Treatment options for localized prostate cancer based on pretreatment serum prostate specific antigen levels

Purpose: We reviewed all available literature on early stage prostate cancer treatment in which pretreatment serum prostate specific antigen (PSA) levels were used to stratify patients. We determined if any conclusions could be reached regarding the optimal therapy of this disease. Materials and Methods: A MEDLINE search was conducted to obtain all articles in English on prostate cancer treatment from 1986 to 1996 in which PSA levels were used to stratify patients and evaluate outcome, Studies were considered eligible only if they met all criteria of pretreatment PSA values recorded and grouped for subsequent evaluation, posttreatment PSA values monitored continuously, definitions of biochemical control stated and median followup given. Results: Of the 16 surgical studies identified only 3 met the inclusion criteria, Of the 30 radiation therapy articles identified 15 met the inclusion criteria, including 2 on conformal external beam radiotherapy, 8 on conventional external beam radiotherapy and 5 on interstitial brachytherapy. No studies using neutrons or combined hormonal therapy with surgery or radiotherapy were identified in which patients were stratified by pretreatment PSA. Results for all therapies were extremely variable with the 3 to 5-year rates of biochemical control ranging from 48 to 100% for patients with a pretreatment PSA of less than 4 ng./ml., 44 to 90% for PSA more than 4 to 10 ng./ml. and 27 to 89% for PSA more than 10 to 20 ng./ml, Even using the same treatment modality, a wide range of results were obtained, No treatment option consistently produced superior results. Conclusions: When data were reviewed from studies using pretreatment serum PSA to stratify patients, no consistently superior treatment option in the radiotherapy or surgical literature emerged. These data suggest that standard definitions of disease stage and biochemical cure must be adopted to evaluate treatment efficacy and advise patients on the most appropriate treatment option for the disease.