A PSA only recurrence (biochemical failure) post a primary treatment for prostate cancer is relatively common, approximately 30% of those treated! A biochemical failure is characterized a return of increasing PSA without any other evidence of cancer on a scan. Failure can happen immediately after primary treatment has been completed or many years after the completion of treatment.

Although it is common to treat a biochemical failure both aggressively and immediately after failure, it is not very clear if this response actually extends life. A biochemical recurrence does not create clinical symptoms or directly lead to prostate cancer mortality. The quality of life and eventual mortality from prostate cancer only comes from disease progression. With this in min, we need to ask if it is at all beneficial to treat a biochemical recurrence when it is first detected or is it better to just escalate aggressive monitoring for disease progression before starting active treatment?

Uchio et al. performed a study using 623 veterans who had been diagnosed with prostate cancer between 1991 to 1995. All of the subject men had either a radical prostatectomy or radiation therapy as a primary treatment.

Major outcome measures were biochemical recurrence which was defined as a PSA level of > 0.4 ng/ml for men treated with surgery or as the PSA nadir +2 ng/ml for men treated with radiation therapy and prostate cancer mortality with a 16 year follow-up (through 2006).

At the end of the follow up period:

1- 387/623 men (62 percent) had died

2- 48/387 deaths (12 percent) were due to prostate cancer

Of the men who received surgery (n = 225) the cumulative incidence of biochemical recurrence was:

1- 35 percent at 5 years of follow-up

2- 37 percent at 10 years of follow-up

3- 37 percent at 15 years of follow-up

The prostate cancer-specific mortality among men who failed surgery (n = 81) was:

1- 3 percent at 5 years of follow-up

2- 11 percent at 10 years of follow-up

3- 21 percent at 15 years of follow-up

The cumulative incidence of biochemical recurrence among the men receiving radiation therapy (n = 398) was:

1- 35 percent at 5 years of follow-up

2- 46 percent at 10 years of follow-up

3- 48 percent at 15 years of follow-up

The prostate cancer-specific mortality among men who failed radiation therapy (n = 161) was:

1- 11 percent at 5 years of follow-up

2- 20 percent at 10 years of follow-up

3- 42 percent at 15 years of follow-up

This study found that a biochemical recurrence was associated with an increased risk of prostate cancer specific mortality, even though the individual probability of this outcome was relatively low. Biochemical recurrences are associated with an increased risk for prostate cancer-specific death, but only a minority of men will go on to die from prostate cancer.

Since the cohort in this study were older men, it is not unreasonable to assume that they also had other co-morbidity issues, so we are unable to make any conclusions about risk factors that would be faced by younger men who experience a biochemical recurrence.

These findings point out that we need to develop better strategies for both defining and managing treatment failure in prostate cancer.

Just like when initial the initial diagnosis of prostate cancer is made, there are many factors that must be weighted when deciding whether to treat a biochemical recurrence. Factors such as:

1- the PSA doubling time and velocity

2- the over all health of the man

3- the age of the man

We still have a lot to learn about when to treat a biochemical failure and when to just be more conservative and work to preserve the quality of life in our treatment approach.

Joel T Nowak, M.A., M.S.W.