Biochemical recurrence in patients with prostate cancer after primary definitive therapy: treatment based on risk stratification

Neal D Shore; Judd W Moul; Kenneth J Pienta; Johannes Czernin; Martin T King; Stephen J Freedland

doi:10.1038/s41391-023-00712-z

Biochemical recurrence in patients with prostate cancer after primary definitive therapy: treatment based on risk stratification

Prostate Cancer Prostatic Dis. 2023 Sep 7. doi: 10.1038/s41391-023-00712-z. Online ahead of print.

Authors

Neal D Shore^#¹, Judd W Moul^#², Kenneth J Pienta³, Johannes Czernin⁴, Martin T King⁵, Stephen J Freedland^{6

7}

Affiliations

¹ Carolina Urologic Research Center, Myrtle Beach, SC, USA.
² Duke Cancer Institute, Duke University, Durham, NC, USA.
³ Johns Hopkins School of Medicine, Baltimore, MD, USA.
⁴ David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
⁵ Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA.
⁶ Samuel Oschin Comprehensive Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Stephen.Freedland@cshs.org.
⁷ Veterans Affairs Medical Center, Durham, NC, USA. Stephen.Freedland@cshs.org.

^# Contributed equally.

PMID: 37679602
DOI: 10.1038/s41391-023-00712-z

Abstract

Background: Nearly one-third of patients with prostate cancer (PCa) experience biochemical recurrence (BCR) after primary definitive treatment. BCR increases the risk of distant metastasis and mortality in patients with prognostically unfavorable features. These patients are best managed with a tailored treatment strategy incorporating risk stratification using clinicopathological factors, next-generation imaging, and genomic testing.

Objective: This narrative review examines the utility of risk stratification for the management of patients with BCR in the context of clinical trial data, referencing the latest recommendations by European and US medical societies.

Methods: PubMed was searched for relevant studies published through May 21 2023 on treatment of patients with BCR after radical prostatectomy (RP) or external beam radiotherapy (EBRT).

Results: European and US guidelines support the risk-stratified management of BCR. Post-RP, salvage EBRT (with or without androgen deprivation therapy [ADT]) is an accepted treatment option for patients with BCR. Post-EBRT, local salvage therapies (RP, cryotherapy, high-intensity focused ultrasound, stereotactic body radiotherapy, and low-dose-rate and high-dose-rate brachytherapy) have demonstrated comparable relapse-free survival rates but differing adverse event profiles, short and long term. Local salvage therapies should be used for local-only relapses while ADT should be considered for regional or distant relapses. In practice, patients often receive ADT, with varying guidance for intermittent ADT vs. continuous ADT, due to consideration of quality-of-life effects.

Conclusions: Despite a lack of consensus for BCR treatment among guideline associations and medical societies, risk stratification of patients is essential for personalized treatment approaches, as it allows for an informed selection of therapeutic strategies and estimation of adverse events. In lower-risk disease, observation is recommended while in higher-risk disease, after failed repeat local therapy, ADT and/or clinical trial enrollment may be appropriate. Results from ongoing clinical studies of patients with BCR should provide consensus for management.

Publication types

Review