Risk associated with rapid rise in PSA immediately following HIFU

An article in the April issue of Clinical Medical Insights: Oncology suggests that a rapid post-treatment increase in the PSA levels of men treated for localized prostate cancer with high-intensity focused ultrasound (HIFU) may indicate later risk for biochemical recurrence. The full text of this article by Inamoto et al. is freely available on line.

Inamoto and his colleagues had noted that a rapid increase in the PSA level post-treatment was common among many of the patients they had been treating with HIFU. Their goal was to  determine the incidence and magnitude of this rapid increase in the serum PSA level and its correlation with clinical factors.

The authors assessed rapid increase in PSA level following HIFU treatment in the same manner as one  might assess a PSA “bounce”  in men being treated with radiation therapy — an increase of ≥ 0.2 ng/ml with a spontaneous return to the pre-bounce level or lower. Their patients were stratified according to neoadjuvant PSA level, T stage, risk group, age, Gleason score, pre-treatment PSA level, post-treatment PSA nadir, and number of HIFU sessions.

Here are the baseline results of their study:

  • The total number of patients included in this analysis was 176.
  • The patients included men at low, intermediate, and high risk for prostate cancer progression.
  • A rapid increase in PSA was seen in 53 percent of these patients within a median follow-up of 43 months.
  • 85.1 percent of patients achieved a PSA nadir within 3 months of treatment.
  • The onset of a rapid increase in PSA level was (in all cases) observed within 2 days of HIFU therapy.
  • The average (median) magnitude of the rapid increase was 23.69 ng/ml.
  • A magnitude of the rapid increase in PSA >2 ng/ml was observed in 89.4 percent of cases.
  • Multivariate analysis indicated that a rapid increase in PSA post-treatment and the number of HIFU sessions were significant predictors of biochemical recurrence.
  • The presence of a rapid increase in PSA and the risk of biochemical failure was statistically significant only in the group of patients with low- and intermediate-risk disease.

Inamoto et al. conclude that men treated with HIFU for low- and intermediate-risk, localized prostate cancer, and who have a rapid post-treatment increase in their PSA level, may be at increased risk for later biochemical recurrence of their disease.

3 Responses

  1. With a significant rise in PSA following HIFU, it looks like a no-brainer to me that such patients “may” be at increased risk for later biochemical recurrence.

  2. Does this mean that HIFU is now a very doubtful remedy overall, and is contraindicated for “salvage” treatment for the future? If so, how could HIFU have been touted for such a long times to be the be all and end all of treatments? It seems in prostate cancer treatment we take one step forward and two steps back. As a T3b/Stage 3 Gleason 8 patient, there seems to be little hope around at present. I would like to tell readers that I had PSAs done every year since the age of 33 and the dreaded disease still caught me out! I believe that once there is any significant rise in PSA, biopsies should be done immediately (it was in my case but the doctor said no trace of prostate cancer was found and to have the PSA test done every 6 months.) If I had had the PSA taken 3 monthly thereafter, instead of the 6 months he recommended, I would have caught the cancer much earlier and be in a far better place today!

  3. Dear Mike:

    (1) No … This does not mean that HIFU is “a doubtful remedy overall.” This is a small retrospective analysis of a series of relatively early HIFU patients at one institution. One cannot and should not make global interpretations of what does and doesn’t work on the basis of this study. It is merely a signal that we need to be aware of a potential risk.

    (2) HIFU has been heavily promoted by the manufacturers and by s select group of early physician advocates for the technique (just like robot-assisted surgery, proton beam radiation, cryotherapy, stereotactic body radiation, and other techniques before it). Some would use the term “over-promoted” … since there have been few long-term data on which to base any rational expectations of outcomes.

    (3) Respectfully, I would suggest that your personal experience — which is certainly distressing — is more likely to be a reflection of an aggressive form of cancer than any likelihood that getting PSA tests every 3 months would have definitively helped you to get a biopsy or earlier. The problem is simply that the PSA test is neither specific nor accurate as a test to identify prostate cancer. We badly need a better test.

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