Definitive radiation therapy can be given to patients with disease that fails only locally following prostatectomy.[1,2,3,4] An occasional patient can be salvaged with prostatectomy after a local recurrence following definitive radiation therapy; however, only about 10% of patients treated initially with radiation therapy will have local relapse only. In these patients, prolonged disease control is often possible with hormonal therapy, with median cancer-specific survival of 6 years after local failure.
Cryosurgical ablation of recurrence following radiation therapy is associated frequently with a high complication rate. This technique is still undergoing clinical evaluation.
Hormonal therapy is used to manage most relapsing patients with disseminated disease who initially received locoregional therapy with surgery or radiation therapy. (Refer to the Standard Treatment Options for Stage IV Prostate Cancer section of this summary for more information.)
It is not clear whether additional treatments given on the basis of rising PSA in asymptomatic men with prostate cancer increase OS. Biochemical evidence of failure on the basis of elevated or rising PSA alone, therefore, may not be sufficient to alter treatment, and using surrogate endpoints for clinical decision-making is, therefore, controversial.
PSA is often used to monitor patients after initial therapy with curative intent, and elevated or rising PSA is a common trigger for additional therapy even in asymptomatic men. After radical prostatectomy, detectable PSA levels identify patients at elevated risk of local treatment failure or metastatic disease; however, a substantial proportion of patients with elevated or rising PSA levels after initial therapy with curative intent may remain clinically free of symptoms for extended periods of time.
For example, in a retrospective analysis of nearly 2,000 men who had undergone radical prostatectomy with curative intent and who were followed for a mean of 5.3 years. 315 men (15%) demonstrated an abnormal PSA of 0.2 ng/ml or higher, which is evidence of biochemical recurrence.
Of these 315 men, 103 men (34%) developed clinical evidence of recurrence.
The median time to development of clinical metastasis after biochemical recurrence was 8 years.
After the men developed metastatic disease, the median time to death was an additional 5 years.
Likewise, after radiation therapy with curative intent, persistently elevated or rising PSA may be a prognostic factor for clinical disease recurrence. However, reported case series have used a variety of definitions of PSA failure. Criteria have been developed by the American Society for Therapeutic Radiology and Oncology Consensus Panel.[11,12] The implication of the various definitions of PSA failure for overall survival (OS) is not known, and as in the surgical series, many biochemical relapses (rising PSA alone) may not be clinically manifested in patients treated with radiation therapy.[13,14]