Good article on current options for managing early biochemical recurrance

Hi -

Here's a good article that sums up the state of the art and options for managing biochemical recurrence. It may be of particular interest I think for folks in the early stages considering when to initiate salvage radiation and/or hormone therapy, and what other treatments to consider.

www.hematologyandoncology.net/index.php/archives/january-2013/management-of-biochemically-recurrent-prostate-cancer-after-local-therapy-evolving-standards-of-care-and-new-directions/

Abstract: ... BCR can be predictive of the development of subsequent distant metastases and ultimately death, but BCR often predates other signs of clinical progression by several years. Although patients may be concerned about their rising PSA levels, physicians attempting to address patient anxiety must inform them that BCR is not typically associated with imminent death from disease, and that the natural history of biochemical progression may be prolonged. Misinterpretation of the significance of early changes in PSA may cause patients to receive androgen deprivation therapy (ADT) prematurely, especially in settings where the disease is unlikely to impact survival. In addition, knowledge of the morbidities associated with ADT (hot flashes, impotence, sarcopenia, metabolic syndrome, bone loss, and increased risk of vascular disease) has accelerated the search for alternative treatment options for these patients. Clinical trials investigating when and how to best use and supplement hormonal therapies in this patient population are under way, as are trials of novel nonhormonal targeted agents, immunotherapies, natural products, and other pharmaceuticals that have been approved by the US Food and Drug Administration (FDA) for other indications. This review will summarize the acceptable standards of care for the management of biochemically recurrent prostate cancer, and will also outline some novel experimental approaches for the treatment of this disease state.

Post Edited (proscapt) : 2/23/2013 10:48:02 PM (GMT-7)

Many logical observations, spot on, enjoyed article, thanks.

Reinforced many of my beliefs.  Thanks again !

Bookmarking this one

Pro,

Great article.

This absolutely should silence those that question my oncologist plan with me. Even with my rising PSA post surgery and post radiation. You don't just treat a number, even the new oncologist in Charleston said the same thing. Your article mentions the QOL issues associated with HT, so there are doctors that don't want to subject their patients to those issues needlessly, just because of evidence of BCR.

Both my oncologists believe in treating the patient as a whole, never treating a number. Too many men panic in those situation, and the doctor recently told me, its often the patient, not the doctor, that is pushing for some kind of immediate treatment, because as he put it, "They feel they need to be doing something".

In my case, my doctors are all too aware, that I am already dealing with major QOL issues that are impacting my daily life. Thus, no rush to go to HT or Chemo at this point, but to continue to do, as
Casey recently correctly stated, to continue Watchful Waiting, and see how things progress.

All the doctors are prepared to recommend any treatment needed, when they feel the time is right.

David

Many views, here is how I see it.  (1)  Regardless of sensitivity MY (if,when) BCR will be >0.2  (2)  MY PSADT will be calculated from that point. (3) Studies using possibly 53 different definitions of BCR is understood.  (4) PSADT will vary if using different definitions of BCR.

  

“To describe biochemical recurrence after RP, a panel of experts from the American Urological Association (AUA) evaluated 53 different definitions of BCR following RP observed in the literature, and recommended adoption of a single definition. This involved the presence of a PSA greater than 0.2 ng/mL measured 6–13 weeks after RP, followed by a confirmatory test showing a persistent PSA greater than 0.2 ng/mL.⁹ Ultra-sensitive PSA assays have recently improved detection levels down to 0.01 ng/mL, and may possibly lead to better treatment outcomes through earlier adoption of salvage radiation therapy following RP.^10,11 However, false positives occurring because of trace amounts of PSA produced by residual benign prostatic tissue, along with uncertainty about whether ultra-low levels of PSA will be followed by continued PSA increases, have led practitioners to continue to rely on the AUA definition for determining when clinically-relevant biochemical recurrence has occurred after prostatectomy.”

Reachout,
The reasons for this is that a higher PSADT is more indicative of metastasis than a low PASDT. Also a high PASAD is associated with more aggressive cancers than a low PSADT and are harder to kill.
A high PSADT means that the cancer is growing faster and that makes it more dangerous.

JohnT,
Isn't a lower PSADT more aggressive than a higher PSADT?
Seems to me that shorter = lower = faster doubling time. No?

RalphV

Reachout, I think you are on the right track. A pathologist once explained to me that radiation is most effective or killing the cells when they are actively dividing, and should not be done when PSA is undetectable. Longer PSADT = cells divide slower = radiation may not hurt some of these cells resting in a certain cell phase. Chemo works on a similar principle.

This sentence was interesting to me from the article:

"However, 20-40% of patients undergoing RP, and 30-50% of patients undergoing RT will experience biochemical recurrance within 10 years."

I thought BCR was much lower for RT, guess not.

Good article...

Interesting in how they focused/discussed a lot on ADT during the SRT for BCR... (jeesh... a lot of acronyms there)...

In my particular case, and at my post op path and subsequent PSA levels, both the uro and rad docs indicated ADT would not be required. So... not all SRT cases may require ADT and have to be concerned with those potential side effects. In my case, that made my decision process much easier.

pasayten

Dave, well evidence exists that salvage HT+RT yields better results than salvage RT alone. But in this article they are talking about initial treatment. I thought BCR rate was much lower for RT than surgery, but apparently not so. The only reason I can think of is that patients undergoing RT as initial treatment may be more advanced cases from the start.

HD_Rider Here is a link to the abstract of a study that compared Early PSADT (values <0.2) to standard PSADT (values>0.2).  The author concluded that there was a low correlation between the two.  I'm not sure if this is what you were looking for.  Does early prostate-specific antigen doubling time (ePSADT) after radical prostatectomy, calculated using PSA values from the first detectable until the first recurrence value, correlate with standard PSADT? A report from the Shared Equal Access Regional Cancer Hospital Database Group. http://www.ncbi.nlm.nih.gov/pubmed/19549124 .  

Is the jury really still out?

Seems to me HT coupled with RT is becoming the standard of care?

Mel

oops, you did give an opinion. Becoming standard of care.

Bohemond, I can't locate the article now, but I read that PSADT from ultrasensitive tests prior to BCR tend to be much shorter than after BCR or 0.2 or so. In other words, the PSADT gets longer once you climb to detectable levels. However, I'm like you, my PSA took a jump from .17 to .23 in 3 months before my SRT started so I don't know if it would have slowed down after that.