rate. Authors found that overall, the addition of aRT was associated with an improved CSM rate compared to aHT alone (HR: 0.37; P < 0.001). Furthermore, when the patient cohort was stratified into various risk groups, patients with PLN count <2, Gleason score 7-10, pT3b/pT4 stage or positive surgical margins (HR: 0.3, P = 0.002) and patients with positive lymph node count of 3-4 (HR: 0.21; p=0.02) were the only two groups that demonstrated significant increase in survival with the addition of aRT.

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