What should be done for patients with rising PSA levels and normal testosterone levels following definitive radiotherapy or radical prostatectomy?

From Cancer Guidelines Wiki

What should be done for patients with rising PSA levels and normal testosterone levels following definitive radiotherapy or radical prostatectomy?

For a more detailed introduction, please read the Biochemical relapse section.

Androgen deprivation therapy (early versus delayed)

If radiation therapy is not undertaken following surgery, the decision would be whether to start hormone treatments due to the rising PSA or wait until metastases become evident through scans. The time to a cancer becoming evident on a scan after a rising PSA is very variable. If the PSA is rising slowly (slow doubling time) and the cancer recurred two years following surgery, only 15% of patients will have cancer seen on a scan at seven years. If however the PSA recurred before two years and the PSA doubled at a rate of less than every 10 months, then 90% of patients have disease on a scan at seven years.[1]

There is only one RCT in this scenario[2] and this involved the use of a 5-alpha reductase inhibitor as a hormonal manipulation with potency sparing properties. The results were presented in terms of change in PSA levels and are of no clinical relevance to routine practice.

See Emerging therapies for more on treatments being examined in continuing clinical trials.

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Evidence summary and recommendations

Evidence summary Level References
There is no level I or II evidence providing guidance for any intervention. II [2]
Evidence-based recommendationQuestion mark transparent.png
The optimal timing of androgen deprivation therapy in patients with biochemical relapse of disease without evidence of overt metastatic disease is not defined. Eligible patients should be informed about the current TROG Trial comparing early versus delayed hormonal therapy in this group.


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References

  1. Pound CR, Partin AW, Eisenberger MA, Chan DW, Pearson JD, Walsh PC. Natural history of progression after PSA elevation following radical prostatectomy. JAMA 1999 May 5;281(17):1591-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10235151.
  2. 2.0 2.1 Andriole G, Lieber M, Smith J, Soloway M, Schroeder F, Kadmon D, et al. Treatment with finasteride following radical prostatectomy for prostate cancer. Urology 1995 Mar;45(3):491-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7533461.

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Appendices