About one third of men develop biochemically recurrent disease based only on rising prostate-specific antigen (PSA) in the absence of visible disease on conventional imaging.
For patients with biochemical recurrent prostate cancer, there is no uniform guideline for subsequent management.
Prudent that biochemical recurrent prostate cancer should initially be evaluated for salvage radiation or prostatectomy, with curative intent.
In selected cases, high-intensity focused ultrasound and cryotherapy may be considered in patients that meet very narrow criteria as defined by non-randomized trials.
If salvage options are not practical or unsuccessful, androgen deprivation therapy (ADT) is a standard option for disease control.
Patients may be followed using PSA doubling time as a trigger to initiate ADT.
Based on retrospective data, a PSA doubling time of less than 3–6 months has been associated with near-term development of metastasis and thus could be used signal to initiate ADT.
Once treatment is begun, patients and their providers can choose between an intermittent and continuous ADT strategy.
The intermittent approach may limit side effects but in patients with metastatic disease studies could not exclude a 20% greater risk of death.
In men with biochemical recurrence, large studies have shown that intermittent therapy is non-inferior to continuous therapy, thus making this a reasonable option.
As new imaging (PSMA) strategies are developed, it may alter how the disease is monitored and perhaps managed.
Patients have no symptoms related to their disease and thus many prefer options that minimize toxicity.
In the EMBARK trial 60% of subsequent deaths of patients were not attributable to prostate cancer.
In patients with PC with high risk biochemical recurrence (doubling time PDA of less than nine months) enzalutamide plus leuprolide was superior to leuprolide alone with respect to metastasis free survival, and enzalutamide monotherapy was superior to leuprolide alone(Freeland SJ).