Management of Biochemical Recurrence after Primary Curative Treatment for Prostate Cancer: A Review

Abstract

How to manage patients with prostate cancer (PCa) with biochemical recurrence (BCR) following primary curative treatment is a controversial issue. Importantly, this prostate-specific antigen (PSA)-only recurrence is a surrogate neither of PCa-specific survival nor of overall survival. Physicians are therefore challenged with preventing or delaying the onset of clinical progression in those deemed at risk, while avoiding over-treating patients whose disease may never progress beyond PSA-only recurrence. Adjuvant therapy for radical prostatectomy (RP) or local radiotherapy (RT) has a role in certain at-risk patients, although it is not recommended in low-risk PCa owing to the significant side-effects associated with RT and androgen deprivation therapy (ADT). The recommendations for salvage therapy differ depending on whether BCR occurs after RP or primary RT, and in either case, definitive evidence regarding the best strategy is lacking. Options for treatment of BCR after RP are RT at least to the prostatic bed, complete or intermittent ADT, or observation; for BCR after RT, salvage RP, cryotherapy, complete or intermittent ADT, brachytherapy, high-intensity focused ultrasound (HIFU), or observation can be considered. Many patient- and cancer-specific factors need to be taken into account when deciding on the best strategy, and optimal management depends on the involvement of a multidisciplinary team, consultation with the patient themselves, and the adoption of an individualised approach. Improvements in imaging techniques may enable earlier detection of metastases, which will hopefully refine future management decisions.

Positive Association between Preoperative Total Testosterone Levels and Risk of Positive Surgical Margins by Prostate Cancer: Results in 476 Consecutive Patients Treated Only by Radical Prostatectomy

“…Overall rates of PSMs vary from 11 to 38% in open series and from 12 to 32.8% in robot-assisted series [7,14]; moreover, they are not influenced by the 2 approaches [15,16]. Literature patterns of PSMs were confirmed by our study.…”

“…Thus, beyond surgical factors, tumor biology has a pivotal independent role on surgical margins status. Independent clinical predictors of PSMs include BMI, PSA, TPV, PSA density, biopsy tumor grade, and surgical factors [6,7,14].…”

“…PSMs, when associated with features of high-risk PCA, indicate aggressive tumor biology with drawbacks on the natural history of the disease [6,7,14]. Site, number, and extension of PSMs may stratify patients into prognostic groups [6,14].…”

“…The detection of PSMs, cancer extending beyond the prostate (extracapsular extension and/or seminal vesicle invasion), and PSA < 0.1 ng/mL represent negative prognostic factors for disease recurrence and progression. So far, patients who show these features should be counseled because 2 treatment options can be offered [6,7]. The first option includes, when the urinary function is recovered, immediate adjuvant radiotherapy to the surgical bed.…”

Histotripsy: The Next Generation of High‐Intensity Focused Ultrasound for Focal Prostate Cancer Therapy

“…Patients with biochemical evidence of recurrence, which can occur in up to one‐third of men treated primarily with surgery or radiation therapy, are problematic, and treatment strategies in such patients can include androgen deprivation therapy (although this is associated with substantial side effects), radiotherapy, brachytherapy, proton therapy, and HIFU . All salvage treatments are more toxic to the patient than the primary treatment .…”