• Serum PSA is the single most important follow-up parameter in evaluating patients after definitive treatment with either surgery or radiation. A reasonable surveillance schedule should include a history and physical examination and serum PSA every 3 months during the first year, every 6 months for 4 years, and yearly thereafter. Bone scans and CT scans should be obtained only as indicated.
  • In patients who are managed surgically, the serum PSA should nadir to an undetectable level. Occasionally, very low persistent PSA levels that do not progress are noted. In most cases, if the serum PSA becomes detectable and rises above 0.4 ng/mL, the patient continues to show disease progression. Biochemical failure can predate clinical failure by 4 to 6 years. Newer data suggest that biochemical failure is a surrogate marker for ultimate clinical failure and survival. The incidence of a detectable PSA 5 years after radical prostatectomy depends on pathologic stage, being approximately 5 percent for patients with organ confined disease, 17 percent with capsular penetration, 66 percent for seminal vesicle involvement, and 76 percent in patients with lymph node involvement. Patients with high-grade disease who fail early and display a short doubling time may have a survival as early as 7 years, while late failures in low to moderate grade disease who are progressing slowly may live as long as 19 years. The overall 10- to 15-year recurrence rate for localized disease is approximately 20 percent. Further follow-up is necessary to truly define the true impact of clinical failure.
  • There is a role for external beam radiation therapy after post surgical biochemical failures due to local recurrence. Success rates are highest when therapy is instituted before the PSA is greater than 1.0 ng/mL. Percentage for cure ranges between 30 and 50 percent in different series.
  • In general, response to external beam radiation therapy as a primary form of therapy depends on the pretreatment PSA and can be predicted by the PSA nadir after treatment. In other words, overall outcome is best in patients with the lowest post-treatment PSA nadir. Biochemical failure is defined by three consecutive elevations in the PSA level above the nadir. These patients may be candidates for salvage prostatectomy or cryosurgery if they have no evidence of systemic disease or extracapsular extension. The major side effect is significant incontinence in as many as 50 percent of patients. Please refer to the section on radiation therapy for an in-depth discussion.

References

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