Rising PSA In Nonmetastatic Prostate Cancer

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Cancer / Oncology
Article Date: 07 Jan 2009 - 3:00 PDT

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Rising prostate-specific antigen (PSA) in nonmetastatic prostate cancer occurs in two main clinical settings: (1) rising PSA to signal failed initial local therapy and (2) rising PSA in the setting of early hormone-refractory prostate cancer prior to documented clinical metastases.

Most urologists and radiation oncologists are very familiar with the initial very common clinical scenario, commonly called "biochemical recurrence." In fact, up to 70,000 men each year will have a PSA-only recurrence after failed definitive therapy.

The ideal salvage therapy for these men is not clear and includes salvage local therapies and systemic approaches, of which the mainstay is hormonal therapy. Treatment needs to be individualized based upon the patient's risk of progression and the likelihood of success and the risks involved with the therapy. It is unknown how many men per year progress with rising PSA while on hormonal therapy without documented metastases.

This rising PSA disease state is sometimes called, "PSA-only hormone-refractory prostate cancer." As in the setting of initial biochemical recurrence, evidence-based treatment options are limited, and taking a risk-stratified approach is justified. In this article, we will explore these prostate cancer disease states with an emphasis on practical, clinically applicable approaches.

In 2007, nearly 219,000 men are expected to be diagnosed with prostate cancer,[1] approximately 90% will undergo definitive local therapy,[2] and around 30% to 35% will develop biochemical (ie, prostate-specific antigen [PSA]) recurrence within 10 years.[3] Thus, approximately 60,000 to 70,000 men each year develop initial PSA recurrence. Similarly, almost 30,000 men die of prostate cancer annually. Presumably almost all these men progress through hormonal therapy and succumb to the disease in the hormone-refractory disease state.

The natural history of the hormone-refractory nonmetastatic disease state is such that it may take 2 to 3 years between initial elevation in PSA on hormones to documented clinical metastatic disease. As such, there may be 60,000 to 90,000 men alive at any one time in this country with secondarily rising PSA nonmetastatic prostate cancer. In summary, this collective disease state is common, affecting many current era patients and the subject of many clinical encounters by urologists, radiation oncologists, and medical oncologists.

JUDD W. MOUL, MD, LIONEL L. BANEZ, MD, STEPHEN J. FREEDLAND, MD

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