Androgen deprivation therapy is indicated for this patient with possible metastatic prostate cancer. Following surgery for early-stage prostate cancer, the serum prostate-specific antigen (PSA) level should be undetectable. A postoperative serum PSA level of 0.2 ng/mL (0.2 µg/L) or greater is therefore diagnostic of residual or recurrent prostate cancer. Although this finding can represent either locally recurrent or distant metastatic disease, timing is an important discriminating factor in ascertaining the likelihood of local versus distant recurrence. Men who have a persistently elevated PSA level, particularly a rising level immediately following surgery (such as the patient described here), have a high likelihood of harboring distant metastatic disease. Androgen deprivation therapy is therefore indicated for this patient. Prostate cancer cells usually need testosterone to grow. Surgical or chemical castration is highly effective in reducing serum testosterone levels and suppressing prostate cancer cell growth. STAMPEDE, a recent clinical trial, compared the addition of zoledronic acid, docetaxel, and their combination to standard of care long-term hormone therapy in men with high-risk, locally advanced, metastatic or recurrent prostate cancer. Although the addition of zoledronic acid did not improve survival rates over standard of care hormone therapy, docetaxel, when initially added to standard hormone therapy, resulted in improved survival. There were increased side effects with the addition of docetaxel, so that use of this regimen should be weighed against the possibility of adverse events.

Patients with metastatic prostate cancer are first treated with androgen deprivation therapy. Although prostate cancer initially is androgen dependent, over time, cancer cells become androgen independent. Chemotherapy has recently been shown to prolong life expectancy in many of these patients. Since this patient has not yet been treated with androgen deprivation therapy, chemotherapy is not indicated.

A rising PSA level indicates biochemical recurrence, and estimates of survival can be made from the time of completion of treatment to the rise in the PSA, the rate of that rise, and the initial Gleason score. Although recurrent disease after definitive therapy of early-stage prostate cancer is incurable, significant palliation can be achieved with hormone deprivation therapy and chemotherapy. Continuing to monitor the PSA level without initiating therapy is not recommended.

Identification of biochemical recurrence 2 or more years after surgery is more consistent with local recurrence. Studies have shown that salvage radiotherapy is beneficial for men diagnosed with a biochemical recurrence 2 or more years after surgery. In contrast, radiotherapy does not seem to benefit men in whom a PSA level remains detectable following surgery.