What is the next step in management for a patient with a history of prostate cancer, status post total prostatectomy and androgen deprivation therapy (ADT) for one year, now presenting with a steadily rising Prostate-Specific Antigen (PSA) level, albeit less than 1?

From the Guidelines

For a patient with a history of prostate cancer who had a total prostatectomy with ADT for a year, and now has a steadily rising PSA over 3 years (though still less than 1), the next step in management should be referral to radiation oncology for consideration of salvage radiation therapy to the prostate bed. This approach is recommended for biochemical recurrence after prostatectomy, particularly when PSA levels are low, as earlier intervention typically yields better outcomes 1. The radiation would target potential microscopic disease in the surgical bed that may be causing the PSA rise. Some key points to consider in the management of this patient include:

• The definition of biochemical recurrence, which is a rise in PSA in prostate cancer patients after treatment with surgery or radiation, with a PSA of 0.2 ng/mL and a confirmatory value of 0.2 ng/mL or greater following radical prostatectomy 1.
• The importance of evaluating for potential metastatic disease using imaging studies such as a prostate-specific membrane antigen (PSMA) PET scan or conventional imaging (CT and bone scan) 1.
• The consideration of additional ADT alongside radiation therapy, depending on imaging results.
• The need for regular follow-up PSA monitoring every 3-6 months to assess treatment response. It is also important to note that the patient's prognosis is best approximated by the absolute level of PSA, the rate of change in the PSA level over time (PSA “doubling time”), and the initial stage, grade, and PSA level at definitive therapy 1. However, the most recent and highest quality study 1 suggests that salvage radiation therapy to the prostate bed is a recommended approach for biochemical recurrence after prostatectomy, particularly when PSA levels are low. Therefore, the patient should be referred to radiation oncology for consideration of salvage radiation therapy to the prostate bed, and undergo imaging studies to evaluate for potential metastatic disease.

From the FDA Drug Label

1. 1. Laboratory Tests Regular assessments of serum Prostate Specific Antigen (PSA) may be helpful in monitoring the patient’s response. If PSA levels rise during bicalutamide therapy, the patient should be evaluated for clinical progression For patients who have objective progression of disease together with an elevated PSA, a treatment-free period of antiandrogen, while continuing the LHRH analog, may be considered.

The next step in management for a patient with a history of prostate cancer, who has had a total prostatectomy with ADT for a year, and subsequent PSA testing showing steadily rising PSA levels, though still less than 1, is to evaluate for clinical progression. This is because the patient's PSA levels are rising, which may indicate disease progression. The patient should be closely monitored and further testing or treatment options should be considered as needed 2.

• Key considerations:
  • Monitor PSA levels regularly
  • Evaluate for clinical progression if PSA levels rise
  • Consider further testing or treatment options as needed
  • Continue to monitor the patient's condition closely 2

From the Research

Next Steps in Management

The patient has a history of prostate cancer and has undergone total prostatectomy with androgen deprivation therapy (ADT) for a year, followed by a period of steadily rising PSA levels, although still less than 1. The next steps in management can be considered as follows:

• Imaging and Restaging: Given the biochemical progression, imaging plays a critical role in the diagnosis, staging, and management of prostate cancer 3. Multiparametric magnetic resonance imaging (mpMRI) is currently the imaging modality of choice for locoregional staging 3.
• PSMA PET/CT: Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) has been shown to be effective in detecting regional and distant metastatic prostate cancer 4, 5. However, the choice between PSMA PET/CT and planar bone scan plus CT may depend on various factors, including cost and availability 4.
• MRI in Prostate Cancer Screening: MRI can improve risk stratification of men suspected to have prostate cancer and enable targeted biopsies 6. Abbreviated MRI protocols may be considered to reduce examination and interpretation times, as well as costs 7.
• Treatment Planning: The treatment plan may involve androgen deprivation therapy (ADT), surgery, or radiation therapy, depending on the patient's risk group and the extent of the disease 3, 5. The incorporation of PSMA PET/CT findings into the treatment planning may help optimize patient selection and personalize the treatment plan 5.