The Management of Biochemical Recurrence in Prostate Cancer - Episode 4

Considerations for Initiating ADT After Biochemical Recurrence in Prostate Cancer 

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Experts in prostate cancer discuss considerations for initiating ADT therapy after definitive treatment in patients with prostate cancer in the context of biochemical recurrence. 

Raoul S. Concepcion, MD, FACS:When you do have a biochemical recurrence, you’ve defined what that looks like for you regarding surgery and radiation. I think Judd has brought up some very good points relative to looking at the initial Gleason [score] at the time of therapy, especially in the patients with radical prostatectomy [RP]. I think the…data spelled that out at [Johns Hopkins Medicine]. What are the factors that are going to say, like you said, just because you have a biochemical recurrence and a rise in the PSA [prostate-specific antigen] doesn’t necessarily mean it’s cancer cells; it could be benign cells. What are the parameters? What are some of the things that are going to push you to say, “I better initiate ADT [androgen deprivation therapy] in this patient?”

Brian Helfand, MD, PhD: …Or some form of therapy. I think that is a lot of the art form. I think it’s not a simple straightforward [idea] that everyone who has a biochemical recurrence needs treatment. If you look at the data, not everyone who has a biochemical recurrence will ultimately go on to succumb from prostate cancer or develop obvious metastasis. I think that the timing of the recurrence is imperative. Notably, someone who has a PSA recurrence 10 or 15 years later is different than the guy who has a recurrence almost immediately, or within a few months following treatment.

Additionally, regarding the patient’s comorbidities, if a patient is much older, even though it’s a number and very few of us can give up following that number for some reason, we still are reluctant to initiate treatment if there are a lot of comorbidities or underlying factors that they’re more likely to die from. I think timing and how fast that PSA is doubling, or the kinetics underlying that PSA, if those PSA values are increasing rapidly, we’re a lot more concerned that that is prostate cancer. Because, if it is benign glands, the rate of rise or changes over time is going to be a lot slower, and typically, you’re not going to get to a lot higher values like you would if it were cancer.

Raoul S. Concepcion, MD, FACS: I think the Hopkins data in the surgical patient were that if you had a Gleason [score] greater than 8 at the time of surgery, if the biochemical recurrence was inside 3 years, and the PSA doubling time was less than 9 to 12 months, that patient was definitely, to your point, going to be at risk from succumbing to his disease if therapy wasn’t initiated.

Transcript edited for clarity.