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Prostate Cancer
Options for Increasing Prostate-specific Antigen After Radical Prostatectomy
a report by
Per-Anders Abrahamsson
Secretary General, European Association of Urology (EAU)
When prostate-specific antigen (PSA) levels rise to a certain threshold stage will provide some indication of whether the recurrence is local or
after prostate cancer treatment, i.e. radical prostatectomy or radiation metastatic. Also important is the rate of PSA increase before diagnosis
therapy, a patient experiences what is technically known as a (known as PSA velocity) and the time it takes for PSA to double in value
‘biochemical recurrence’. In other words, when this PSA threshold is following treatment, known as PSA doubling time. Similarly, post-
reached, it means that prostate cancer has reappeared in some form, treatment PSA doubling time may also be used to assess the likelihood
either locally in the prostate area or in metastatic form in other tissues that disease is local or metastatic and provide an insight into prognosis.
and organs. In most cases, the cancer remains at a microscopic level, and When post-treatment PSA doubles in less than six months, for example,
many years may pass before any physical evidence is detectable on clinical and certainly when it doubles within three months, it is likely that the
exam or any abnormalities are seen on a scan. In practical terms, cancer has spread and therefore requires systemic treatment. Research
biochemical recurrence means that one is now faced with a chronic has also shown that the length of time it takes PSA to double can be used
disease that will directly affect patient monitoring, and decisions to estimate the likelihood of whether disease will become clinically
concerning a future treatment strategy will have to be made. evident as local or metastatic following biochemical recurrence.
Unfortunately, insufficient research data are available to provide clear
guidance about when salvage therapy should be considered and which Knowing Whether and When to Act
type of second-line therapy is most effective in particular circumstances. Following radical prostatectomy, if PSA indicates that biochemical
recurrence has occurred, the chief concern is to determine whether to
How to Define Biochemical Recurrence consider treatment. If the decision to treat is affirmative, what to do and
PSA is manufactured by both normal prostate cells and prostate cancer when must be considered. Unfortunately, no professional agreement
cells. This is why PSA levels should fall to undetectable levels in men currently exists about when salvage treatment for recurrent prostate
treated with radical prostatectomy, where the prostate is removed. After cancer should begin, or which salvage treatments are best. Of course, if
a prostatectomy, biochemical recurrence is now generally defined as a PSA the cancer appears aggressive – as indicated by the pre-treatment
of ≥0.2ng/ml following at least two tests. However, some physicians use a numbers (see Table 1) or if PSA has doubled in less than six months –
higher threshold of ≥0.4ng/ml or greater to define biochemical recurrence. immediate treatment seems to be the most likely recommendation,
probably with hormone therapy to prevent or delay metastasis.
A Common Challenge
Studies indicate that biochemical recurrence affects roughly 15–30% of However, a large group of patients will find themselves in a grey area,
men initially thought to be curable with localised treatment for prostate with clinical profiles and PSA doubling times that are not sufficient to
cancer. For example, a study published in the Journal of Urology that trigger immediate salvage therapy. For this category, one may opt
followed 3,478 men who underwent radical prostatectomy for prostate to defer treatment until PSA levels rise to a particular level. This means
cancer found that 32% were likely to suffer from biochemical that more frequent PSA testing is to be initiated to monitor progression.
recurrence within 10 years. Another study, published in the Journal of Although many men diagnosed with biochemical recurrence will want to
the American Medical Association, tracked 1,997 men who had take immediate action to stop the cancer, going ahead with therapy for
undergone radical prostatectomy, for an average period of a little over the sake of doing something may cause more harm than good. The risks
five years, and found that 15% experienced biochemical recurrence and complications of salvage surgery or radiation, already high when
within that time. It is important to note, however, that both studies
selected the most favourable patients as part of their screening studies.
Per-Anders Abrahamsson is Secretary General of the
The percentage of patients who experienced biochemical recurrence
European Association of Urology (EAU). He is also a
would likely have been higher if less stringent patient selection criteria
Professor of Urology at Lund University, Chairman of the
Department of Urology at Malmö University Hospital in
had been used. The main message, however, remains unchanged: a
Sweden and an Adjunct Professor in the Department of
rising PSA after initial treatment for prostate cancer is something that Urology at the University of Rochester Medical Center in
many men will have to deal with.
Rochester, New York. Previously, he was Chairman of the
Department of Urology at Lund University Hospital. Professor
Abrahamsson is the author of 275 scientific publications,
Assessing the Risk on a Personal Basis
including book chapters and books, and is a member of the Editorial Boards of several
scientific journals. He has been the main organiser of several international conferences, is a
Several factors contribute to a personalised risk profile. One important
frequently invited speaker at scientific meetings and has received a number of national and
factor is whether a patient is found to have localised or more advanced international awards. Professor Abrahamsson received his MD and PhD from Lund University.
disease at the time of biochemical recurrence. As indicated in Table 1,
E: p-a.abrahamsson@uroweb.org
pre-treatment ‘numbers’ such as Gleason score and pathological cancer
© TOUCH BRIEFINGS 2007 19
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