Monitoring
Your Organisational Guidance
ebpracticenet urges you to prioritise the following organisational guidance:
Recommendations nationales de bonne pratique pour la prise en charge du cancer localisé de la prostate: première partiePublished by: KCELast published: 2014Nationale praktijkrichtlijn voor de aanpak van gelokaliseerde prostaatkanker: deel 1Published by: KCELast published: 2014In a patient who has been treated with curative intent, a prostate-specific antigen (PSA) should be checked every 6-12 months for 5 years and annually thereafter, and a digital rectal examination should be considered if recurrence is suspected.[3] Some physicians pursue more vigorous monitoring, with complete re-staging of the patient by blood and imaging at each annual interval for the first 5 years following definitive treatment.
Multiparametric magnetic resonance imaging (MRI) can be used to monitor local recurrence following radical prostatectomy, even in patients who have low post-operative PSA levels (e.g., <1.5 micrograms/L [<1.5 nanograms/mL]).[424]
Active surveillance
Involves monitoring the course of the disease (with additional use of prostate biopsies) until symptoms or signs of disease become clinically evident, with the expectation to treat with definitive treatment (e.g., radiotherapy or radical prostatectomy, with or without androgen deprivation therapy [ADT]) if there is disease progression.
For active surveillance, PSA levels and digital rectal examination (DRE) are checked no more than every 6 and 12 months, respectively, unless clinically indicated.[3][143] Repeat prostate biopsy and repeat multiparametric magnetic resonance imaging (MRI) are carried out no more often than every 12 months, unless clinically indicated.[3] Intensity of active surveillance may be individualised based on patient and tumour factors, risk of progression, and life expectancy. However, most patients should have repeat biopsies every 2-5 years.
Recurrent disease
If a patient develops signs of recurrent disease, then salvage treatments should be pursued.
PSA doubling time (PSADT) may be used as a prognostic factor in the setting of salvage therapy. Among men experiencing rising PSA after external beam radiotherapy (EBRT), there is a significant association between post-radiation PSADT less than 6 months and length of survival (P = 0.04).[425]
Following radical prostatectomy, the PSADT can help to inform treatment decisions (whether local salvage radiotherapy or hormonal therapy is more appropriate) upon recurrence of disease. For example, when PSA elevations were recorded post-operatively, men with a PSADT longer than 10 months were significantly more likely to remain free of distant disease over the next 5 years.[426]
PSA failure
The PSA nadir after radical prostatectomy occurs at approximately 3 weeks. Following EBRT, the nadir is at about 2-3 years, and after brachytherapy it is at about 3-4 years.
The ASTRO and Radiation Therapy Oncology Group in Phoenix (RTOG-ASTRO Phoenix) defines post-EBRT PSA failure is a PSA rise of ≥2 micrograms/L (≥2 nanograms/mL) above the nadir PSA, with the date of failure not backdated.[256] A recurrence evaluation should be considered when PSA is increasing after radiation even if the rise above nadir is not yet 2 micrograms/L (2 nanograms/mL).
PSA failure after radical prostatectomy is not clearly defined; values between 0.1 and 0.4 micrograms/L (0.1 and 0.4 nanograms/mL) have been used.
The American Urological Association defines biochemical recurrence in the post-prostatectomy setting as a rise in PSA ≥0.2 micrograms/L (≥0.2 nanograms/mL) and a confirmatory value of >0.2 micrograms/L (>0.2 nanograms/mL).[242][427]
The National Comprehensive Cancer Network defines post-prostatectomy PSA persistence/recurrence as PSA level that does not fall to undetectable levels (PSA persistence) or undetectable post-prostatectomy PSA with a subsequent detectable PSA that increases on two or more measurements (PSA recurrence) or increases to PSA >0.1 micrograms/L (>0.1 nanograms/mL).[3]
Patients receiving post-prostatectomy salvage EBRT at lower PSA levels (i.e., early salvage) have demonstrated better outcomes compared with those receiving salvage EBRT at higher PSA levels.[242][255]
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