Follow-up surveillance during and after treatment for prostate cancer
- David F Penson, MD, MPH
David F Penson, MD, MPH
- Professor of Urologic Surgery
- Director of Vanderbilt Center for Surgical Quality and Outcomes Research
- Section Editors
- Nicholas Vogelzang, MD
Nicholas Vogelzang, MD
- Section Editor — Prostate Cancer
- Professor of Medicine
- University of Nevada School of Medicine
- US Oncology Research
- W Robert Lee, MD, MS, MEd
W Robert Lee, MD, MS, MEd
- Section Editor — Prostate Cancer
- Professor of Radiation Oncology
- Duke University Medical Center
- Jerome P Richie, MD, FACS
Jerome P Richie, MD, FACS
- Section Editor — Cancer of the Urethra, Penis, and Ureter; Urologic Surgery; Prostate Cancer
- Elliott Carr Cutler Professor of Surgery
- Harvard Medical School
Prostate cancer is the most common malignancy in men, with approximately 161,000 new prostate cancer diagnoses and approximately 26,700 prostate cancer deaths estimated in the United States in 2017 . Worldwide, there are an estimated 1,600,000 new cases of prostate cancer and 366,000 prostate cancer deaths annually .
Because of the prolonged natural history, there are a large number of cancer survivors who are being followed after initial definitive treatment, as well as men who have presented with or developed evidence of advanced disease. Those with advanced disease include men whose only evidence of advanced disease is an elevated serum prostate-specific antigen (PSA), as well as those with clinically detectable metastases, which may be either asymptomatic or symptomatic.
This topic will discuss the approach to follow-up both in those without evidence of disease after treatment and those with evidence of advanced disease. The follow-up of men with low-risk localized prostate cancer who are managed with active surveillance is discussed separately. (See "Active surveillance for men with low-risk, clinically localized prostate cancer", section on 'Surveillance strategy'.)
LOCALIZED PROSTATE CANCER
Most men with newly diagnosed localized prostate cancer undergo definitive therapy with curative intent (eg, radical prostatectomy, external beam radiation therapy [RT], brachytherapy, cryotherapy, high-intensity focused ultrasound). Most patients with low-risk disease can be managed with active surveillance, with definitive therapy deferred until there is evidence of progressive disease. (See "Initial approach to low- and very low-risk clinically localized prostate cancer" and "Active surveillance for men with low-risk, clinically localized prostate cancer".)
For patients who subsequently progress with either local or disseminated disease, recurrence generally is detected by a rise in the serum prostate-specific antigen (PSA), a highly specific marker for prostate tissue, prior to any radiologic or symptomatic evidence of recurrence or progression. The development of an overt local recurrence or distant metastases usually occurs significantly later in the natural history of the disease. (See 'Serum PSA' below and "Bone metastases in advanced prostate cancer: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)
- Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017; 67:7.
- Global Burden of Disease Cancer Collaboration, Fitzmaurice C, Allen C, et al. Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-years for 32 Cancer Groups, 1990 to 2015: A Systematic Analysis for the Global Burden of Disease Study. JAMA Oncol 2017; 3:524.
- Obek C, Neulander E, Sadek S, Soloway MS. Is there a role for digital rectal examination in the followup of patients after radical prostatectomy? J Urol 1999; 162:762.
- Pound CR, Christens-Barry OW, Gurganus RT, et al. Digital rectal examination and imaging studies are unnecessary in men with undetectable prostate specific antigen following radical prostatectomy. J Urol 1999; 162:1337.
- Johnstone PA, McFarland JT, Riffenburgh RH, Amling CL. Efficacy of digital rectal examination after radiotherapy for prostate cancer. J Urol 2001; 166:1684.
- Lightner DJ, Lange PH, Reddy PK, Moore L. Prostate specific antigen and local recurrence after radical prostatectomy. J Urol 1990; 144:921.
- Roach M 3rd, Hanks G, Thames H Jr, et al. Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: recommendations of the RTOG-ASTRO Phoenix Consensus Conference. Int J Radiat Oncol Biol Phys 2006; 65:965.
- Heidenreich A, Bastian PJ, Bellmunt J, et al. EAU guidelines on prostate cancer. Part II: Treatment of advanced, relapsing, and castration-resistant prostate cancer. Eur Urol 2014; 65:467.
- Terris MK, Klonecke AS, McDougall IR, Stamey TA. Utilization of bone scans in conjunction with prostate-specific antigen levels in the surveillance for recurrence of adenocarcinoma after radical prostatectomy. J Nucl Med 1991; 32:1713.
- Cher ML, Bianco FJ Jr, Lam JS, et al. Limited role of radionuclide bone scintigraphy in patients with prostate specific antigen elevations after radical prostatectomy. J Urol 1998; 160:1387.
- Krämer S, Görich J, Gottfried HW, et al. Sensitivity of computed tomography in detecting local recurrence of prostatic carcinoma following radical prostatectomy. Br J Radiol 1997; 70:995.
- Ceci F, Castellucci P, Graziani T, et al. PET/Computed Tomography in the Individualization of Treatment of Prostate Cancer. PET Clin 2015; 10:487.
- Cookson MS, Roth BJ, Dahm P, et al. Castration-resistant prostate cancer: AUA Guideline. J Urol 2013; 190:429.
- Birtle AJ, Freeman A, Masters JR, et al. Clinical features of patients who present with metastatic prostate carcinoma and serum prostate-specific antigen (PSA) levels < 10 ng/mL: the "PSA negative" patients. Cancer 2003; 98:2362.
- LOCALIZED PROSTATE CANCER
- Surveillance strategies
- - History and physical examination
- Digital rectal examination
- - Serum PSA
- Natural history of PSA-only recurrence
- - Imaging studies
- Bone scan
- Transrectal ultrasound
- Pelvic CT
- - Monitoring for complications of therapy
- Treatment options following recurrence
- MONITORING DURING TREATMENT FOR SYSTEMIC DISEASE
- Rising PSA after initial definitive therapy
- Metastatic prostate cancer
- ACTIVE SURVEILLANCE FOR LOW-RISK PROSTATE CANCER
- INFORMATION FOR PATIENTS