For patients with high risk prostate cancer, is there data to support increased morbidity, such as increased urethral strictures or cystitis, when given postprostatectomy XRT as opposed to definitive XRT?

This is a very relevant question that commonly comes up in practice - should a man with high risk prostate cancer have a prostatectomy, when the chance of him needing post-op RT is reasonably high, if he could have RT/ADT only and possibly avoid the risks associated with surgery? The discussion must consider both disease control and toxicity.

Regarding toxicity, in my initial consultation, I find it helpful to guide patients’ expectations using quality of life data. Although QOL data are subjec...

One needs to take the SWOG data with a grain of salt since those patients who received RT were probably followed by both urologists and radiation oncologists and there may have been more reporting of events in the group who received adjuvant RT. One might consider the followup to be slightly biased in some respects.

Regarding post-prostatectomy morbidity, one of my favorite recent paper is this one from Univ Chicago with prospective QOL data from IMRT-treated postoperative patients. [Corbin...Lia...

I would add this retrospective series from our institution published by Hunter et al in 2013 that reported modern outcomes of IMRT/IGRT in both the definitive and post-operative setting: http://www.ncbi.nlm.nih.gov/pubmed/24674405

While this study is of course neither prospective nor randomized, it does provide some helpful data, notably increased GU but less GI toxicity in the post-prostatectomy patients who were treated to a lower dose than the definitive patients.

Perhaps we can extrapolate from the SWOG 8794 data that postprostatectomy XRT has a 18% rate of urethral stricture so that while we can potentially salvage high risk prostatectomy failures with radiation, the complications are worse then if they recieved radiation definitively upfront. Any thoughts?

Urethral stricture was more common with radiotherapy (38/213 [17.8%]) than with observation (20/210 [9.5%]) (relative risk, 1.9; 95% CI, 1.1-3.1; P = .02). (Thompson IM Jr, JAMA. 2006 Nov 15;296(19):2...