Would you skip adjuvant RT in post prostatectomy patients?

I suspect that once the paper is published and we get a chance to review the data that we may begin to hold off on routine use of adjuvant RT for prostate cancer patients after radical prostatectomy with higher risk features. That said, it should be noted that the study did randomize to early salvage, so if adjuvant is withheld then early adjuvant should be performed. We should remember that both adjuvant and salvage are widely underutilized at this point in the US at least. So, men who are unwilling to undergo salvage maybe should be offered adjuvant. Others might be: extensive positive margins and positive lymph nodes. I'll need to review the paper and see if other subsets might potentially benefit.

Overall, the strategy of tailoring postoperative radiation to those who need it most is probably a sound one.

I have always leaned to early salvage RT, as opposed to direct post-op RT, because prostate bed RT is not always such a "benign" undertaking, and so I like to be convinced that it is absolutely necessary. This study does not change that opinion. That said, I do continue to be amazed at how frequently still, these patients are "watched," until their PSA hits whole numbers. Early salvage means any trace of other than a "0" PSA. Who would I treat directly without waiting for any PSA? Primarily, anybody with a "non-focal" (+) surgical margin, particularly if that finding is seen in conjunction w other high-risk features.

Would just like to add in that RAVES presented at ASTRO 2019 had more classical, at least for US Rad Oncs, inclusion criteria and showed essentially the same findings as RADICALS: Early salvage, without ADT, seems equivalent to adjuvant. Others above have mentioned the caveats on actually doing 'early' salvage. This combined with the ARTISTIC meta-analysis combining RADICALS, RAVES, and GETUG-AFU 17 means that I will almost never recommend adjuvant RT again.

My personal practice would be to continue accepting and encouraging these consults for adjuvant RT, and simply doing the monitoring myself. 50% of these patients require radiation at some point, the other 50% are a 5 minute follow-up for a PSA check every 3-6 months. Certainly some practices will be too busy to accomodate this, but I think managing a stream of patients with a 50% treatment rate is more optimal than expecting a Urologist to remember to send a patient back to me when their PSA becomes detectable.

I personally think that 0.2 is too high of a threshold in the current era. Whether 0.1 is the threshold in the era of ultrasensitive PSA that can see as low as 0.04, or as low as 0.008 (at my institution) is a matter of opinion.

As many have pointed out one problem with Radicals-RT is the patient population they enrolled.

"Patients with post-op PSA≤0.2ng/ml and ≥1 risk factor (pT3/4, Gleason 7-10, positive margins or pre-op PSA≥10ng/ml) were randomized"

Who was going to expect benefit from adjuvant RT in a patient with Gleason 7, negative margins and T2 disease?

A non-rising low level PSA following radical prostatectomy may indicate surgical sparing of a portion of the seminal vesicles and thus would not benefit from radiation.