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
The widespread availability of highly sensitive testing for serum prostate specific antigen (PSA) has led to major shifts in the epidemiology of prostate cancer. These shifts were initially manifested by an increased number of cases, a younger age, and an earlier clinical stage at diagnosis. There has been a decline in the incidence of prostate cancer, presumably due to a decrease in prostate cancer screening in response to the recommendation of the United States Preventive Services Task Force [1,2].
Despite this, clinicians are managing an increasing number of men with localized prostate cancer who have received definitive treatment of their primary tumor (generally with radical prostatectomy or radiation therapy [RT]). These men require follow-up to detect local recurrence or disseminated disease as well as for complications of their treatment. (See 'Localized prostate cancer' below and "Initial approach to low- and very low-risk clinically localized prostate cancer" and "Initial management of regionally localized intermediate, high, and very high-risk prostate cancer".)
In addition, men who have metastatic disease require follow-up to assess the efficacy of their treatment and identify patients who might benefit from alternative treatments. (See 'Metastatic prostate cancer' below and "Overview of the treatment of disseminated prostate cancer".)
The follow-up surveillance for men who have received definitive treatment for prostate cancer as well as those being treated for metastatic disease is discussed in this topic. The natural history and follow-up of patients who have a rising serum PSA following definitive treatment and the follow-up of those being managed initially with active surveillance are discussed separately. (See "Active surveillance for men with low-risk, clinically localized prostate cancer", section on 'Surveillance strategy' and "Rising serum PSA following local therapy for prostate cancer: Diagnostic evaluation".)
LOCALIZED PROSTATE CANCER
Most men with newly diagnosed prostate cancer have localized disease and undergo definitive therapy with curative intent (radical prostatectomy, external beam radiation therapy [RT], brachytherapy). Selected patients with low-risk disease may 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".)
- Jemal A, Fedewa SA, Ma J, et al. Prostate Cancer Incidence and PSA Testing Patterns in Relation to USPSTF Screening Recommendations. JAMA 2015; 314:2054.
- Barocas DA, Mallin K, Graves AJ, et al. Effect of the USPSTF Grade D Recommendation against Screening for Prostate Cancer on Incident Prostate Cancer Diagnoses in the United States. J Urol 2015; 194:1587.
- National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
- 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.
- 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.
- 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
- - Serum PSA
- Natural history of PSA-only recurrence
- - Digital rectal examination
- - Imaging studies
- Bone scan
- Transrectal ultrasound
- Pelvic CT
- - Monitoring for complications of therapy
- Treatment options following recurrence
- - Local recurrence following radical prostatectomy
- - Local recurrence following RT
- - Systemic recurrence
- METASTATIC PROSTATE CANCER
- RISING PSA AFTER INITIAL DEFINITIVE THERAPY
- ACTIVE SURVEILLANCE FOR EARLY PROSTATE CANCER
- INFORMATION FOR PATIENTS