Current controversies in the management of biochemical failure in prostate cancer

Approximately 35% of prostate cancer patients will experience a biochemical recurrence within 10 years of receiving treatment. Among patients who develop biochemical recurrence, approximately one-third will develop radiographic evidence of metastatic disease within 8 years from the time of prostate-specific antigen (PSA) elevation. Development of biochemical recurrence with a rising PSA level causes significant anxiety for both the patient and his treating oncologist. There is no consensus regarding the PSA level that indicates disease recurrence after radical prostatectomy. Androgen-deprivation therapy (ADT) is the standard of care for these patients. The key components that influence the consideration of ADT are the rate of change of the PSA level (PSA doubling time), the patient's anxiety regarding his PSA level, and the side effects associated with ADT. One of the most prominent controversies in the treatment of biochemical recurrence is the timing of ADT (early vs late) for treatment of PSA recurrence. An emerging treatment option is continued active surveillance, especially in patients who are asymptomatic. Other management approaches under investigation include intermittent ADT, the combination of ADT and novel agents, and peripheral androgen blockade.