Attorneys are often consulted by patients who feel that they have not been properly followed after cancer had been treated and that a recurrence could have been diagnosed earlier but was missed. Different cancers have different follow-up recommendations. For prostate cancer, PSA is the mainstay of the follow-up strategy.
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 often not accompanied by signs or symptoms of progressive disease. When PSA rises, the physician is often faced with a quandary. The longer one waits to perform an imaging study, the greater the chance that a recurrence can be confirmed and treatment started.
On the other hand, imaging too early in the course of PSA rising might result in a negative study, frustrated patient, avoidable expense and the need to repeat imaging at a future time. 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 and can still be cured, intense interest has been focused on 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 recurrence even if the absolute PSA values is low. When this fact is not appreciated, a recurrence can be missed because of the PSA, although higher, is still within the “normal” range. There is some controversy on whether any PSA rise warrants re-treatment or whether the PSA Velocity (rate of PSA rise over time) should be used to predict when to intervene.
- Wiegel T, Lohm G, Bottke D, et al. Achieving an undetectable PSA after radiotherapy for biochemical progression after radical prostatectomy is an independent predictor of the biochemical outcome–results of a retrospective study. Int J Radiat Oncol Biol Phys 2009; 73:1009.
- 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.
- Boorjian SA, Karnes RJ, Crispen PL, et al. Radiation therapy after radical prostatectomy: impact on metastasis and survival. J Urol 2009; 182:2708.
- Andrew J. Stephenson, Salvage Radiotherapy for Recurrent Prostate Cancer After Radical Prostatectomy, JAMA. 2004;291:1325-1332
The Hematologist/Oncologist who wrote this article had been Associate Professor of Medicine while a full-time attending at the University Hospital of a Medical School until 2009. Prior to 2004 had been an Associate Clinical Professor of Medicine. He is currently in private practice. He is the first author of over thirty academic articles, chapters, and several books. Over the past two decades, he held the positions of Interim Chief of Hematology and Oncology, Director of the Cancer Center, Chief of Hematology and Oncology and Chief of Service and concurrently Director of the Cancer Center Network of the Health and Hospitals Corporation and Co-Director of Oncology at a University Hospital and Medical Center. He developed and ran two clinical research programs as well as a community advocacy group, a consulting group, and a non-profit educational institution. In addition to Internal Medicine and Oncology. He is Board Certified in Quality Assurance and Utilization Review and holds an MBA. He was listed several times as the best in his specialty by the Castle Connolly Guide to America’s Top Doctors.