Monitoring

In 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 exam should be considered if recurrence is suspected.[3] Some physicians pursue more vigorous monitoring, with complete restaging 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 postoperative PSA levels (e.g., <1.5 nanograms/mL).[434]

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., radiation therapy or radical prostatectomy, with or without androgen deprivation therapy [ADT]) if there is disease progression.

For active surveillance, PSA levels and digital rectal exam (DRE) are checked no more than every 6 and 12 months, respectively, unless clinically indicated.[3][141]​​ 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 individualized based on patient and tumor 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 radiation therapy (EBRT), there is a significant association between postradiation PSADT less than 6 months and length of survival (P = 0.04).[435]

Following radical prostatectomy, the PSADT can help to inform treatment decisions (whether local salvage radiation therapy or hormonal therapy is more appropriate) upon recurrence of disease. For example, when PSA elevations were recorded postoperatively, men with a PSADT longer than 10 months were significantly more likely to remain free of distant disease over the next 5 years.[436]

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 nanograms/mL above the nadir PSA, with the date of failure not backdated.[259] A recurrence evaluation should be considered when PSA is increasing after radiation even if the rise above nadir is not yet 2 nanograms/mL.

PSA failure after radical prostatectomy is not clearly defined; values between 0.1 and 0.4 nanograms/mL have been used.

  • The American Urological Association defines biochemical recurrence in the postprostatectomy setting as a rise in PSA ≥0.2 nanograms/mL and a confirmatory value of >0.2 nanograms/mL.[245][437]​​

  • The National Comprehensive Cancer Network defines postprostatectomy PSA persistence/recurrence as PSA level that does not fall to undetectable levels (PSA persistence) or undetectable postprostatectomy PSA with a subsequent detectable PSA that increases on two or more measurements (PSA recurrence) or increases to PSA >0.1 nanograms/mL.​[3]

Patients receiving postprostatectomy salvage EBRT at lower PSA levels (i.e., early salvage) have demonstrated better outcomes compared with those receiving salvage EBRT at higher PSA levels.​[245][258]

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