Living with Prostate Cancer
Radiation Therapy Following Prostatectomy
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If your PSA starts to rise after you’ve undergone prostatectomy, so-called "salvage" radiation therapy might be a good option to explore. With this approach, external beam radiation is delivered to the area immediately surrounding where the prostate used to be, in the hopes of eradicating any remaining prostate cells that have been left behind. Sometimes, radiation is given after surgery for men with high risk disease (positive margins, seminal vesicle invasion, positive capsular extension), even in the absence of a PSA rise. If you did not get radiation immediately, doing so later based on a rising PSA is often reasonable. (Brachytherapy is not an option because there is no prostate tissue in which to embed the radioactive seeds.)
But the procedure is not for everyone. If there are obvious sites of disease outside of the immediate local area, if any tumor cells have been found in your lymph nodes, or if your Gleason score was 8-10, post-surgery radiation therapy may not be right for you. In this high risk situation, additional therapy may be warranted such as hormonal therapies or clinical trials. Also, in men who are considered good candidates for radiation after prostatectomy, it can be very effective, but five-year disease-free rates tend to be considerably higher in men whose pre-therapy PSA levels are lower than 0.2 ng/mL compared with those whose pre-therapy PSA levels are greater than 0.2 ng/mL. Therefore, if you and your doctors are considering post-surgery radiation, ideally you should start before your PSA goes above 0.2-0.4 ng/mL. Side effects from the radiation therapy can be significant, and are additive to those previously received with surgery. These include rectal bleeding, incontinence (urinary leakage), strictures and difficulty urinating, diarrhea, and fatigue. Be sure to discuss with your doctors what you can reasonably expect before deciding on a course of therapy. In some cases, hormone therapy might be added for a short period before radiation to allow your urinary function to heal, or during the radiation treatment, which can also add to the side effects that you might experience.
Because the anatomy looks different and the tumor is often not visible on imaging or felt on physical exam, the radiation oncologist has to carefully balance between delivering sufficient radiation to destroy the prostate cells while not damaging the healthy tissue. Once again, practitioner skill can make an important difference in outcomes.
In some cases, particularly if the tumor was considered high-grade and therefore at greater risk of spreading to the surrounding areas, your doctor might decide to initiate radiation therapy right after you’ve healed from your surgery. This approach, known as adjuvant therapy, typically starts about six weeks after surgery, and is unrelated to "salvage" radiation therapy that is administered if the PSA begins to rise.