What Does Failure After Surgery or Radiation Mean?

ObjectiveThe accurate definition of what constitutes treatment failure after surgery and radiotherapy for localised prostate cancer is critical to patient management. The current post-radiotherapy (post-RT) standard is the 2006 ASTRO definition of an increase of 2 ng/ml above the nadir level. After radical prostatectomy (RP) one definition is the detection of prostate-specific antigen (PSA) at or above 0.2 ng/ml following surgery, although some might argue that any detectable PSA is a sign of treatment failure.Diagnosis and TreatmentThe localisation of the origin of the PSA rise is difficult, and imaging and/or biopsy is often unhelpful. Postsurgical recurrence is present in the pelvis in a significant proportion of patients. Prostate/seminal vesical biopsy can be helpful in the post-irradiation setting, but the utility of cross-sectional imaging of the primary site is limited. PSA kinetics can be helpful in identifying aggressive disease, but PSA bounce must be considered, particularly after brachytherapy and high dose RT. Treatment responses are seen in patients, particularly when the PSA is <0.2 ng/ml and the interval to PSA failure is >18 months, but side effects can be significant.ConclusionsThe natural history of progression after failure is often prolonged. Most importantly, a significant number of men who fail treatment will not die of prostate cancer. This should be borne in mind when considering salvage therapy to the primary with interventional procedures, or systemic treatment with adjuvant hormonal and/or other therapies. Treatment can help some patients, but there is considerable associated morbidity in many cases. In the post-treatment failure scenario, it is critically important to consider the risk–benefit ratio for individual patients.