Treatment Options in Patients with Biochemical Failure after Radical Prostatectomy: Deferred Treatment

Abstract

Most patients diagnosed with localized prostate cancer today are cured with surgery or radiation therapy to the prostate. However, a subset of patients can be defined as having a high risk of failure with standard treatment. This risk stratification for disease recurrence is based on established parameters for T stage, Gleason score and PSA. For radical prostatectomy cases biochemical progression is broadly defined as any elevation of PSA postoperatively, which is caused by local progression or distant micrometastases. Bone scans and pelvic computerized tomography are commonly used for re-staging in men with biochemical progression, but recent study suggests that their value is limited in men with PSA recurrence less than 10 ng/ml. For patients at high risk either adjuvant therapy, immediate salvage treatment after biochemical progression or deferred salvage treatment after biochemical progression is possible. Adjuvant therapy for progression after surgery has been applied in other tumors and may improve local control, progression free survival and survival. Placebo controlled randomized studies on adjuvant hormonal therapy have resulted in improved progression free survival and prolonged survival. Drug toxicity and the impact of treatment on quality of life are important considerations when selecting an adjuvant therapy. However with PSA monitoring early disease recurrence can be detected and will identify patients with progressive prostate cancer who will be candidates for salvage treatment. Treatment of PSA biochemical progression is divided into 2 main categories of salvage local treatments and systemic therapy. For local salvage treatment after radical prostatectomy external beam radiation can be used. Proper patient selection is critical to the success of all salvage local treatments. Hormonal therapy is the mainstay of systemic treatment for biochemical recurrence. Alternative approaches, such as intermittent and low dose hormonal therapy, and the use of chemopreventive agents, such as vitamins, minerals and other supplements, are analyzed in prospective trials. Conclusions: Biochemical progression after radical prostatectomy remains a common problem. Treatment should not only improve survival, but also preserve quality of life.