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The problem of the rising PSA after definitive therapy (surgery or radiation therapy) for localised prostate cancer

The development of a rising PSA is a disappointing development in patients who have been treated for localised prostate cancer as it indicates that the cancer has not been sterilised (by removal in surgery patients or killed by radiation therapy). The problem for the doctor is to decide whether the cancer is active again only within the prostate or whether it has spread to other organs (metastasised) or whether both these events have occurred.
 
In general it is now possible to predict which patients are likely to have local relapse in the prostate and those who are more likely to have disease spread to further afield. Thus, patients with a low Gleason score (less than 7) and no seminal vesicle invasion or lymph nodes at presentation and whose PSA starts to rise from its nadir at over 18 months from therapy and with a slow PSA velocity (less than 0.75 ng/ml/year) and with a PSA doubling time of over six months, then this patient is likely to have relapsed locally in the prostate region.
 
By contrast, the patient with a high Gleason score tumour that was invading the seminal vesicles and whose PSA started to rise within the first year after therapy and with a high PSA velocity and short doubling time has much more likely developed metastatic disease to other organs.