One consequence of the routine adoption of PSA monitoring after treatment of early stage prostate cancer is the identification of men with a PSA-only recurrence. In this situation, increases in serum PSA over the pretreatment baseline are not accompanied by signs or symptoms of progressive disease. If the rise in the PSA is slow and occurs after a prolonged period, the site of relapse is generally at the site of the original tumor. Since a significant number of these men are relatively young and otherwise healthy, intense interest has been focused upon their treatment, with particular attention to survival, and the impact of therapy on quality of life.
Treatment options for men with a PSA-only recurrence after radical prostatectomy include external beam radiation therapy (RT) to the prostatic bed with or without treatment of the pelvic lymph nodes (salvage RT), androgen deprivation therapy (ADT), a combination of salvage RT plus ADT, or observation. Most of the available data regarding these approaches has come from observational series. Long-term results of randomized clinical trials will be required to define the optimal approach.
After prostatectomy, PSA should be 0.0 or close to zero. Rising PSA suggests failure even if the absolute PSA values is low.There is some controversy on whetehr any PSA rise warrants re-treatment or whether the PSA Velocity should be used to predict when to intervene.
Re-irradiation is rarely an option after initial curative radiation ahd been given.
Anti androgen therapy offers potential quality of life advantages over castration-based therapies, with recent data showing that the majority of men retain some sexual activity and function on bicalutamide (‘Casodex’) 150 mg. LHRH agonists, the most commonly used drug class for hormone therapy, are given in the form of regular shots: once a month, once every three months, once every four or six months, or once per year.
With intermittent hormone therapy, the LHRH agonist is used for six to twelve months, during which time a low PSA level is maintained. The drug is stopped until the PSA rises to a predetermined level, at which point the drug is restarted. During the “drug holidays” in between cycles, sexual function and other important quality of life measures might return. However, the clinical benefits of this approach remain unclear, and large clinical trials are currently underway to evaluate its use in this setting.
Hormone therapy typically is effective for only a few years, but this period can range from several months to many decades.
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Trock BJ, Han M, Freedland SJ, et al. Prostate cancer-specific survival following salvage radiotherapy vs observation in men with biochemical recurrence after radical prostatectomy. JAMA 2008; 299:2760.
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