Current Urology Reports

, Volume 5, Issue 3, pp 179–187 | Cite as

Management of patients with an increasing prostate-specific antigen after radical prostatectomy

  • Masood A. Khan
  • Alan W. Partin
Article

Abstract

Since the late 1980s, early detection and monitoring of men for prostate cancer by serum prostate-specific antigen (PSA) measurement has resulted in an increase in the number of men presenting with a potentially curable disease. During the same time, in an attempt to provide a definitive cure, radical prostatectomy has been performed increasingly and now is regarded as the management option of choice for many patients with clinically localized prostate cancer. Radical prostatectomy involves the removal of all of the prostate tissue resulting in the serum PSA level to steadily decline to an undetectable level within 4 to 6 weeks after surgery. Despite improvements in surgical technique and a marked downward stage shift brought about by serum PSA testing, approximately 25% of men ultimately will experience a subsequent increase in serum PSA to a detectable level indicating disease recurrence after radical prostatectomy within 15 years. In this brief review, the factors associated with a high risk for disease recurrence after radical prostatectomy are discussed. Factors indicating whether the increasing serum PSA is caused by local recurrence or metastatic disease and the management options available to address serum PSA recurrence also are discussed.

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References and Recommended Reading

  1. 1.
    American Cancer Society: Cancer Facts and Figures. Atlanta: American Cancer Society; 2003.Google Scholar
  2. 2.
    Catalona WJ, Smith DS, Ratliff TL, et al.: Detection of organ-confined prostate cancer is increased through prostate-specific antigen based screening. J Am Med Assoc 1993, 70:948–954.CrossRefGoogle Scholar
  3. 3.
    Mettlin CJ, Murphy GP, Ho R, Menck HR: The National Cancer Data Base report on longitudinal observations on prostate cancer. Cancer 1996, 77:2162–2166.PubMedCrossRefGoogle Scholar
  4. 4.
    Oesterling JE, Chan DW, Epstein JI, et al.: Prostate-specific antigen in the preoperative and postoperative evaluation of localized prostatic cancer treated with radical prostatectomy. J Urol 1988, 139:766–772.PubMedGoogle Scholar
  5. 5.
    Khan MA, Han M, Partin AW, et al.: Long-term cancer control of radical prostatectomy in men younger than 50 years of age: update 2003. Urology 2003, 62:86–91.PubMedCrossRefGoogle Scholar
  6. 6.
    Carter HB, Partin AW: Diagnosis and staging of prostate cancer. In Campbell’s Urology, edn 8. Edited by Walsh PC, Retik AB, Vaughan ED, et al. New York: Elsevier Science; 2002:3055–3079.Google Scholar
  7. 7.
    Polascik TJ, Oesterling JE, Partin AW: Prostate-specific antigen: a decade of discovery: what we have learned and where we are going. J Urol 1999, 162:293–306.PubMedCrossRefGoogle Scholar
  8. 8.
    Stamey TA, Kabalin JN, McNeal JE, et al.: Prostate-specific antigen in the diagnosis and treatment of adenocarcinoma of the prostate. II: radical prostatectomy treated patients. J Urol 1989, 141:1076–1083.PubMedGoogle Scholar
  9. 9.
    Noldus J, Graefen M, Huland E, et al.: The value of the ratio of free-to-total prostate specific antigen for staging purposes in previously untreated prostate cancer. J Urol 1998, 159:2004–2007.PubMedCrossRefGoogle Scholar
  10. 10.
    Ercole CJ, Lange PH, Mathiesen M, et al.: Prostate-specific antigen and prostatic acid phosphatase in the monitoring and staging of patients with prostatic cancer. J Urol 1987, 138:1181–1184.PubMedGoogle Scholar
  11. 11.
    Rainwater LM, Morgan WR, Klee GG, et al.: Prostate-specific antigen testing in untreated and treated prostatic adenocarcinoma. Mayo Clin Proc 1990, 65:1118–1126.PubMedGoogle Scholar
  12. 12.
    Catalona WJ, Smith DS, Ornstein DK: Prostate cancer detection in men with serum PSA concentrations of 2.6 to 4.0 ng/ mL and benign prostate examination: enhancement of specificity with free PSA measurements. JAMA 1997, 277:1452–1455.PubMedCrossRefGoogle Scholar
  13. 13.
    Rietbergen JB, Hoedemaeker RF, Kruger AE, et al.: The changing pattern of prostate cancer at the time of diagnosis: characteristics of screen-detected prostate cancer in a populationbased screening study. J Urol 1999, 161:1192–1198.PubMedCrossRefGoogle Scholar
  14. 14.
    Partin AW, Yoo JK, Carter HB, et al.: The use of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage in men with localized prostate cancer. J Urol 1993, 150:110–114.PubMedGoogle Scholar
  15. 15.
    Partin AW, Carter HB, Chan DW, et al.: Prostate-specific antigen in the staging of localized prostate cancer: influence of tumor differentiation, tumor volume, and benign hyperplasia. J Urol 1990, 143:747–752.PubMedGoogle Scholar
  16. 16.
    Gleason DF: The Veterans Administration Cooperative Urological Research Group: histological grading and clinical staging of prostatic carcinoma. In Urologic Pathology: The Prostate. Edited by Tannenbaum M. Philadelphia: Lea & Febiger; 1977:171–197.Google Scholar
  17. 17.
    Epstein JI, Pizov G, Walsh PC: Correlation of pathologic findings with progression after radical retropubic prostatectomy. Cancer 1993, 71:3582–3593.PubMedCrossRefGoogle Scholar
  18. 18.
    Epstein JI, CarMichael MJ, Pizov G, et al.: Influence of capsular penetration on progression following radical prostatectomy: a study of 196 cases with long-term follow-up. J Urol 1993, 150:135–141.PubMedGoogle Scholar
  19. 19.
    Partin AW, Piantadosi S, Sanda MG, et al.: Selection of men at high-risk for disease recurrence for experimental adjuvant therapy following radical prostatectomy. Urology 1995, 45:831–838.PubMedCrossRefGoogle Scholar
  20. 20.
    CarMichael M, Veltri RW, Partin AW, et al.: Deoxyribonucleic acid ploidy analysis as a predictor of recurrence following radical prostatectomy for stage T2 disease. J Urol 1995, 153:1015–1019.PubMedCrossRefGoogle Scholar
  21. 21.
    Pound CR, Partin AW, Eisenberger MA, et al.: Natural history of progression after PSA elevation following radical prostatectomy. JAMA 1999, 281:1591–1597. The authors determined that PSADT (< 10 months), time to initial serum PSA rise (< 2 years), and prostatectomy Gleason score (> 7) are strongly predictive for progression to distant metastases or prostate cancer-specific death in men with rising serum PSA after radical prostatectomy.PubMedCrossRefGoogle Scholar
  22. 22.
    Chan TY, Partin AW, Walsh PC, Epstein JI: Prognostic significance of Gleason score 3 + 4 versus Gleason score 4 + 3 tumor at radical prostatectomy. Urology 2000, 56:823–827. The authors determined that in the presence of Gleason score 7 disease, a score of 3 + 4 has a significantly different prognosis than 4 + 3.PubMedCrossRefGoogle Scholar
  23. 23.
    Stamey TA, McNeal JE, Yemoto C, et al.: Biological determinant of cancer progression of men with prostate cancer. JAMA 1999, 281:1395–1400.PubMedCrossRefGoogle Scholar
  24. 24.
    Partin AW, Pound CR, Clemens JQ, et al.: Prostate-specific antigen after anatomic radical prostatectomy: the Johns Hopkins Experience after 10 years. Urol Clin North Am 1993, 20:713–725.PubMedGoogle Scholar
  25. 25.
    Humphrey PA, Walther PJ, Currin SM, et al.: Histologic grade, DNA ploidy, and intraglandular tumor extent as indicators of tumor progression of clinical stage B prostate carcinoma. Am J Surg Pathol 1991, 15:1165–1170.PubMedCrossRefGoogle Scholar
  26. 26.
    Partin AW, Kattan MW, Subong EN, et al.: Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer: a multi-institutional update. JAMA 1997, 277:1445–1451.PubMedCrossRefGoogle Scholar
  27. 27.
    Blute ML, Bergstralh EJ, Partin AW, et al.: Validation of Partin tables for predicting pathological stage of clinically localized prostate cancer. J Urol 2000, 164:1591–1595.PubMedCrossRefGoogle Scholar
  28. 28.
    Partin AW, Mangold LA, Lamm DM, et al.: Contemporary update of prostate cancer staging nomograms (Partin tables) for the new millennium. Urology 2001, 58:843–848. This study reports the updated Partin tables used to predict the likelihood of organ-confined disease based on preoperative factors, taking into account contemporary cohorts presenting with a new diagnosis of prostate cancer.PubMedCrossRefGoogle Scholar
  29. 29.
    Khan MA, Partin AW, Mangold LA, et al.: The probability of biochemical recurrence by analysis of pathologic stage, Gleason score, and margin status for localized prostate cancer. Urology 2003, 62:866–871.PubMedCrossRefGoogle Scholar
  30. 30.
    Lange PH, Ercole CJ, Lightner DJ, et al.: The value of serum prostate-specific antigen determinations before and after radical prostatectomy. J Urol 1989, 141:873–879.PubMedGoogle Scholar
  31. 31.
    Connoly JA, Shinohara K, Presti JC Jr, Carroll PR: Local recurrence after radical prostatectomy: characteristics in size, location, and relationship to prostate-specific antigen and surgical margins. Urology 1996, 47:225–231.CrossRefGoogle Scholar
  32. 32.
    Lightner DJ, Lange PH, Reddy PK, Moore L: Prostate-specific antigen and local recurrence after radical prostatectomy. J Urol 1990, 144:921–926.PubMedGoogle Scholar
  33. 33.
    Cher ML, Bianco FJ Jr, Lam JS, et al.: Limited role of radionuclide bone scintigraphy in patients with prostate-specific antigen elevations after radical prostatectomy. J Urol 1998, 160:1387–1391.PubMedCrossRefGoogle Scholar
  34. 34.
    Kramer S, Gorich J, Gottfried HW, et al.: Sensitivity of computered tomography in detecting local recurrence of prostatic carcinoma following radical prostatectomy. Br J Radiol 1997, 70:995–999.PubMedGoogle Scholar
  35. 35.
    Castellino RA: Retroperitoneal and pelvic lymph node imaging. Cancer 1991, 67:1219–1222.PubMedCrossRefGoogle Scholar
  36. 36.
    Fujii Y, Higashi Y, Owada F, et al.: Magnetic resonance imaging for the diagnosis of prostate cancer metastatic to bone. Br J Urol 1995, 75:54–58.PubMedCrossRefGoogle Scholar
  37. 37.
    Harisinghani MG, Barentsz J, Hahn PF, et al.: Noninvasive detection of clinically occult lymph-node metastases in prostate cancer. N Engl J Med 2003, 348:2491–2499.PubMedCrossRefGoogle Scholar
  38. 38.
    Murphy GP, Elgamal AA, Su SL, et al.: Current evaluation of the tissue localization and diagnostic utility of prostate specific membrane antigen. Cancer 1998, 83:2259–2269.PubMedCrossRefGoogle Scholar
  39. 39.
    Swindle PW, Kattan MW, Scardino PT: Markers and meaning of primary treatment failure. Urol Clin North Am 2002, 30:377–401.CrossRefGoogle Scholar
  40. 40.
    Seltzer M, Naitoh J, Cangiano T, et al.: Comparison of computed tomography, positron emission tomography, and monoclonal antibody scan for evaluation of lymph node metastases in patients with PSA relapse after treatment for localized prostate cancer [Abstract]. J Urol 1998, 159:1109A.Google Scholar
  41. 41.
    Partin AW, Pearson JD, Landis PK, et al.: Evaluation of serum prostate-specific antigen velocity after radical prostatectomy to distinguish local recurrence from distant metastases. Urology 1994, 43:649–659.PubMedCrossRefGoogle Scholar
  42. 42.
    Cadeddu JA, Partin AW, DeWeese TL, Walsh PC: Long-term results of radiation therapy for prostate cancer recurrence following radical prostatectomy. J Urol 1998, 159:173–177.PubMedCrossRefGoogle Scholar
  43. 43.
    Patel A, Dorey F, Franklin J, deKernion JB: Recurrence patterns after radical retropubic prostatectomy: clinical usefulness of prostate-specific antigen doubling times and log slope prostate specific antigen. J Urol 1996, 156:1725–1729.CrossRefGoogle Scholar
  44. 44.
    Haab F, Meulemans A, Boccon-Gibod L, et al.: Effect of radiation therapy after radical prostatectomy on serum prostatespecific antigen measured by an ultrasensitive assay. Urology 1995, 45:1022–1027.PubMedCrossRefGoogle Scholar
  45. 45.
    Forman JD, Meetze K, Pontes E, et al.: Therapeutic irradiation for patients with an elevated post-prostatectomy prostate specific antigen level. J Urol 1997, 158:1436–1440.PubMedCrossRefGoogle Scholar
  46. 46.
    Garg MK, Tekyi-Mensah S, Bolton S, et al.: Impact of prostatectomy prostate-specific antigen nadir on outcomes following salvage radiotherapy. Urology 1998, 51:998–1002.PubMedCrossRefGoogle Scholar
  47. 47.
    Song DY, Thompson TL, Ramakrishnan V, et al.: Salvage radiotherapy for rising or persistent PSA after radical prostatectomy. Urology 2002, 60:281–287. These authors report on the importance of the absence of Gleason score ≥ 8 disease in determining the ability of salvage radiation therapy to successfully address a rise in serum PSA after radical prostatectomy.PubMedCrossRefGoogle Scholar
  48. 48.
    Liauw SL, Webster WS, Pistenmaa DA, Roehrborn CG: Salvage radiotherapy for biochemical failure of radical prostatectomy: a single-institution experience. Urology 2003, 61:1204–1210. In a similar note, these authors reported on the importance of the absence of seminal vesicle involvement in determining the ability of salvage radiation therapy to successfully address a rise in serum PSA after radical prostatectomy.PubMedCrossRefGoogle Scholar
  49. 49.
    Cox JD, Gallagher MJ, Hammond EH, et al.: Consensus statements on radiation therapy of prostate cancer: guidelines for prostate re-biopsy after radiation and for radiation therapy with rising prostate-specific antigen levels after radical prostatectomy. American Society for Therapeutic Radiology and Oncology Consensus Panel. J Clin Oncol 1999, 17:1155–1563. These authors reported on the recommendations for adjuvant radiation therapy after radical prostatectomy from the American Society for Therapeutic Radiology and Oncology Consensus Panel.PubMedGoogle Scholar
  50. 50.
    Eulau SM, Tate DJ, Stamey TA, et al.: Effect of combined transient androgen deprivation and irradiation following radical prostatectomy for prostate cancer. Int J Radiat Oncol Biol Phys 1998, 41:735–740.PubMedCrossRefGoogle Scholar
  51. 51.
    Huggins C, Hodges CV: The effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. Cancer Res 1941, 1:293–297.Google Scholar
  52. 52.
    Cox RL, Crawford ED: Estrogens in the treatment of prostate cancer. J Urol 1995, 154:1991–1998.PubMedCrossRefGoogle Scholar
  53. 53.
    Moul JW: Prostate-specific antigen only progression of prostate cancer. J Urol 2000, 163:1632–1642.PubMedCrossRefGoogle Scholar
  54. 54.
    See WA, Wirth MP, McLeod DG, et al.: Bicalutamide as immediate therapy either alone or as adjuvant to standard care of patients with localized or locally advanced prostate cancer: first analysis of the early prostate cancer program. J Urol 2002, 168:429–435. These authors report on the beneficial impact of adjuvant antiandrogen (bicalutamide) after radical prostatectomy or radiation therapy for men with locally advanced prostate cancer. However, overall survival data are immature and longer follow-up is needed to determine if there is a survival benefit associated with bicalutamide.PubMedCrossRefGoogle Scholar
  55. 55.
    Denis LJ, Carnelro de Moura JL, Bona A, et al.: Goserelin acetate and flutamide versus bilateral orchiectomy: a phase III EORTC Trial (30853). Urology 1993, 42:119–129.PubMedCrossRefGoogle Scholar
  56. 56.
    Eisenberger MA, Blumenstein BA, Crawford ED, et al.: Bilateral orchiectomy with or without flutamide for metastatic prostate cancer. N Engl J Med 1998, 339:1036–1042.PubMedCrossRefGoogle Scholar
  57. 57.
    Kurek R, Renneberg H, Lubben G, et al.: Intermittent complete androgen blockade in PSA relapse after radical prostatectomy and incidental prostate cancer. Eur Urol 1999, 35:27–31.PubMedCrossRefGoogle Scholar
  58. 58.
    Andriole G, Lieber M, Smith J, et al.: Treatment with finasteride following radical prostatectomy. Urology 1995, 45:491–497.PubMedCrossRefGoogle Scholar
  59. 59.
    Harding P, Moul JW, Mcleod DG: Combination of flutamide and finasteride in PSA-only recurrence after prior local prostate cancer therapy [Abstract]. J Urol 1998, 159:130.Google Scholar
  60. 60.
    Lisle T, Mackenzie S, Ziada A, et al.: Androgen deprivation therapy using finasteride and low dose flutamide to treat PSA failure following therapy for clinically localized adenocarcinoma of the prostate (CaP) [Abstract]. J Urol 1999, 161:299.CrossRefGoogle Scholar
  61. 61.
    Pili R, Kruszewski MP, Hager BW, et al.: Combination of phenylbutyrate and 13-cis retinoic acid inhibits prostate tumor growth and angiogenesis. Cancer Res 2001, 61:1477–1485.PubMedGoogle Scholar
  62. 62.
    Pound CR, Brawer MK, Partin AW: Evaluation and treatment of men with biochemical prostate-specific antigen recurrence following definitive therapy for clinically localized prostate cancer. Rev Urol 2001, 3:72–84.PubMedGoogle Scholar
  63. 63.
    Figg WD, Raje S, Bauer KS, et al.: Pharmacokinetics of thalidomide in an elderly prostate cancer population. J Pharm Sci 1999, 88:121–125.PubMedCrossRefGoogle Scholar
  64. 64.
    Khan MA, Carducci MA, Partin AW: The evolving role of docetaxel (Taxotere) in the management of androgen-independent prostate cancer. J Urol 2003, 170:1709–1716.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2004

Authors and Affiliations

  • Masood A. Khan
    • 1
  • Alan W. Partin
    • 1
  1. 1.Johns Hopkins HospitalJames Buchanan Brady Urological InstituteBaltimoreUSA

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