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April 2025 | George M. Pikler, M.D., Ph.D., FACP, Lead Oncology Advocate N1X10

Checking PSA Levels Too Soon After Prostatectomy May Lead to Overtreatment

A persistent prostate-specific antigen (PSA) following radical prostatectomy (RP) for prostate cancer (PC) is associated with a worse prognosis compared with achieving an undetectable PSA level. A recent paper (1) published by multi institutional researchers reported that while 1.5 to 2.0 months following RP is considered an acceptable interval to assess for persistent PSA, it may be too short to allow for clearance of the PSA from the serum, particularly at higher pre-RP PSA levels and too short to accurately identify recurrence and inform treatment decisions. Rather, PSA levels should be measured for at least 3 months to avoid overtreatment, investigators recommended.

The cohort study included approximately 42,000 patients with PC. Researchers aimed to evaluate the time necessary to accurately document a persistent PSA level after RP. They investigated whether a significant interaction existed between a presurgical PSA level of > 20 ng/mL vs ≤ 20 ng/mL and a persistent PSA vs undetectable PSA after RP on prostate cancer–specific and all-cause mortality risk, adjusting for known prognostic factors, age at surgery as well as the year of surgery, and the time-dependent use of postsurgical radiation therapy (RT) and/or androgen deprivation therapy (ADT). They also investigated whether an increasing persistent PSA level was associated with a worse prognosis.

Among patients with a persistent PSA, pre-prostatectomy levels of > 20 ng/mL were associated with reduced all-cause and prostate cancer–specific mortality risk compared to patients with levels of ≤ 20 ng/mL. The study authors wrote, “To find a reason for the more favorable prognosis in patients with a higher pre–radical prostatectomy PSA level, we hypothesized that a higher proportion of patients with a pre–radical prostatectomy PSA greater than 20 ng/mL compared with 20 ng/mL or less assessed for a persistent PSA at the conventional 1.5-month to 2.0-month time point post-RP could have reached an undetectable PSA level if further PSA assessment was performed before initiating post-RP therapy for a presumed persistent PSA.”

“The clinical significance of these findings is that they highlight the need to monitor PSA after surgery for longer than the commonly practiced 1.5 to 2 months before concluding that PSA levels are persistent and initiating additional therapy,” said senior study author Anthony D’Amico, MD, PhD, Chief of Genitourinary Radiation Oncology at Brigham and Women’s Hospital. “It can take longer than 3 months for many patients who have PSA levels > 20 prior to surgery to completely clear the PSA from their bloodstream.”

(1) JAMA Oncology. 2025, March 13
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Erica

Erica Cross, PA

PA

Erica is a board certified Physician Assistant. She obtained her Master’s degree in Physician Assistant studies from Our Lady of the Lake College in Baton Rouge, LA. She began practicing in 2011 and has worked clinically in Orthopedics and Dermatology. The majority of her career has been spent in a Dermatology practice where she assisted in Mohs surgery, treating various types of skin cancer. She also teaches in the medical simulation department at the University of South Alabama and enjoys every aspect of medical education.