Editing AUA: Advanced Prostate Cancer (2023) (section)

== Biochemical Recurrence (“rising PSA”) Without Metastatic Disease After Exhaustion of Local Treatment ==

* '''<span style="color:#ff0000">Definition of biochemical recurrence: rise in PSA in prostate cancer patients after treatment with surgery or radiation</span>'''
** '''<span style="color:#ff0000">PSA ≥0.2ng/mL and a confirmatory value of ≥0.2ng/mL following radical prostatectomy</span>'''
** '''<span style="color:#ff0000">Nadir + 2.0ng/mL following radiation</span>'''
* Risk factors for biochemical recurrence (also risk factors for clinical recurrence) (3):
*# Grade
*# Stage
*# Pre-treatment PSA
* Inform patients with biochemical recurrence after exhaustion of local therapy regarding the risk of developing metastatic disease
** Given the indolent nature of some cancers, not all patients with a detectable PSA following primary treatment are destined to experience clinical recurrence or cancer-related death.
*** See [https://test.urologyschool.com/index.php/Biochemical_Recurrence#Natural_history Pound et al. study]

=== <span style="color:#ff0000">Diagnosis and Evaluation</span> ===

* '''<span style="color:#ff0000">PSMA PET imaging should be used preferentially, where available, in patients with PSA recurrence after failure of local therapy as an alternative to conventional imaging due to its greater sensitivity, or in the setting of negative conventional imaging</span>'''

=== <span style="color:#ff0000">Management</span> ===
* '''<span style="color:#ff0000">First-line: observation or clinical trial</span>'''
** Lack of evidence for optimal treatment approach
** '''Currently no systemic treatments with proven efficacy in men without metastatic disease who are not candidates for additional local therapy.'''
*** For most men with a biochemical recurrence following prostatectomy, early salvage radiotherapy with or without adjuvant ADT remains the preferred treatment strategy.
** '''The overall course of a rising PSA after failure of local therapy is highly variable'''
*** '''Time to PSA recurrence and PSA doubling-time are associated with risk of subsequent metastases, prostate cancer-related death, and death from any cause.'''
* '''<span style="color:#ff0000">Not recommended: ADT</span>'''
** '''<span style="color:#ff0000">Should not be routinely initiated</span>'''
*** Two large observational studies found no difference in mortality in patients treated with immediate vs. deferred ADT for biochemical recurrence.
*** It is recognized that ADT is sometimes given to men with rapid PSA rises in the absence of radiographic metastases in an attempt to delay the appearance of metastases. There is no evidence to determine the best time to start ADT in the absence of radiographic metastases.
*** '''If ADT is initiated in the absence of metastatic disease, intermittent ADT may be offered in lieu of continuous ADT.'''

* Follow-up
** History and Physical
** Labs: serial PSA
*** PSA kinetics contribute to the risk of clinical recurrence.
** Imaging:
*** Based on overall PSA and PSA kinetics
**** Higher risk of metastases (PSADT <12 months): periodic staging with cross-sectional imaging (CT, MRI) and technetium bone scan, and/or preferably PSMA PET imaging