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APCCC 2026: Which Patients Planned for Salvage Radiotherapy Need Systemic Therapy and for How Long?

(UroToday.com) The 2026 Advanced Prostate Cancer Consensus Conference (APCCC) meeting featured a treatment of PSA recurrence session and a presentation by Dr. Valerie Fonteyne discussing which patients planned for salvage radiotherapy need systemic therapy and for how long. Dr. Fonteyne started her presentation by providing a table highlighting that early salvage radiotherapy is standard of care:

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Regarding ADT use, this was at the discretion of the treating physician in the RADICALS-RT trial1 and was not used in the RAVES trial.2 In the GETUF-AFU 17 trial,3 all patients received 6 months of ADT. A summary of all treatment intensification trials is provided in the following three tables:

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In 2024, Pommier and colleagues4 performed an individual patient data analysis of randomized trials from the ICECaP database to assess for prognostic factors in post-prostatectomy salvage radiotherapy setting with and without hormone therapy. This analysis included 1,647 patients from 3 randomized clinical trials assessing salvage radiotherapy. On multivariable analysis, PSA ≥ 0.5 ng/mL at salvage radiotherapy start, Gleason Score ≥ 8, and negative margin status were the three strongest prognostic factors. Three prognostic groups defined by number of these risk features (high risk: 2 or 3; intermediate risk: 1, and low risk: 0) were strongly associated with overall survival, metastasis free survival, and clinical progression outcomes with salvage radiotherapy alone or with hormone therapy. This prognostic group definition was also relevant for patients with persistent PSA post radical prostatectomy and for patients treated < 1 year from radical prostatectomy to salvage radiotherapy, and with and without hormone therapy:

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Morgan et al.5 recently developed and validated a digital pathology-based multimodal artificial intelligence (MMAI) model to predict outcomes in post-radical prostatectomy biochemical recurrence patients undergoing salvage therapy. With a median follow-up of 9.3 years, the MMAI score was significantly associated with distant metastasis (sHR 2.17 per standard deviation; 95% CI 1.65-2.85; p < 0.001) and remained independently prognostic after adjusting for clinical variables and treatment. The 10-year time-dependent area under the receiver operating characteristic curve for MMAI was 0.74 compared with 0.68 for a clinical nomogram. Binary risk categorization demonstrated a higher 10-year distant metastasis incidence in the MMAI high-risk (25%) than in the low-risk (8.8%) group. The absolute reduction in 10-year distant metastasis incidence with hormone therapy + salvage radiotherapy versus salvage radiotherapy alone was 21% in the high-risk group versus 2.5% in the low-risk group:

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Dr. Fonteyne concluded her presentation discussing which patients planned for salvage radiotherapy need systemic therapy and for how long with the following take-home points:

  • Early salvage radiotherapy remains standard of care
  • PSA thresholds can be used to guide the addition of ADT:
    • ≤0.5 ng/mL: No ADT
    • 0.5-1.5 ng/mL: 6 months of ADT
    • 1.5 ng/mL: 24 months of ADT
  • Selecting the right patient for treatment intensification is key
  • The use of androgen receptor pathway inhibitors instead of ADT is now being investigated

Presented by: Valerie Fonteyne, MD, PhD, Ghent University Hospital, Ghent, Belgium

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2026 Advanced Prostate Cancer Consensus Conference (APCCC), Lugano, Switzerland, Thurs, April 30 – Sat, May 2, 2026.  

References:

  1. Parker CC, Clarke NW, Cook AD, et al. Timing of radiotherapy after radical prostatectomy (RADICALS-RT): A randomized, controlled phase 3 trial. Lancet 2020;396(10260):1413-1421.
  2. Kneebone A, Fraser-Browne C, Duchesne GM, et al. Adjuvant radiotherapy versus early salvage radiotherapy following radical prostatectomy (TROG 08.03/ANZUP RAVES): A randomized, controlled, phase 3, non-inferiority trial. Lancet Oncol. 2020;21(10):1331-1340.
  3. Sargos P, Chabaud S, Latorzeff I, et al. Adjuvant radiotherapy versus early salvage radiotherapy plus short-term androgen deprivation therapy in men with localized prostate cancer after radical prostatectomy (GETUG-AFU 17): A randomized, phase 3 trial. Lancet Oncol 2020;21(10):1341-1352.
  4. Pommier P, Xie W, Ravi P, et al. Prognostic factors in post-prostatectomy salvage radiotherapy setting with and without hormonotherapy: An individual patient data analysis of randomized trials from the ICECaP database. Radiother Oncol. 2024 Dec:201:110532.
  5. Morgan TM, Ren Y, Tang S, et al. Development and validation of a multimodal artificial intelligence-dervied digital pathology-based biomarker predicting metastasis among patients with biochemical recurrence after radical prostatectomy in NRG/RTOG trials. Eur Urol. 2025 Dec 22 [Epub ahead of print].