Assessing and treating patients with increasing prostate specific antigen following radical prostatectomy

In patients who undergo local treatment for clinically localized prostate cancer evidence of increasing serum prostate specific antigen usually antedates the development of clinically evident metastasis by many years. Prostate specific antigen is used to guide subsequent salvage strategies, such as postoperative radiotherapy, androgen ablation or active surveillance with delayed intervention. We discuss options for management in patients who have increasing prostate specific antigen after radical prostatectomy.

The current status of treatment approaches was reviewed to provide an update on frequently used management strategies.

Increasing prostate specific antigen values of 0.2 to 0.4 ng/ml are used to indicate recurrent disease after surgery. Restaging is recommended to determine whether metastatic disease can be detected, although many patients with low prostate specific antigen values will have no detectable metastases. Local therapy should be used for select patients in the absence of metastases but the results are most satisfactory for relatively slowly increasing prostate specific antigen with values below 1.0 ng/ml and lower Gleason score neoplasms because these tumors are more likely to have localized recurrences.

Current knowledge about patients with biochemical relapse after radical prostatectomy is primarily related to their natural history. Although approximately 70% of these patients are unlikely to die of the disease, they remain at risk for the development of metastasis and disease related morbidity. Currently no general consensus exists regarding standard systemic treatment approaches for these patients and inclusion in clinical trials remains the most important priority.