IRRADIATION FOR ELEVATED POST-PROSTATECTOMY PROSTATE SPECIFIC ANTIGEN 1439

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EDITORIAL COMMENT

The authors demonstrated that postoperative adjuvant radiother- apy in some patients is beneficial. The major point that can be extracted from the data is that perhaps it is better to begin radio- therapy early rather than later. If radiotherapy cannot manage an extremely small volume of local tumor recurrence that is not even palpable, one has to wonder how radiotherapy can eliminate a larger volume tumor in the prostate. Nevertheless, patients who have local and only local recurrence clearly benefited from adjuvant radiother- apy.

Biopsy data from this institution’ and other studies suggest that approximately 45% of the men with detectable PSA after radical prostatectomy have local recurrence. What is not clear is how many of those patients also have distant recurrence but it certainly must be substantial. Therefore, local radiotherapy overall may be expected to eradicate tumor in perhaps a third of patients in the long term. This is, of course, a worthwhile endeavor. However, complications, even those cited in this article, while not usually incapacitating, can seriously impact on quality of life. Therefore, it is incumbent on us to be able to select better patients who may be cured by the treatment.

No mention is made of the impact of the therapy on potency, which is important in some cases. The authors demonstrated that patients with positive nodes and seminal vesicle involvement do poorly, and success in those with stage T3 disease can be expected to decrease further with time. It is surprising that grade does not seem to influence outcome, since that has not been the general impression. Also, the authors did not mention time from surgery to detectable PSA, which is almost certainly important, since most urologists have observed that patients in whom PSA never becomes undetectable usually have distant metastases. Of course, this must be qualified depending on tumor grade and whether there was residual low grade tumor, since some of these patients may have only had local disease. PSA doubling time’ should also be considered when making a deci- sion about adjuvant therapy. It is important to recognize that many patients in whom PSA increases many months or years after surgery and who have a slow PSA doubling time are alive up to 7 to 10 years after surgery with no intervention. However, in the final analysis one cannot ignore the important data in this article, although we must continue to define better the patients for whom postoperative radiotherapy is beneficial.

Jean B. deKernion Division of Urology Uniuersity of California-Los Angeles Los Angeles, California

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2. Patel, A., Dorey, F. and deKernion, J. B.: Biochemical and clin- ical recurrence after radical retropubic prostatectomy: utility of the log slope PSA. J. Urol., part 2, 157: 115, abstract 447, 1997.

REPLY BY AUTHORS

The importance of the data in this article as well as the important conclusion that early versus late intervention appears to result in a greater probabilty of control are acknowledged in the comment. How- ever, we differ, as do the data, in saying that only a third of patients benefit in the long run. Current published data clearly show that