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Advancements in Prostate Cancer Care: Exploring Hopeful Interventions for Elevated PSA after Surgery

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Improving Treatment for Biochemical Relapse after Prostate Surgery

An Exciting Breakthrough for Men with Post-Surgical PSA Rise

When it comes to prostate cancer, a radical prostatectomy is a common surgical treatment that offers hope to many men. However, within 10 years of the operation, 20% to 40% of patients may experience elevated prostate-specific antigen (PSA) levels, indicating a possible recurrence of the disease. This condition, known as a biochemical relapse, is typically managed by administering radiation to the prostate bed. In recent years, researchers have discovered that combining pelvic bed radiation therapy (PBRT) with other treatments can further enhance its effectiveness in lowering PSA levels. This groundbreaking finding has the potential to revolutionize the treatment of biochemical relapse in men who have undergone a radical prostatectomy.

The significance of this discovery is supported by the results of a large-scale study known as the SPPORT phase 3 clinical trial. Spanning nearly 300 medical centers across the United States, Canada, and Israel, this study, funded by the National Cancer Institute, involved 1,797 men who had undergone a prostatectomy. All of these men exhibited post-surgical PSA levels ranging between 1 and 2 nanograms per milliliter (ng/mL).

The participants were divided into three groups through random assignment, with each group receiving different treatments. Group 1 received PBRT alone, while Group 2 received PBRT combined with four to six months of androgen deprivation therapy (ADT), which inhibits testosterone and restricts the growth of prostate tumors. Group 3 received the most extensive treatment, consisting of PBRT, ADT, and radiation to the pelvic lymph nodes, which are typically the first sites affected by spreading prostate cancer. The aim was to determine which treatment strategy was most effective in preventing disease progression.

The results of the study clearly indicate that more intensive treatments yield better outcomes. After five years, over 70% of men in Group 1 remained free from disease progression, compared to 80.3% of men in Group 2 and an impressive 87.4% of men in Group 3. In terms of PSA elevation, 145 men in Group 1 experienced further increases, while only 104 men in Group 2 and 83 men in Group 3 faced the same issue. A similar pattern emerged in terms of the development of metastases, where cancer becomes resistant to hormonal therapy after spreading.

Undoubtedly, the more intensive treatments did have more short-term side effects, particularly diarrhea. However, it is important to note that these side effects diminished for all groups after three months of treatment.

While the findings are highly promising, the authors of the study stress the need for longer follow-up to confirm whether the addition of ADT and pelvic node radiation to PBRT can indeed extend survival rates. Furthermore, the efficacy of a relatively new therapeutic approach for biochemical relapse, which involves using advanced imaging techniques to identify and directly treat small metastases throughout the body using radiation, was not evaluated in this study.

According to Dr. Marc Garnick, an esteemed expert in prostate diseases, it is crucial for men to understand that any detectable level of PSA after a radical prostatectomy is considered abnormal and requires further evaluation. The traditional PSA range of 0 to 4 ng/mL no longer applies after surgery. The study's evidence supporting additional benefits from combining ADT and pelvic radiation therapy is significant. However, further follow-up is necessary to determine whether this approach should become the standard of care for biochemical relapse.

Overall, this groundbreaking study offers hope and potential new avenues for the effective management of biochemical relapse after prostate surgery. Further research and follow-up are needed to solidify these findings and explore additional treatment options for patients in need.

William H. McDaniel, MD

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School.

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