Who benefits most from early salvage radiation therapy after prostatectomy?

We are grateful for the opportunity to provide commentary on the recent work by Fossati et al., entitled “Impact of Early Salvage Radiation Therapy in Patients with Persistently Elevated or Rising Prostate-specific Antigen After Radical Prostatectomy” (1). The optimal post-operative management of patients with prostate cancer who undergo radical prostatectomy (RP) is unclear. In general, there are two strategies for approaching radiotherapy. Adjuvant radiation therapy (ART) typically refers to post-operative radiation in the setting of high risk pathologic features but with an undetectable post-prostatectomy PSA, where the presence of residual prostate cancer is suspected but unknown. In this setting, radiation is typically delivered within a few months of surgery once there has been adequate recovery of urinary function. In contrast, salvage radiation therapy (SRT) refers to post-operative radiation in the setting of a rising or persistently detectable PSA, indicative of active prostate cancer and may be delivered several years after the initial RP (2). However, it is important to note that these definitions lack consensus.