An expert’s brief commentary on follow-up strategies in patients receiving focal therapy, including monitoring for disease relapse or recurrence.
Mark Emberton, BSc, MBBS, FRSC (Urol), MD, FMedSci: So the question of follow up comes up a lot. And it is not straightforward. So compared to surgery which you're just looking for basically a zero PSA, every focal treatment is completely bespoke to the individual. So it's a completely personalized care in that every prostate is different and every cancer is different, and therefore every treatment is different. And so the proportion of tissue that you're treating differs. The degree to which the cancer secretes PSA differs. So the only important thing after treatment once you establish the PSA nadir, which I tend to do at three months is PSA stability. And PSA stability is a remarkably reliable outcome. PSA within an individual who has been treated focally is remarkably valid and reliable. And any rise in PSA in somebody who has had focal treatment would raise alarm bells. What I add to PSA is certainly in the first three years is a yearly MRI. Because I want to be able to see recurrence if it occurs, and I wanna see that early if it occurs. And then the first couple of years what I'm really looking for is infield recurrence. In other words answering the question of have I got it all? Once you get to year two year three and the patient hasn't recurred, the patient is highly unlikely to recur. And we know, this is the case for all solid organ cancers. Most recurrence in breast cancer occurs at 18 months. I think it's the same in prostate. So once you get to year three, that's an important milestone and I tend then to deescalate the MRI and maybe do the MRI every couple of years. But continue doing the PSA every six months. And the PSA are done by the patient with a family doctor. The patient self-manage it. They know their reference range and they alert me when the, if and when there's a trigger. Having said that, it's difficult to wean men off MRI. Many of the men get used to MRI and get considerable reassurance from a normal MRI, and then de-escalating them or increasing the interval between MRIs can sometimes be a long discussion.