The value of second-line treatment for men with biochemical recurrence


Biochemical failure (also known as biochemical recurrence) after first-line treatment for prostate cancer is assessed based on a rising PSA level. This is a relatively common event and can happen shortly after first line treatment or many years later. The problem is that we really don’t know how important biochemical recurrence is in an individual patient at a specific point in time. After all, if a biochemical recurrence is never going to lead to clinical symptoms of prostate cancer (let alone prostate cancer-specific mortality), why would one want to treat it?

Uchio et al. have carried out an observational study in 623 US veterans diagnosed with prostate cancer between 1991 to 1995, all of whom were given first-line treatment with a radical prostatectomy or radiation therapy. Major outcome measures were biochemical recurrence (which was defined defined as a PSA level of ≥ 0.4 ng/ml for patients treated with surgery or as the PSA nadir+2 ng/ml  for men treated with radiation therapy) and prostate cancer mortality, determined through 2006 — an effective follow-up period of 16 years in a cohort of men (US veterans) known to be at significant risk for co-morbid conditions.

The results of their study showed the following:

  • By the end of 2006
    • 387/623 men (62 percent) had died
    • 48/387 deaths (12 percent) were due to prostate cancer
  • The cumulative incidence of biochemical recurrence among patients who received surgery (n = 225) was
    • 35 percent at 5 years of follow-up
    • 37 percent at 10 years of follow-up
    • 37 percent at 15 years of follow-up
  • Prostate cancer-specific mortality among men who failed surgical treatment (n = 81) was
    • 3 percent at 5 years of follow-up
    • 11 percent at 10 years of follow-up
    • 21 percent at 15 years of follow-up
  • The cumulative incidence of biochemical recurrence among patients receiving radiation therapy (n = 398) was
    • 35 percent at 5 years of follow-up
    • 46 percent at 10 years of follow-up
    • 48 percent at 15 years of follow-up
  • The prostate cancer-specific mortality among men who failed radiation therapy (n = 161) was
    • 11 percent at 5 years of follow-up
    • 20 percent at 10 years of follow-up
    • 42 percent at 15 years of follow-up

As the authors observe, biochemical recurrence was associated with an increased risk of prostate cancer-specific mortality in the study population, but the individual probability of this outcome was relatively low.

The authors conclude that although biochemical recurrence is associated with an increased risk for prostate cancer-specific death, when biochemical recurrence does occur only a minority of men go on to die of their disease.

They further conclude that new and better strategies for defining and managing treatment failure in prostate cancer are necessary today, pointing out that ‘the phrase “most men die with prostate cancer, not of it” applies to elderly veterans, even after failure of primary treatment.’

The following factors should always be taken into account in discussions with patients and family members about how to treat biochemical failure after first-line therapy:

  • The time it takes for the patient’s PSA level to double (PSA doubling time) — and not just whether those levels have exceeded some specific threshold.
  • The patient’s physiological age and overall health status.

We have previously commented on another recent paper, by Daskivich et al., that recommends the use of the Total Illness Burden Index for Prostate Cancer, or TIBI-CaP, questionnaire as a method to assess the degree to which illnesses other than their cancer severely impact the daily lives of men with prostate cancer. There is good reason for patients with biochemical recurrence who have significant comorbidities to consider conservative management as opposed to aggressive therapy. Second-line therapy may well have significant impact on these patients’ quality of life with minimal potential for affecting their long-term survival.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: