Interpreting a rising prostate-specific antigen after brachytherapy for prostate cancer

Department of Radiation Oncology, British Columbia Cancer Agency, Center for the Southern Interior, Kelowna, British Columbia, Canada.
International Journal of Urology (Impact Factor: 1.8). 08/2012; 20(2). DOI: 10.1111/j.1442-2042.2012.03120.x
Source: PubMed

ABSTRACT The aim of the present study was to review the English language literature on the topic of prostate-specific antigen bounce after brachytherapy and present a summary of the current knowledge. Although ultimately prostate-specific antigen is a reliable measure of success after prostate brachytherapy, it can be very misleading in the first 3 years because of the frequency with which temporary benign rises in prostate-specific antigen occur. We have reviewed the English language literature on the topic of prostate-specific antigen bounce under the following headings: prostate neoplasms, brachytherapy, biochemical definition of prostate-specific antigen failure, "benign prostate-specific antigen bounce" and "prostate-specific antigen spike". We included brachytherapy delivered as either low dose rate or high dose rate, and either as monotherapy or as a boost combined with external beam radiotherapy. A benign self-limited rise in prostate-specific antigen after prostate brachytherapy is seen in an average of 35% of patients, but increases in frequency with younger age. In patients aged less than 55 years, it is observed in up to 68%. Other factors, such as sexual activity, dose, prostate volume and the use of high dose rate versus low dose rate have been implicated in affecting the frequency of the benign bounce. Benign increases in prostate-specific antigen are frequent after prostate brachytherapy. It is important to recognize and correctly diagnose this phenomenon in order to avoid unnecessary salvage treatment.

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    ABSTRACT: To evaluate the outcome of low-dose-rate permanent brachytherapy combined with anti-androgen deprivation therapy for intermediate-risk prostate cancer excluding biopsy Gleason score 4 + 3. Patients included in the intermediate-risk group were those presenting clinical stage T1c to T2c (by magnetic resonance imaging staging), Gleason score 3 + 4 or lower and/or prostate-specific antigen less than 20 ng/mL, whereas those with clinical stage T1c to T2a, Gleason score 3 + 3 and prostate-specific antigen less than 10 ng/mL represented the low-risk group, and were used as controls. In the intermediate-risk group, therapy with a luteinizing hormone-releasing hormone analog was continued for at least 6 months before and after permanent brachytherapy. A total of 147 low-risk group patients and 139 intermediate-risk group patients were included in the study. The median follow up was 51 and 52 months for the intermediate-risk group and low-risk group, respectively. The 5-year overall, cause-specific and distant-metastasis-free survival rates in the low-risk group and intermediate-risk group were 97.6/99.2, 100/100 and 100/100%, respectively. The 5-year biochemical disease-free survival in these groups were 95.9 and 92.5%, respectively (P = 0.18). There was no sexual activity and desire for erection before treatment in 50%, and in 46% of the patients in the low-risk group and intermediate-risk group, respectively. Overall satisfaction score at 2 years after permanent brachytherapy significantly improved, compared with pretreatment (P = 0.0399). In intermediate-risk prostate cancer, excluding biopsy Gleason score 4 + 3, permanent brachytherapy combined with androgen deprivation therapy for 6 months or more represents an effective treatment option in Japanese patients, based on a favorable prognosis, adverse event profile and quality of life analysis.
    International Journal of Urology 08/2013; 21(3). DOI:10.1111/iju.12245 · 1.80 Impact Factor
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    ABSTRACT: Objectives To evaluate the interim outcomes of low-dose-rate permanent brachytherapy (PB) combined with short-term androgen deprivation therapy (ADT) in Japanese men with intermediate-risk prostate cancer excluding those with a Gleason score of 4 + 3. Methods The Protocol-intermediate-risk group (Protocol-IRG) was defined as clinical stage T1c–T2c, Gleason score of 3 + 4, or lower and prostatic-specific antigen (PSA) level lower than 20 ng/mL. A total of 308 patients underwent brachytherapy in the protocol-IRG group (n = 152) or in the low-risk group (n = 156). Patients in Protocol-IRG had received at least 6 months of ADT before and after PB. Supplemental external beam radiotherapy was not used. Planned followup by PSA was carried out every 3 months for the first 2 years and every 6 months thereafter. The PSA failure was defined as nadir + 2 ng/mL. Patients' Expanded Prostate Cancer Index Composite was recorded before and 3 years after treatment. Results The median followup was 68 and 68 months for the protocol-IRG and the low-risk groups, respectively. The 5-year biological disease-free survival rates in the low-risk and protocol-IRG groups were 94.8 and 94.6%, respectively. As far as survival rates were concerned, there were no significant differences between the two groups. Overall satisfaction and sexual function at 3 years after PB had significantly improved compared with pretreatment (p = 0.01 and p = 0.01, respectively). Conclusions In intermediate-risk prostate patients, excluding those with a biopsy Gleason score of 4 + 3, brachytherapy with short-term ADT can be an effective treatment option for Japanese men.
    Brachytherapy 10/2014; 14(2). DOI:10.1016/j.brachy.2014.09.001 · 1.99 Impact Factor
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    ABSTRACT: Purpose: The purpose of this study was to characterize benign prostate-specific antigen (PSA) bounces of at least 2.0 ng/mL and biochemical failure as defined by the Phoenix definition after prostate brachytherapy at our institution, and to investigate distinguishing features between three outcome groups: patients experiencing a benign PSA bounce, biochemical failure, or neither. Material and methods: Five hundred and thirty consecutive men treated with low-dose-rate brachytherapy with follow-up of at least 3 years were divided into outcome groups experiencing bounce, failure, or neither. A benign bounce was defined as a rise of at least 2.0 ng/mL over the pre-rise nadir followed by a decline to 0.5 ng/mL or below, without intervention. Patient and tumor characteristics, treatment variables, and PSA kinetics were analyzed between groups. Results: Thirty-two (6.0%) men experienced benign bounces and 47 (8.9%) men experienced failure. Men experiencing a bounce were younger (p = 0.01), had a higher 6-month PSA level (p = 0.03), and took longer to reach a final nadir (p < 0.01). Compared to the failure group, men with bounce had a lower pre-treatment PSA level (p = 0.01) and experienced a rise of at least 2.0 ng/mL that occurred sooner after the implant (p < 0.01) with a faster PSA doubling time (p = 0.01). Only time to PSA rise independently differentiated between bounce and failure (p < 0.01), with a benign bounce not being seen after 36 months post-treatment. Prostate-specific antigen levels during a bounce reached levels as high as 12.6 ng/mL in this cohort, and in some cases took over 5 years to decline to below 0.5 ng/mL. Conclusions: Although there is substantial overlap between the features of benign PSA bounces and failure, physicians may find it useful to evaluate the timing, absolute PSA level, initial response to treatment, and rate of rise when contemplating management for a PSA rise after low-dose-rate brachytherapy.
    Journal of Contemporary Brachytherapy 10/2014; 6(3):247-53. DOI:10.5114/jcb.2014.45093