Patient Identification and Selection
Definitions of a biochemical recurrence (BCR) are dependent on the modality of primary treatment. After radical prostatectomy, PSA should fall to undetectable levels. A PSA rise to 0.2 ng/ml with a second confirmatory value >0.2 ng/ml is a generally accepted definition of BCR. Following radiotherapy, biochemical recurrence, as defined by Phoenix definition is considered to be an increase in PSA value of 2 ng/ml above nadir.
Once BCR is identified, one must determine its significance. Certainly, PSA recurrence precedes metastatic disease; however, the timing of metastatic disease and its likely impact on the patient's quality or quantity of life should be considerations. There must be a balance between treatment to delay or prevent metastatic disease and overtreatment of disease that might not meaningfully impact the patient's overall or cancer-specific survival.
First, the assessment for the metastatic disease should be undertaken. In-depth review of staging imaging for BCR is beyond the scope of this review, but in salvage candidates, restaging should include abdominal and pelvic cross-sectional imaging (CT or MRI) and bone scan. Current guidelines also strongly support the use of PET imaging including C-11 choline, F-18 fluciclovine, and gallium PSMA PET CT/MRI.[1,2] Once the metastatic disease is excluded, biopsy for confirmation of local recurrence is mandatory prior to local salvage treatment.
Risk stratification including utilization of clinical information from the time of initial diagnosis and treatment and PSA kinetics are helpful for patient selection. Short interval to biochemical failure and higher biopsy Gleason score have been identified as predictors of adverse oncologic outcomes in those with BCR after radiation in a recent systematic review. Furthermore, guidelines have proposed risk stratifying patients into BCR groups based on PSA doubling time, interval to biochemical failure, and grade group. This has recently been validated in a postradical prostatectomy cohort. Additionally, guidelines support salvage local therapy after radiation only in select patients with PSA <10 ng/ml, original grade group ≤3, original clinical stage T1-T2, NX/N0, and a life expectancy >10 years.[1,2] A shared decision-making discussion should be held prior to proceeding with salvage treatment of any type.
Curr Opin Urol. 2021;31(3):188-193. © 2021 Wolters Kluwer Health, Inc.