Treatments For Recurrent Prostate Cancer
Recurrent prostate cancer is cancer that comes back after it has been treated. Recurrent prostate cancer is also diagnosed when theprostate-specific antigen level starts to rise quickly after initialtreatment but there are no other signs of cancer. This is called a biochemicalrecurrence or PSA failure.
The following aretreatment options for recurrent prostatecancer. Your healthcare teamwill suggest treatments based on your needs and work with you to develop atreatment plan. The type of treatment that you receive will depend on:
- the treatments you’ve already had
- where the cancer comes back
- whether the cancer has spread
- your overall healthand whether you have other illnesses
- your age and life expectancy
- your personal preferences
Cancer That Is Thought To Still Be In Or Around The Prostate
If the cancer is still thought to be just in the area of the prostate, a second attempt to cure it might be possible.
After surgery: If youve had a radical prostatectomy, radiation therapy might be an option, sometimes along with hormone therapy.
After radiation therapy: If your first treatment was radiation, treatment options might include cryotherapy or radical prostatectomy, but when these treatments are done after radiation, they carry a higher risk for side effects such as incontinence. Having radiation therapy again is usually not an option because of the increased potential for serious side effects, although in some cases brachytherapy may be an option as a second treatment after external radiation.
Sometimes it might not be clear exactly where the remaining cancer is in the body. If the only sign of cancer recurrence is a rising PSA level , another option for some men might be active surveillance instead of active treatment. Prostate cancer often grows slowly, so even if it does come back, it might not cause problems for many years, at which time further treatment could then be considered.
Factors such as how quickly the PSA is going up and the original Gleason score of the cancer can help predict how soon the cancer might show up in distant parts of the body and cause problems. If the PSA is going up very quickly, some doctors might recommend that you start treatment even before the cancer can be seen on tests or causes symptoms.
Symptoms From Lymphoma In The Chest
When lymphoma starts in the thymus or lymph nodes in the chest, it may press on the nearby trachea , which can cause coughing, trouble breathing, or a feeling of chest pain or pressure.
The superior vena cava is the large vein that carries blood from the head and arms back to the heart. It passes near the thymus and lymph nodes inside the chest. Lymphomas in this area may push on the SVC, which can cause the blood to back up in the veins. This can lead to swelling in the head, arms, and upper chest. It can also cause trouble breathing and a change in consciousness if it affects the brain. This is called SVC syndrome. It can be life-threatening and must be treated right away.
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How Soon Can We Detect This
One of the main advantages of surgery over radiotherapy for prostate cancer is that following prostate removal, the PSA should be very low , which we can of course detect with blood tests. If metastasis occurs, because the metastatic cells originated in the prostate and therefore make PSA, the PSA level in the blood starts to rise. Once it has reached a given threshold additional or salvage treatment will be discussed.
A PSA level of more than 0.2 ng/ml defines biochemical recurrence. At this stage the cancer is still much too small to be seen on scanning. If it can be seen on a scan it is termed clinical recurrence, which generally does not occur until the PSA level is more than 0.5 ng/ml. Symptoms, such as bone pain, dont usually occur until the PSA is more than 20 ng/ml.
What Factors Increase The Chance Of Cancer Recurrence
The likelihood of metastasis occurring increases with higher grade and stage of the cancer as the more aggressive and developed the cancer is, the higher the chance of it breaking out of the prostate. More specifically:
- High Gleason grades
- High clinical stages
- Positive surgical margins .
However, most prostate cancers are cured with surgery. As an example, using my results from operations performed on over 2,300 men with a variety of stages and grades, 96.3% of operations resulted in full cancer cure. Some combinations of minor prostate cancer had a 100% cancer cure rate, but the higher you go, the lower the full cancer cure rate.
The commonest sites of recurrence of prostate cancer following surgery are:
- the prostate bed 80% of recurrence cases
- lymph nodes 15% of cases
- bones 5% of cases.
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Treating Advanced Prostate Cancer
If the cancer has reached an advanced stage, it’s no longer possible to cure it. But it may be possible to slow its progression, prolong your life and relieve symptoms.
Treatment options include:
- hormone treatment
- chemotherapy
If the cancer has spread to your bones, medicines called bisphosphonates may be used. Bisphosphonates help reduce bone pain and bone loss.
Treatment Options After Recurrence
After surgery to remove your prostate
PSA levels are usually extremely low about a month after surgery. You may hear your doctor saying that your PSA level is undetectable . If your PSA level starts to rise, this might mean the cancer has come back.
Your doctor might recommend:
- hormone treatment
After external beam radiotherapy
PSA levels usually get lower slowly over months or years. Defining the limit for cure is complicated and you should ask your cancer specialist. Usually a level of 2 ng/ml above the lowest point after treatment is taken as a sign of recurrence, or 3 increases in a row .
Your treatment options may be:
- surgery to remove your prostate
- hormone treatment
- high frequency ultrasound
After internal beam radiotherapy
PSA can rise temporarily after brachytherapy. This is called PSA bounce. The level then lowers slowly. Usually a level of 2 ng/ml above the lowest point after treatment is taken as a sign of recurrence.
After hormone treatment
If you are given hormone treatment alone, the PSA can rise after you finish hormone treatment. It may then become stable or static. If it rises this may suggest the cancer is becoming resistant to the hormone treatment.
If hormone treatment is no longer controlling your cancer, your doctor may suggest:
- abiraterone
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Why Cancer Comes Back
The simplest explanation is that the treatment you had before didn’t destroy all the cancer cells in your body. Even very small cells that were left behind can grow into tumors over time.
That doesn’t mean you got the wrong treatment. Cancer cells are tricky, and some can survive aggressive therapies. It only takes a few cells.
Dizziness When You Change Position
You might feel dizzy if you sit or stand up suddenly. This is more common if you are 65 or older, but it can happen at any age. If you already feel dizzy from cancer or its treatment, changing positions quickly can make the dizziness worse.You can be at risk of falling if you are dizzy at any age. But older adults are more likely to have a serious injury if they fall.
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My Takeaways From This Article
Im not a doctor or a medical services provider, just an eleven-year prostate cancer survivor, so the following comments are just my opinion and should be considered as such.
I read in the article that between 15-40% of men who undergo a radical prostatectomy for localized prostate cancer will experience a recurrence of the disease. This reinforces for me the absolute criticality of detecting prostate cancer at the earliest possible stage. That means beginning an annual prostate cancer screening program at age 35 and personally tracking any changes from one year to the next.
Secondly, its just as critical to know if you have an aggressive form of prostate cancer. Your pathologist will play a critical role here, because the pathologist dissects the prostate tissue following surgery and gives the prostate cancer a Gleason grade, showing how advanced it is.
This article suggests that men diagnosed with aggressive prostate cancer should go through a course of radiation treatment. I cant comment medically on that suggestion, but this seems to me to be a logical course of action. I was not given localized radiation therapy following my surgery nor was it even mentioned. At 13 years since surgery my PSA remains at .04 .06, so perhaps Im in the non-recurrence bucket but maybe not. One never knows. I wish I had been advised about other additional treatment options following my surgery.
What Is The Psa Test
Prostate-specific antigen, or PSA, is a protein produced by normal, as well as malignant, cells of the prostate gland. The PSA test measures the level of PSA in a mans blood. For this test, a blood sample is sent to a laboratory for analysis. The results are usually reported as nanograms of PSA per milliliter of blood.
The blood level of PSA is often elevated in men with prostate cancer, and the PSA test was originally approved by the US Food and Drug Administration in 1986 to monitor the progression of prostate cancer in men who had already been diagnosed with the disease. In 1994, FDA approved the use of the PSA test in conjunction with a digital rectal exam to test asymptomatic men for prostate cancer. Men who report prostate symptoms often undergo PSA testing to help doctors determine the nature of the problem.
In addition to prostate cancer, a number of benign conditions can cause a mans PSA level to rise. The most frequent benign prostate conditions that cause an elevation in PSA level are prostatitis and benign prostatic hyperplasia . There is no evidence that prostatitis or BPH leads to prostate cancer, but it is possible for a man to have one or both of these conditions and to develop prostate cancer as well.
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Can Prostate Cancer Be Prevented
There are no clear prevention strategies for prostate cancer. There is some conflicting evidence that a healthy diet composed of low fat, high vegetables and fruits may help reduce your risk of prostate cancer. Routine screening, with PSA blood test and physical exam, is important to detect prostate cancer at an early stage. A healthy diet and regular exercise are also critical in maintaining good health and preventing disease in general.
What Does Psa Velocity Mean
PSA velocity or PSA doubling time, both of which measure the rate at which your PSA rises, can be a very significant factor in determining is the aggressiveness of your cancer. Men with a shorter PSA doubling time or a more rapid PSA velocity after initial therapy tend to have more aggressive disease, and are therefore more likely to need more aggressive therapies. Likewise, men who have recurrence soon after surgery have a higher risk of aggressive disease.
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Getting Help And Support
You may find it helpful to talk to other people in the same situation if you are finding it hard to cope with the fact that you have had cancer. Or you could talk to a trained counsellor. This can help you to find ways of dealing with the fear and worry.
You can get in touch with a counsellor by contacting one of the counselling organisations.
You can phone the Cancer Research UK nurses if you would like to talk to someone outside your own friends and family. Talk to the Cancer Research UK nurses on freephone 0808 800 4040, from 9am to 5pm, Monday to Friday.
You can also look at our section about coping emotionally with cancer.
Or you can share your experiences with other people and find out how they coped by using our online forum, Cancer Chat.
What Happens If My Psa Rises After Surgery
If your PSA starts to rise after youve undergone prostatectomy, salvage radiation therapy might be a good option to explore, and has been shown to improve outcomes over time. With this approach, external beam radiation is delivered to the area immediately surrounding where the prostate was , in the hopes of eradicating any remaining prostate cells that have been left behind. Depending on your PSA level, the addition of hormone therapy can improve outcomes with salvage radiation for details, please see Local Treatments for Recurrent Prostate Cancer in our most recent patient guide. Other trials are looking at more aggressive experimental systemic therapies for these patients.
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To Treat Or Not To Treat
Recurrences located in the surrounding prostate tissue are known as local recurrence. If the recurrence is outside of the pelvic area, it is called a distant or metastatic recurrence.
Sometimes higher levels of PSA are seen. but there is no clear diagnosis on an imaging test. In addition, if it is a slow growing cancer, patients can decide to choose active surveillance instead of treatment.
How Common Is Recurrence Of Prostate Cancer
According to the American Cancer Society, nearly 100% of men with low- to intermediate-grade prostate cancer can expect to live at least five years after the initial diagnosis. Since many men who get prostate cancer are already elderly, they are more likely to die from causes other than the cancer.
More than 90% of the time prostate cancer is discovered while it is either confined to the prostate gland or has spread beyond the prostate only to a small degree, referred to as regional spread.
Among the less than 10% of men whose prostate cancers have already spread to distant parts of the body at the time of diagnosis, about 30% are expected to survive at least five years.
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Cancer Treatments Linked To Dizziness
Some types of chemotherapy may cause dizziness. Drug-related dizziness may go away after you have taken the drug for a few days or weeks. Tell your health care team about the dizziness and any other symptoms you have during chemotherapy. Today, many medications are available to treat the side effects from chemotherapy.
Radiation therapy to the brain, spine, or other parts of the body related to the nervous system can also cause dizziness.
Types Of Radical Prostatectomy
There are three main types of radical prostatectomy:
- Retropubic. In this procedure, the surgeon uses an incision in the lower abdomen to remove the prostate and the lymph nodes for examination. This procedure allows for a nerve-sparing approach, which can lower but not totally eliminate the risk of impotence following surgery. In the nerve-sparing approach, the surgeon tries to preserve one or both of the small nerve bundles needed for unassisted erections. However, if the cancer has spread to the nerves, this approach may not be advised.
- Laparoscopic. In this recently developed procedure, the prostate is removed in a fashion similar to a retropubic prostatectomy, but the procedure is performed through five very small incisions using lighted, magnified scopes and cameras. The prostate specimen is then removed in a small bag through one of the incisions, which is expanded to 2 to 3 cm to allow specimen removal.Potential benefits of this procedure are less pain and earlier return to full activities. Nerve-sparing methods and lymph node dissections can be performed with this technique as well.
- Perineal. In this procedure, the prostate is removed through an incision in the skin between the scrotum and anus. The lymph nodes can’t be removed through this incision. If the lymph nodes need to be examined, removal can be done through a small abdominal incision or by a laparoscopic procedure. A nerve-sparing approach can be performed perineally.
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Delirium Is A Confused Mental State That Can Occur In Patients Who Have Cancer
Delirium is a confused mental state that can occur in patients who have cancer, especially advanced cancer. Patients with delirium have problems with the following:
- Attention.
There are three types of delirium:
- Hypoactive: The patient is not active and seems sleepy, tired, or depressed.
- Hyperactive: The patient is restless or agitated.
- Mixed: The patient changes back and forth between being hypoactive and hyperactive.
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What To Do When Radiation And Hormone Therapy Fail
For some men, radiation and hormone therapy do not put the brakes on prostate cancer that recurs after prostatectomy, and the disease continues to spread. In such cases, one treatment option may include chemotherapy with docetaxel , which may extend survival and effectively treat cancer pain. Another option is the immunotherapy sipuleucel-T , which for now is limited to men with metastatic prostate cancer who have no symptoms or whose cancer pain does not require use of narcotics and who have not responded to hormone therapy.
Two other choices for men who have not responded to traditional hormone therapy are abiraterone , a form of hormone therapy that has been approved by the Food and Drug Administration for advanced cancer that has resisted previous hormone therapy and enzalutamide , which is approved for men whose prostate cancer has spread and not responded to both hormone therapy and chemotherapy .
For the majority of men who undergo prostatectomy for localized prostate cancer, the disease does not recur. However, for those men who do experience prostate cancer recurrence, there are treatment options, and patients should discuss the risks and benefits of all the alternatives with their healthcare providers and loved ones before making a decision.
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