SWOG trial 8794 and EORTC trial 22911 demonstrated that adjuvant radiation reduces the risk of biochemical failure over radical prostatectomy alone. In a new analysis Swanson et al stratified patients enrolled in the SWOG trial as to their preradiation PSA levels and correlated with outcomes such as PSA treatment failure, local recurrence, and distant failure. 374 patients with a median follow up of 10.2 years were eligible fort his study. For patients with a postsurgical PSA of ≤0.2ng/ml radiation was associated with reductions in the 10 year risk of biochemical failure (72% to 42%), local failures (20% to 7%), and distant failures (12% to 4%). For patients with a postsurgical PSA between higher than 0.2 and ≤1ng/ml, reductions in the 10 year risk of biochemical failure (80% to 73%), local failures (25% to 9%), and distant failures (16% to 12%) were realized. In patients with postsurgical PSA higher than 1ng/ml the respective findings were 94% versus 100%, 28% versus 9%, and 44% versus 18%. The authors conclude that the pattern of treatment failure in high risk patients is predominantly local with a surprisingly low incidence of metastatic failure. Adjuvant radiation to the prostate bed reduces the risk of metastatic disease and biochemical failure at all postsurgical PSA levels.