Post-prostatectomy prostate cancer treated with radiation therapy: adverse features and ADT use in a statewide consortium

Background The 2024 AUA/ASTRO/SUO guidelines recommend early salvage radiation (RT) for biochemical recurrence after radical prostatectomy and androgen deprivation therapy (ADT) for high-risk features. Increasingly, men with high-risk disease are undergoing radical prostatectomy. We therefore characterized contemporary RT and ADT practices within the Michigan Radiation Oncology Quality Consortium (MROQC) and Michigan Urological Surgery Improvement Collaborative (MUSIC). Methods Patients receiving post-prostatectomy RT from 06/09/20–09/18/24 were eligible. Prospectively collected data included surgical pathology and radiation/ADT details. RT was adjuvant (pre-RT PSA <0.1 ng/mL), consolidative (persistent PSA ≥0.1), or salvage (all others). Multivariable analyses evaluated associations between clinicopathologic features and ADT use. Results Among 345 patients across 26 centers, 56% had ≥1 high-risk feature: pT3b/T4 (24%), pN1 (6%), Grade Group (GG) 4/5 (30%), pre-RT PSA >0.5 ng/mL (27%). Radiation was adjuvant (10%), consolidative (28%), or salvage (62%), initiated at median PSA of 0.07 (IQR : 0.03-0.09), 0.5 (IQR : 0.3-1.5), and 0.3 ng/mL (IQR : 0.2-0.5), respectively. Median time to RT was 8, 6, and 29 months. ADT was intended in 60%; commonly ≤6-month duration (65%), with a minority recommended ≥24 months (17%) or AR-pathway inhibitors (5%). On MVA, ADT was associated with: pT3b/T4 (OR = 2.77 [1.34–5.93]), pN1 (OR = 6.22 [1.35–47.57]), GG 4/5 (OR = 2.87 [1.51–5.56]), pre-RT PSA >0.5 (OR = 2.11 [1.17–3.91]). Conclusions Within MROQC, over half who received post-prostatectomy radiation had high-risk features; nearly 30% required consolidation for persistently positive PSA. ADT was associated with high-risk features, but few received ADT intensification. Studies are needed to personalize ADT, especially for those with persistent PSA, who are frequently treated yet under-represented in trials.