Panel Advises What to Do When PSA Rises After Cancer Therapy

ORLANDO--Today, after more than 10 years of research, PSA-relatedtesting can daunt even the most experienced urologists, said apanel of experts at the American Urological Association meeting.Three panelists advised urologists on how to interpret a risingPSA after prostate cancer treatment and what further actions totake when this occurs.

Patrick C. Walsh, MD, of Johns Hopkins University School of Medicine,advised that in patients who have had a radical prostatectomy,"any PSA that is measurable should be considered elevated."But, he cautioned, "be certain the result came from a labyou can trust, or else repeat it." Dr. Walsh also told theaudience to consider any induration on rectal examination as alocal recurrence.

For patients with an elevated PSA after surgery, for whom distantmetastases are suspected, the work-up should include a pelvicCT scan, bone scan, and chest x-ray. Thereafter, Dr. Walsh recommendsannual bone scans.

Timing of PSA recurrence is also instructive. "If it occurswithin a year, or the Gleason score is 8 to 10, or positive seminalvesicles or positive lymph nodes are found, most likely that patientwill fail from distant metastases," he said. Alternatively,PSA recurrence more than a year out, or with a Gleason score 2to 7, or negative nodes and negative seminal vesicles, is possiblya local recurrence.

After Radiotherapy or Cryosurgery

Evaluating a rising PSA after radiotherapy or cryosurgery posesother challenges. "A good guideline is to begin measuringPSA 3 months after radiotherapy," said Peter C. Scardino,of Baylor College of Medicine, Houston. He cautioned that earliertesting may be misleading.

"The most important prognostic factor in radiotherapy-treatedpatients is pretreatment PSA, with a rising PSA after treatmentwell accepted as an indication of recurrent cancer," he said.

Elderly patients with comorbid conditions are often poor candidatesfor further definitive therapy, while young, otherwise healthymen are generally good candidates. If the patient is a good candidatefor further therapy, "next, prove the recurrence is localby biopsy, and rule out metastases," Dr. Scardino said. Asalvage radical prostatectomy is then warranted in patients withboth a positive biopsy 1 year or more after radiation and a risingPSA, he said.

As to whether cryotherapy should be used similarly, Dr. Scardinosaid that sufficient outcome data are not yet available, but hedoes refer patients who want cryotherapy.

Jean deKernion, MD, of the UCLA School of Medicine, addressedthe question of how to manage patients with a rising PSA followinghormonal therapy. "Although, to my knowledge, no one hasever been cured of metastatic hormone-independent prostate cancerby any combination of chemotherapy, it doesn't mean you can'thelp," he said.

Among chemotherapeutic regimens, Dr. deKernion has found ketoconazole(Nizoral) is the most effective in the short-term, with tolerableside effects. Other regimens that also look promising, accordingto early data, combine estramus-tine (Emcyt) and etoposide (VePesid),or vinorelbine (Navelbine) and estramus-tine. Dr. deKernion discouragedthe use of suramin because of its "high toxicity and limitedeffect." He advises enrolling those patients "who arehealthy, feel good, and want treatment" in chemotherapeutictrials, a strategy that in the long run may yield more successfultherapies.