Making Individualized Decisions in the Midst of Uncertainties: The Case of Prostate Cancer and Biochemical Recurrence

The decision about whether to pursue aggressive treatment is one of the most common decisions in all of oncology, and it always includes uncertainties, patient preferences, and priorities. Often patients and physicians must make this decisionwithout guidance from randomized trial data. Even when trials have been conducted and demonstrated an overall benefit from an aggressive treatment, patients and physicians still must decide whether a benefit is likely at an individual level based on a patient’s comorbid illnesses, life expectancy, and other medical or personal considerations. Consequently, the decision-making process for a prostate cancer (PCa) patient at the time of biochemical recurrence (BCR) is really no different than the decision-making process for primary PCa treatment and, in fact, is not that different from the process for any other cancer. In the current issue of European Urology, Punnen and colleagues performed a beautiful systematic review of the literature on the management options for BCR in PCa [1], a common clinical situation faced by hundreds of thousands of men worldwide each year. What the authors found were many predictive models aimed at distinguishing patients who have local versus distant recurrence—an important distinction because the former is curable with aggressive salvage therapy but the latter is not. Few published models, however, have been externally validated, and many have only modest accuracy. Other studies have reported on factors associated with clinical progression and death in patients who develop a BCR, factors associated with achieving a prostate-specific antigen (PSA) response from salvage radiation therapy (RT) after prostatectomy, and efficacy and morbidity from salvage treatments in various