Dr Dreicer on Managing Biochemical Failure Post-Radical Prostatectomy in Prostate Cancer

Robert Dreicer, MD, deputy director and director of solid tumor oncology in the Division of Hematology/Oncology, and professor of medicine and urology at the University of Virginia Cancer Center, discusses the complexities surrounding biochemical failure after radical prostatectomy in patients with prostate cancer. This condition, commonly indicated by a rise in prostate-specific antigen (PSA) levels post-surgery or radiation therapy, occurs in 30% to 40% of cases.

Dreicer emphasizes the role of prostate-specific membrane antigen (PSMA) PET imaging, which has become a standard in detecting biochemical failure. This imaging modality helps to precisely identify the location of recurrence, thus guiding further treatment decisions.

The phase 3 EMBARK trial (NCT02319837) assessed the addition of enzalutamide (Xtandi) to leuprolide (Lupron; n = 355) in patients with biochemically recurrent prostate cancer and observed a significant improvement in metastasis-free survival (MFS) with the combination vs leuprolide alone (n = 358), with a median value that was not reached in either arm (HR, 0.42; 95% CI, 0.30-0.61; P < .001). The 3-year MFS rates were 92.9% with the enzalutamide combination and 83.5% with leuprolide alone; corresponding 5-year MFS rates were 87.3% and 71.4%, respectively.

Although these findings suggest that earlier intervention could potentially improve outcomes for patients experiencing PSA failure, Dreicer cautions that applying more intensive therapies in this setting, particularly in men aged 50 to 80 years, must be carefully considered due to the potential risks associated with these treatments.

Dreicer emphasizes the importance of balancing prostate cancer outcomes with the overall health and well-being of the patient. Although focusing on controlling prostate cancer progression is crucial, the potential adverse effects of aggressive treatments, such as increased cardiovascular risk, must also be considered. This holistic approach to patient care necessitates a thorough evaluation of the benefits and risks associated with early and intensive treatment strategies.

Managing biochemical failure post-radical prostatectomy requires a nuanced approach that incorporates advanced diagnostic tools like PSMA-PET imaging to help evaluate the potential benefits of early therapeutic interventions such as enzalutamide. However, Dreicer explains that it is essential to weigh these benefits against the potential risks to ensure optimal patient outcomes. This comprehensive perspective is vital for making informed clinical decisions that address both cancer control and overall patient health.