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Biochemical relapse after radical treatment for prostate cancer — MSRA MCQ

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HardProstate CancerBiochemical relapse after radical treatment for prostate cancerMSRA

A 69-year-old man is followed up after radical prostatectomy for pT3a Gleason score 4+4=8 prostate adenocarcinoma. He subsequently received salvage prostate-bed radiotherapy for biochemical recurrence. His PSA became undetectable but has risen on the same assay from 0.12 micrograms/L to 0.24 micrograms/L after 6 months and to 0.48 micrograms/L after a further 6 months. CT and bone scan show no metastases. He has no bone pain, urinary obstruction, weight loss or neurological symptoms. He is not receiving androgen-deprivation therapy and wishes to start hormone treatment immediately to prevent metastatic disease. What is the most appropriate management now?

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Correct answer: E — Discuss the biochemical relapse at the urological cancer multidisciplinary team and continue surveillance without routinely starting hormonal therapy

Explanation lettering: B = shown as A · D = shown as B · A = shown as D

This is biochemical relapse after previous radical local treatments, with no proven metastases or symptomatic local progression. The PSA has doubled every 6 months, so the PSA doubling time is approximately 6 months, not less than 3 months. NICE advises MDT discussion for biochemical evidence of hormone-relapsed disease and advises against routinely offering hormonal therapy unless there is symptomatic local progression, proven metastases, or a PSA doubling time of less than 3 months. A is attractive because the PSA is clearly rising, but a PSA threshold alone does not justify immediate continuous androgen deprivation in this setting. B incorrectly applies NICE guidance on intermittent therapy: this is an approach for people already receiving long-term ADT, not an indication to commence it. C is a metastatic-disease option for selected people prioritising sexual function and is not appropriate for asymptomatic non-metastatic biochemical relapse. D uses a risk threshold relevant to some systemic-treatment pathways, but does not meet the NICE criterion for routinely initiating hormonal therapy in biochemical relapse. MDT review also allows reassessment of imaging, eligibility for trials and future treatment sequencing.

Reference: NICE NG131: Prostate cancer: diagnosis and management, recommendations 1.5.11 and 1.5.59 (2019; amended 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations