What To Ask When Your Psa Is Rising After Initial Treatment
For the majority of men, prostate cancer is treatable and curable and does not come back after initial treatment. However, about 25%33% of men with prostate cancer will experience a recurrence of their cancer after surgery or radiation. Some of these men can still be cured with additional treatment, but some men develop a form of prostate cancer that, while not curable, remains TREATABLE for a very long time.
Below is a list of questions to ask when your PSA is rising after initial treatment.
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 , with the aim 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 Therapies for Locally Recurrent Prostate Cancer in PCFs Prostate Cancer Patient Guide. Clinical trials are investigating more aggressive systemic therapies.
What Happens During Radical Prostatectomy
You will have general anesthesia during your prostate surgery. Your surgical team inserts a catheter to drain urine.
After your surgeon removes your prostate, they check it under a microscope to see if cancer has extended beyond the edge of the prostate or into the seminal vesicles or lymph nodes. If it has, the cancer may have spread. In that case, you may need other treatment.
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The Role Of Radical Prostatectomy In High
Because of the increase in prostate cancer patients, urologists can detect more clinically localized prostate cancer in patients before the disease has progressed to advanced stages. Nevertheless, some patients are still diagnosed with high-risk prostate cancer. Even though several treatment options are available for high-risk prostate cancer patients, including radical prostatectomy, radiotherapy, and hormone therapy, used alone or in combination, the recurrence rate is high regardless of the type of treatment. Nevertheless, in the experience of many urologists, a substantial proportion of high-risk prostate cancer patients are cured by local definite therapy or multimodality treatment. Thus, several treatment combinations have been attempted as treatments in these patients. Among them, radical prostatectomy is regarded as the first step in high-risk prostate cancer patients, on a selective basis. In some high-risk prostate cancer patients, surgery is a one-step modality in treatment and has an excellent oncological prognosis. However, because of the lack of evidence and well-controlled comparative prospective studies, the best course of treatment can be unclear, and oncological outcomes often appear heterogeneous. We therefore review the current literature on clinical outcomes in high-risk prostate cancer.
What Happens Before Radical Prostatectomy
Before radical prostatectomy, your provider will ask you about your health history. Youll also need to tell your provider what drugs and vitamins you take. You may need to stop taking some of your medications a few days before your surgery, especially drugs that cause blood thinning.
Your hospital will give you specific instructions, including how long before your surgery to stop eating and drinking.
To check your health before your procedure, you also may need:
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Differences Among Risk Groups
Men with PCa have been classified into low-, intermediate- and high-risk Groups for tumor recurrence and disease specific mortality, based on PSA level, clinical or pathological staging and GS. High-risk patients have PSA level 20ng/mL or GS 8 or clinical/pathological stage T2c . Lymph-node positive and PSM have also been reported as poor prognosis factors.
Risk Group classification predicts biochemical and clinical progression as well as PCa specific mortality and overall survival. The risk of disease progression in these groups has been validated for patients submited to RP in many studies. In patients from Mayo Clinic, BCR rates were 2.3 and 3.3-fold greater in high and intermediate-risk in comparison with low-risk patients, respectively. In those patients, mortality rates in high and intermediate-risk patients were greater than 11 and 6-fold over low-risk men .
Therefore, it is crutial to understand the role of each clinical and pathologic feature in PCa BCR and disease progression.
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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Success Of Radical Prostatectomy
The goal of radical prostatectomy is to cure prostate cancer. But a prostate cancer cure is only possible from prostatectomy if your prostate cancer is limited to the prostate.
During radical prostatectomy, a member of your treatment team examines your removed prostate under a microscope to see if your cancer has reached the edge of the prostate. If so, the prostate cancer has probably spread. In these cases, you may need more treatments.
Men with no evidence of prostate cancer spread have an 85% chance of surviving 10 years after radical prostatectomy.
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:
- radiotherapy to where the prostate was
- hormone treatment
After external beam radiotherapy
PSA levels usually get lower slowly over months or years. Saying at what level your PSA should be 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 brachytherapy
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:
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Defining Patients At Risk After Radical Prostatectomy
Accurate risk characterization could result in an appropriate management of post-RP patients. However, the optimal post-operative approach to these patients is a subject of continuous debate because the risk definition after RP relies on clinical, pathological features and PSA kinetics. Furthermore, the choice of treatment should be tailored according to prognostic factors and/or risk stratification.
Up to one-third of patients treated with RP may have adverse pathologic features , defined as positive surgical margins, extra-prostatic extension, seminal vesicle invasion, and/or lymph node invasion and high Gleason score.
Only patients with at least two of the following pathologic features are at higher risk of cancer specific mortality and may significantly benefit from adjuvant treatment after RP: pathologic Gleason score 8, pT3/pT4 disease, and the presence of nodal disease .
In the study of Abdollah et al. men with low-volume nodal disease , ISUP grade 25 and pT34 or R1, as well as men with 3 to 4 positive nodes were more likely to benefit from RT after surgery, while the other subgroups did not .
However, the level of evidence for the management of pN1 patients is still low .
The most sensitive and the only validated biomarker for disease persistence and recurrence remains PSA and PSA-based parameters . Persistent PSA is defined in the majority of studies as detectable post-RP PSA of 0.1 ng/mL within 4 to 8 weeks of surgery and occurs in 520% of men after RP .
How Are Hormone Therapies For Prostate Cancer Administered
LHRH agonists, the most commonly used drug class for hormone therapy, are given in the form of regular shots: once a month, once every three months, once every four or six months, or once per year. These long-acting drugs are injected under the skin and release the drug slowly over time. LHRH antagonists include degarelix and relugolix, an oral form.
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Treating Prostate Cancer That Doesnt Go Away Or Comes Back After Treatment
If your prostate-specific antigen blood level or another test shows that your prostate cancer has not been cured or has come back after the initial treatment, further treatment can often still be helpful. Follow-up treatment will depend on where the cancer is thought to be and what treatment you’ve already had. Imaging tests such as CT, MRI, or bone scans may be done to get a better idea about where the cancer is.
How Long Does It Take To Recover From A Robotic Prostatectomy
The recovery time for a robotic prostatectomy can be as short as 2 to 3 weeks. But it can be longer if you develop complications or have other health problems. Your surgeon can give you the best idea about what to expect.
Heres a general idea of what your timeline will look like:
- Youll likely be able to walk immediately after the procedure.
- After about 2 weeks, you can perform aerobic exercises like easy jogging.
- After about 4 weeks, youll be able to resume light weightlifting.
- You can usually drive about 2 weeks later.
- Youll be free to perform sexual activity once your healthcare team removes the catheter. But nearly all people lose erectile function in the first few months.
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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 the prostate-specific antigen level starts to rise quickly after initial treatment but there are no other signs of cancer. This is called a biochemical recurrence or PSA failure.
The following are treatment options for recurrent prostate cancer. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment 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 health and whether you have other illnesses
- your age and life expectancy
- your personal preferences
If Your Prostate Cancer Has Spread
If cancer has spread to other parts of your body it cant be cured. This is advanced prostate cancer. Treatment can help to control the cancer and your symptoms. This might be:
- hormone treatment to lower your testosterone levels
- bisphosphonates to help with bone pain
- radiotherapy to particular parts of the skeleton
- radioactive liquid treatment radiotherapy , such as radium-223
If hormone therapy is no longer working for you, you might have:
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Prostate Cancer Survival Rates Are Favorable Overall
Thinking about survival rates for prostate cancer takes a little mental stretching. Keep in mind that most men are around 70 when diagnosed with prostate cancer. Over, say, five years, many of these men will die from other medical problems unrelated to prostate cancer.
To determine the prostate cancer survival rate, these men are subtracted out of the calculations. Counting only the men who are left provides whatâs called the relative survival rate for prostate cancer.
Taking that into consideration, the relative survival rates for most kinds of prostate cancer are actually pretty good. Remember, weâre not counting men with prostate cancer who die of other causes:
- 92% of all prostate cancers are found when they are in the early stage, called local or regional. Almost 100% of men who have local or regional prostate cancer will survive more than five years after diagnosis.
- Fewer men have more advanced prostate cancer at the time of diagnosis. Once prostate cancer has spread beyond the prostate, survival rates fall. For men with distant spread of prostate cancer, about one-third will survive for five years after diagnosis.
Many men with prostate cancer actually will live much longer than five years after diagnosis. What about longer-term survival rates? According to the American Society of Clinical Oncology, for men with local or regional prostate cancer:
- the relative 10-year survival rate is 98%
- the relative 15-year survival rate is 95%
Remission And The Chance Of Recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someones risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA-only or biochemical recurrence.
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Are Other Tests Needed
A doctor will not generally recommend further treatment after a single PSA test result. They will typically monitor a persons PSA levels over time to see whether they are rising.
PSA testing is only one way to check a persons health after having a prostatectomy. A doctor may use an imaging test to look for a tumor or a growing number of cancer cells.
They are also likely to ask the individual about any possible symptoms that could suggest that prostate cancer has returned.
What Is A Prostatectomy
A prostatectomy is a surgical procedure for the partial or complete removalof the prostate. It may be performed to treatprostate cancerorbenign prostatic hyperplasia.
A common surgical approach to prostatectomy includes making a surgicalincision and removing the prostate gland . This may beaccomplished with either of two methods, the retropubic or suprapubicincision , or a perineum incision .
Prior to having a prostatectomy, it’s often necessary to have aprostate biopsy. Please see this procedure for additional information.
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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.
What Are Antiandrogens And Should They Be Part Of My Treatment Plan
Antiandrogens can be helpful in preventing the flare reaction associated with LHRH agonists resulting from an initial transient rise in testosterone. They can help block the action of testosterone in prostate cancer cells. Their use for at least the first 4 weeks of LHRH agonist therapy can relieve the symptoms often seen from the flare reaction, ranging from bone pain to urinary frequency or difficulty. You should ask your doctor whether continuing these pills for longer-term cancer control might be beneficial for you.
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