Editorial Comment to Postoperative prostate‐specific antigen nadir improves accuracy for predicting biochemical recurrence after radical prostatectomy: Results from the Shared Equal Access Regional Cancer Hospital (SEARCH) and Duke Prostate Center databases

Abstract

The follow up and management of patients who have undergone surgery for prostate cancer involves surveillance for recurrent disease and the functional rehabilitation of the patient. There are a number of established nomograms for predicting biochemical relapse in prostate cancer1 using available tumor and patient specific data, thus allowing the practitioner to tailor the follow up regime to the patient. This paper has introduced another commonly available variable, the PSA nadir, which involves no extra cost to the patient or the clinician.2 The authors have added this to the established nomogram variables to develop a more accurate nomogram. The paper uses some very good statistical tools to show the superiority of their nomogram, but it does not go on to show the clinical value of this improvement. They have validated their nomogram for both the traditional and the ultrasensitive prostate-specific antigen (uPSA) assays, showing the superiority of their nomogram. There is differing opinion on the merits of the use of the uPSA assay, which has advantages over standard assays in postoperative surveillance and prognostication. It allows for earlier detection of biochemical relapse by approximately 11–18 months over traditional methods.3, 4 Defining biochemical relapse in uPSA monitored patients is still debated. Some authors feel there is too much “background noise” with uPSA at the very lowest levels to make this technique specific enough.5 Others recommend that two sequential rises in uPSA is not specific enough and that one should wait to see four sequential rises before diagnosing biochemical failure.4 By identifying and characterizing relapsing patients early, they can be offered salvage therapeutic interventions. It has been suggested that early salvage treatment helps increase the chance of relapse-free survival.6 This paper provides further literature to support the use of the uPSA assay. The strengths in this paper are found in their statistical handling of the data. The principal weakness is the retrospective nature of their cohort. The clinical value of their nomogram is unclear and an evaluation of this in comparison with other nomograms in a prospective study would be valuable. I look forward to using this assay with my prostatectomy patients.