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Case History

Image not available. A 65-year-old man attends the outpatient department 1 year after undergoing radical radiotherapy. He feels well and leads an active life. Biochemistry reveals increased levels of prostate-specific antigen (PSA). He is not on any medication and examination is unremarkable.

What are the treatment options for PSA-only progression?

What are the treatment options for patients in whom prostatectomy has been unsuccessful?

What are the treatment options for patients in whom radiotherapy has been unsuccessful?

What are the hormonal treatment options?

What other treatments are available?

Background

Image not available. Because of the changing demographic patterns of prostate cancer1 and changing clinical practice, clinicians see a growing population of men who have received primary treatment for localized prostate cancer and who require follow-up for disease progression and monitoring for the complications of radical therapy. Regular history taking, physical examination and PSA testing every 6–12 months are thought to be sufficient.2 Follow-up strategies for these men should focus on identifying relapse and the potential complications of progression (e.g. bone pain, spinal cord compression). Disease recurrence may manifest by biochemical (PSA-only) relapse, local recurrence or metastatic (systemic) disease.

Discussion

What are the treatment options for PSA-only progression?

Image not available. PSA-only early progression (biochemical failure) after radical prostatectomy or radiotherapy for early-stage disease is a common scenario. In 1997, a consensus panel convened by the American Society for Therapeutic Radiology and Oncology (ASTRO) agreed guidelines to define PSA recurrence after radiotherapy,3 but these are neither widely used nor binding.

For men with a rising serum PSA level following definitive local treatment for early-stage disease, a thorough diagnostic evaluation including history, examination, haematology and biochemistry testing including PSA, and computed tomography (CT) and bone scans are indicated. Consideration can be given to repeating the biopsy. The main goal is to assess the likelihood of recurrence of localized rather than systemic disease to select those men who are candidates for potentially curative local salvage therapy. The curative options for men with a PSA-only recurrence include prostate bed irradiation in the situation of failed prior prostatectomy, and salvage prostatectomy and possibly cryotherapy in the situation of failed primary radiotherapy. Factors that help to identify patients at risk of not responding to primary treatment are: short time to biochemical recurrence, rapid PSA doubling time and high Gleason score.4

What are the treatment options for patients in whom prostatectomy has been unsuccessful?

For men with failed prostatectomy, who are thought to have a localized recurrence, irradiation provides durable benefit if there is no adverse pathology (i.e. Gleason score Image not available.8, negative seminal vesicles or nodes), a low serum PSA (Image not available.1.5 ng/ml) at recurrence, and at least a 1-year recurrence-free interval. Although a persistently detectable serum PSA level following prostatectomy most often indicates occult metastatic disease, emerging data suggest that radiotherapy can cure a small ...

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