Radiation Therapy Following Prostatectomy

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.

Terms to know from this article:

Prostatectomy

An operation to remove part or all of the prostate. Radical (or total) prostatectomy is the removal of the entire prostate and some of the tissue around it.

External beam radiation

A form of radiation therapy in which the radiation is delivered by a machine pointed at the area to be radiated. May be known as external beam radiation (EBR, XBR), external beam radiation therapy (EBRT, XBRT).

Seminal vesicle

A gland that helps produce semen.

Brachytherapy

A procedure in which radioactive material sealed in needles, seeds, wires, or catheters is placed directly into or near a tumor. Also called internal radiation, implant radiation, or interstitial radiation therapy.

Lymph nodes

A rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissue. Lymph nodes filter lymph (lymphatic fluid), and they store lymphocytes (white blood cells). They are located along lymphatic vessels. Also called a lymph gland.

Gleason

Gleason Score (GS) - Gleason Grade: A system of grading prostate cancer cells based on how they look under a microscope. Gleason scores range from 2 to 10 and indicate how likely it is that a tumor will spread. A low Gleason score means the cancer cells are similar to normal prostate cells and are less likely to spread; a high Gleason score means the cancer cells are very different from normal and are more likely to spread.

Incontinence

Inability to control the flow of urine from the bladder (urinary incontinence) or the escape of stool from the rectum (fecal incontinence).

Hormone

A chemical made by glands in the body. Hormones circulate in the bloodstream and control the actions of certain cells or organs. Some hormones can also be made in a laboratory.

Oncologist

A doctor who specializes in treating cancer. Some oncologists specialize in a particular type of cancer treatment. For example, a radiation oncologist specializes in treating cancer with radiation.

PSA

prostate-specific antigen (PSA): A substance produced by the prostate that may be found in an increased amount in the blood of men who have prostate cancer, benign prostatic hyperplasia, or infection or inflammation of the prostate.

Tumor

A mass of excess tissue that results from abnormal cell division. Tumors perform no useful body function. They may be benign (not cancerous) or malignant (cancerous).

Grade

The grade of a tumor depends on how abnormal the cancer cells look under a microscope and how quickly the tumor is likely to grow and spread. Grading systems are different for each type of cancer.

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