Rising prostate specific antigen after radical prostatectomy: a case based review

Prostate specific antigen (PSA) has been proven to be a valuable tool in the diagnosis and staging of early prostate cancer and as a sensitive marker of residual or recurrent cancer after curative therapy. In 1998, 200 000 new cases of prostate cancer were reported in the SEER database. Two-thirds of these, or 134 000 men, underwent definitive therapy for localized cancer, including approximately 75 000 radical prostatectomies. It has been reported that 20%-50% of radical prostatectomy patients will have a PSA only recurrence. One can therefore estimate that every year 15 000 to 38 000 men will have a rising PSA following definitive surgical therapy. This elevation of PSA often precedes clinical failure by many years and poses a difficult management problem for which there are not, as yet, definitive management guidelines. This paper will review the definition of PSA recurrence, the natural history, diagnostic options and the therapeutic choices, as illustrated by several genuine cases.