MDT (multi-disciplinary team) guidance for managing prostate cancer

• Pound et al. carried out a retrospective review of 1997 men undergoing radical prostatectomy
by a single surgeon for clinically localised disease with no neoadjuvant or adjuvant treatment. 98
A PSA ≥0.2 ng/ml was deemed evidence of recurrence.
o At 15 years, 15% had PSA elevation and 34% of these had developed metastases.
o The median time from PSA elevation to metastatic disease was 8 years.
o After development of metastases, the median actuarial time to death was 5 years. In the
survival analysis, time to biochemical progression, Gleason grade and PSA doubling time
were predictive of the probability and time to the development of metastatic disease.
• After completion of radiotherapy and hormonal treatment, testosterone recovery usually occurs.
This may cause some PSA elevation that is related to normal prostate tissue recovery and not
disease recurrence.
• The definition of disease recurrence in the setting of combined therapy remains a matter
of debate and consensus is awaited.
• Benign PSA rises (PSA bounce) occur in approximately 12% of patients following EBRT
and 30% following LDR brachytherapy in the absence of neoadjuvant hormonal treatment
(starting between 18 months and 2 years after treatment).
Local recurrence after radical prostatectomy
Overview
• Overall, approximately 40% of patients who have a radical prostatectomy have biochemical
evidence of recurrence at some point.
• Determining whether relapse is local or distant is important in determining optimal treatment.
However, post-prostatectomy imaging is unhelpful as this will always be negative, so there is
no way of defining local versus distant disease categorically. Other factors that may aid this
distinction include:
o Timing and pattern of PSA relapse (rapid rise post-operatively indicates distant spread)
o Involvement of seminal vesicles or lymph nodes
o Margin status at surgery
o Gleason grade
• Radical salvage treatment is usually via radiotherapy to the prostate bed +/− hormone therapy.
The optimal time of treatment, i.e. immediate adjuvant or early salvage EBRT, is currently
uncertain. The timing and duration of hormone therapy is also unclear.
• The RADICALS study is investigating the timing of radiotherapy (immediate versus early salvage)
and hormone duration. 50
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