I read with interest the article by Hanks and
colleaguesand the reviews that followedon the evidence for cure in
prostate cancer. The data were encouraging, and the concepts raised were
stimulating. Any discussion of tumor control and patient cure in prostate cancer
inevitably refers to prostate-specific antigen (PSA) control. The 5-, 10-, and
15-year posttreatment PSA level is worthy of debate.
In discussing cure in prostate cancer patients, the minimum definition should
be clinical control at the time of death. The maximum designation would be PSA
control at death. Not many clinicians and patients are interested in the risk of
cancer failure after death. This is important because 40% to 60% of men will die
of non-cancer-related causes in the 10 to 15 years following treatment of
prostate cancer. The article does not report mortality from prostate cancer
following external radiation. The surgical literature suggests that the average
time to cancer death after PSA failure is 13 to 15 years.
PSA and Local Treatment
Another point of interest centers on the risk of PSA failure more than 3
years after treatment. PSA relapse is reduced with appropriate local treatmenteg,
prostatectomy, two-dimensional radiation therapy, three-dimensional conformal
radiation therapy, dose escalation, intensity-modulated radiation therapy,
implant, or a combination of these approaches. PSA failures related to local
relapse (and late metastases) may benefit from more aggressive local treatment.
However, a major cause of PSA failure is related to metastatic disease already
present at the time of local treatment. Hence, the rate of PSA failure may be
related to patient and tumor selection rather than the effectiveness of the
GILBERT LAWRENCE, MD, DMRT, FRCR
Regional Cancer Center, Radiation Oncology,
Faxton-St. Luke’s Healthcare,
Utica, New York
1. Hanks GE, Hanlon AL, Horitz EM: Evidence for cure of ‘young’ men with
prostate cancer. Oncology 15(5):563-574, 2001.