How Do We Deal with Rising PSA after Primary Therapy?

Rising prostate-specific antigen (PSA) levels following primary therapy for prostate cancer may cause patients undue anxiety and stress. This paper explores the management of this increasingly common problem. Key issues are identifying the patient at risk of PSA progression, when and how to investigate a rising PSA, and what treatments to consider. Treatment decisions will be influenced by whether disease recurrence is local or systemic (although definitive diagnosis can be difficult) and patient choice. As patients with a rising PSA are generally relatively young and active, the quality of life implications of treatment are important. When hormone therapy is considered, antiandrogen monotherapy offers potential quality of life advantages over castration-based therapies, with recent data showing that the majority of men retain some sexual activity and function on bicalutamide (‘Casodex') 150mg. The cases of three patients with treatment failure, as determined by PSA progression, after primary therapy (radical prostatectomy, radiotherapy or watchful waiting) are presented to illustrate some of the problems associated with managing rising PSA levels. In each case, the patient was still sexually active. Successful outcomes, in terms of patient satisfaction, were achieved with continued observation, salvage local therapy and bicalutamide 150mg therapy, respectively.