A total of 3 randomized clinical trials have demonstrated a significant clinical benefit with adjuvant radiation in patients with high-risk prostate cancer after radical prostatectomy, with each showing improved biochemical control outcomes, and one trial (SWOG 8794) also demonstrating increased overall survival. How broadly these results have informed clinical practice has evolved over time, given the widespread availability of ultrasensitive prostate-specific antigen level testing and increased awareness that the high-risk patients are not a uniform cohort. In this review, we discuss the evidence from published and ongoing trials as well as current controversies, focusing on unanswered questions such as when postoperative radiation should be offered and whether the inclusion of androgen-deprivation therapy improves clinical outcomes. The emerging interest in genomic prediction tools and the enhanced sensitivity of novel imaging modalities should offer strategies to improve patient selection, which would help to identify men who may benefit from postoperative radiation while avoiding unnecessary treatment and toxicities in other men.
Copyright © 2016. Published by Elsevier Inc.