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 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 postoperative PSA levels (e.g., <1.5 micrograms/L [<1.5 nanograms/mL]).[416]

Active surveillance

In a patient who is being managed by active surveillance, the PSA level should be checked no more than every 6 months and a digital rectal examination performed no more than every 12 months.[3] Furthermore, repeat prostate biopsy and repeat multiparametric MRI are carried out no more often than every 12 months, unless clinically indicated.[3] If active surveillance reveals disease progression, then definitive treatments should be pursued.

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).[417]

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 postoperatively, men with a PSADT longer than 10 months were significantly more likely to remain free of distant disease over the next 5 years.[418]

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.[260]​ 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).[233][244]​​

  • 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).[26]

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.[233][245]​​

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