Wait for it.

Top Line: Are we done considering adjuvant radiation for resected prostate cancer?

The Study: We now have results of the RAVES trial to serve as another nail in the coffin. It enrolled 333 men across 32 centers in Australia and New Zealand with high-risk prostatectomy pathology (positive margins, extraprostatic extension, or seminal vesicle invasion) and a post-op PSA ≤0.1. They were then randomized to adjuvant radiation within 6 months of surgery or salvage radiation only upon a PSA ≥0.2, with radiation in either arm consisting of 2 Gy x 32 = 64 Gy to the prostate bed without ADT. The primary endpoint was establishing noninferiority of the salvage arm in regards to biochemical recurrence, which at 5 years was 86% with the adjuvant and 87% with the salvage approach (strikingly similar to RADICALS-RT where it was 85% and 88%, respectively). While you’d think this looks pretty noninferior, in a move straight out of the breast cancer playbook, statistically speaking it wasn’t established due to lower than anticipated events. What can’t be disputed is that only half of men in the salvage arm received radiation.

TBL: More data demonstrates that waiting for an early rise in PSA before proceeding with early salvage radiation allows half of men to avoid radiation while maintaining excellent biochemical control. | Kneebone, Lancet Onocl 2020

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