The dilemma of patients with a rising PSA level after definitive local therapy for prostate cancer

Patients with a rising prostate-specific antigen (PSA) levels after definitive local therapy now represent one of the largest and fastest growing groups of men with prostate cancer. The great majority of these men are asymptomatic with no other evidence of disease, and their clinical outcomes have been widely variable and poorly understood. Recently, several groups have analyzed their institutions' data and reported on certain pathologic and clinical variables that have increased our understanding of the natural history of these men, and to some extent allowed for the development of predictive models to aid in deciding who should be treated more aggressively and who should be watched. This article reviews and critically evaluates the most relevant available data for this group of men, and offers a summary of the most useful models and predictive variables after both radical prostatectomy and radiotherapy. This article also offers recommendations for strategies to improve our current knowledge of the natural history of these men, to facilitate the development and implementation of clinical trials in this population, and to ultimately be able to offer the most appropriate recommendations to our patients in the clinic.