Transcript: BCR and risk of progression
Bertrand Tombal, MD, PhD
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The first thing when you're confronted to a biochemical recurrence, or BCR, is to recognise the important fact that not all patient are equal. It's an extremely heterogeneous group of patient. And the second is to reassure patient that most of them will do fine. That actually the risk of metastasis remains relatively to very low in most of them. We know since the end of the '90s and studies done in the US that in order to be at risk of metastasis, you need to have at least one of the three following characteristic, which are extremely important. The first one is your initial Gleason score. Indeed, a Gleason score is a surrogate of the cancer aggressiveness. It's a surrogate of all the genetic abnormalities who make a disease. And your initial Gleason score is very important. If it was equal or more than 8, then you are at risk of progression. In contrast, if you had a 6 or 7, your risk of metastasis will remain for a while very low.
The second and very important is when did you recur? Did you recur right after the treatment or did you recur a long time after the treatment? For prostatectomy, usually we say within or after three years, meaning that the patient, which is 65, had a radical prostatectomy for a Gleason 7 five years ago, has nothing to do with the patient who had a prostatectomy for a Gleason 9 and has a biochemical recurrence 6 months after. We are speaking about two totally different patient in term of risk, and it's very important to reassure the first one. Then these two, I always tell the patient, these two characteristic, you have them or you don't have them. Either you have a high or low Gleason score, and the timing of your first recurrence is predefined. Once you have these two characteristics, there is a third one, which is extremely important as well, how is your PSA rising? Is it rising fast or slowly?
The way to quantify that is to use the PSA doubling time. Keep in mind that we are speaking about a cell which is getting, not getting bigger and bigger, but one then two then two then two, so it's a logarithmic regression. I would advise you not to try to calculate it intuitively, but to use one of the many calculator you can find on the internet. Also, don't measure your PSA doubling time on two value and don't measure it when it's very low, like below 0.2. It's becoming more efficient when the PSA gets a little bit higher. Then once again, we will use as a kind of indicator that your PSA should not double in less than one year, and PSA doubling time around one year is a characteristic. So to summarise, low risk, high risk. High risk are those with the Gleason superior or equal to 8, a recurrence within three years post-surgery, 18 months for radiotherapy, and most importantly, a PSA doubling time less or inferior to 12 months.
All the other, according of the different value, they can be considered as low risk. They probably deserve attention, close monitoring, maybe too much imaging, but the category of patient on which we should focus on because this is aggressive disease - are the patient at high risk? So I do repeat once again, rapid PSA doubling time less than one year, rapid recurrence, three-year surgery, 18 months range radiotherapy, and a Gleason score equal or superior to 8 at the initial diagnostic. That initial processing will be key. Today, I see many of my colleague, there is a slight rise in PSA, oh, they go, "We're gonna do imaging. We're gonna do this, that." No, no, no. First thing, you stratify the patient. That is the most important. Is it a low risk or a high risk? Think about tigers and kitties. Kitties, leave them purring. They don't need anything. Tiger, attack them.
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MA-MM-14627, April 2025.