What Does It Mean
In greatest series about BCR after RP there was no man with local or distant clinical disease without an increase in PSA at the time of progression. Rising PSA is the first sign of disease progression after RP, however it does not necessarily lead men to metastatic disease or cancer mortality in few years . This is the key to understand variation among BCR definition. BCR defined as PSA 0.2ng/mL presents higher rates of biochemical progression, while clinical progression, assessed by metastatic disease or cancer specific mortality, was more associated with PSA 0.4ng/mL . Regardless the BCR definition, it shoud not be used as a landmark to start treatments. Although better oncologic outcomes were observed when salvage treatment was administrated at lower PSA levels, the correct timing of its administration depends on pathologic features, functional status, quality of life effects and patients preferences .
Han and colleagues evaluated 2.091 men submited to RP without adjuvant radiotherapy for a median follow-up of 5.9 years. Recurrence was noted in 17% of patients. Overall actuarial 5, 10 and 15 year BCR rates were 16%, 28% and 39%, respectively. Same years rates for metastatic disease were 4%, 11% and 19% and for PCa specific mortality 1%, 4% and 11%, respectively .
Can You Live 10 Years With Metastatic Prostate Cancer
Of the 794 evaluable patients, 77% lived < 5 years, 16% lived 5 up to 10 years, and 7% lived > or = 10 years. Factors predicting a statistical significant association with longer survival included minimal disease, better PS, no bone pain, lower Gleason score, and lower PSA level.
How Your Doctor Monitors You After Treatment
After treatment you have follow up appointments, which usually include regular blood tests to check the levels of a protein called prostate specific antigen . They check to see if your PSA level rises. And they also look at how quickly it rises.
An increase in PSA can mean there are prostate cancer cells in your body. The cells might be in or around the prostate. Or they might have spread to other parts of your body. You might need treatment if it rises.
Prostate cancer that comes back after treatment is called recurrent prostate cancer.
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Psa Levels And Prostate Cancer Relapse
For people with relapsed cancer, the threshold to determine relapse will change based on whether surgery or radiation was used to treat it:
- PSA levels drop to zero after surgery. The cancer has returned if PSA levels are over 0.2 nanograms per milliliter .
- PSA levels are low but present after radiation. A relapse has occurred when the PSA levels rise 2 points higher than the lowest score achieved after radiation.
What If My Psa Rises While Im On Hormone Therapy
When the PSA is rising or cancer is spreading despite a low level of testosterone, prostate cancer is called castration-resistant, or hormone-refractory. Despite this name, some hormonal therapies may still work. But prostate cancer in this setting may progress and become more aggressive and resistant, and you should be prepared to discuss additional treatment strategies with your doctor. This is the time when a medical oncologist, if not already involved in your care, gets involved. These doctors specialize in medical, systemic treatments for prostate cancer, which is useful at this time given that your disease is typically metastatic, meaning that it is not confined to only one location. Cancer cells in this situation have typically spread through the blood stream or lymphatics to other places in the body, and localized treatments are rarely helpful except in circumstances where where you are having symptoms, such as problems with urination.
Fortunately, more and more treatments for metastatic castration-resistant prostate cancer have become available in recent years, including certain newer androgen directed therapies, taxane chemotherapy, immunotherapy, PARP inhibitors, and, in 2022, lutetium-PSMA radionuclide therapy. Additional tests are required for some of these treatments to see if your particular type of prostate cancer is likely to respond. See Chapter 5 in PCFs Prostate Cancer Patient Guide for more details.
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Prostate Cancer Recurrence Isnt Limited To The Prostate
It is important to understand exactly where the recurrent prostate cancer is located in your body so that you and your doctor can choose the most appropriate treatment plan for you.
There are limitations with each of the current imaging tests used to locate recurrent prostate cancer.
While routine imaging tests including bone scans, CT scans, and MRIs can help provide some information about recurrent prostate cancer, these tests have limitations. There are newer advanced imaging tests available today. Talk to your doctor about which imaging tests are right for you.
Salvage Radiation Therapy After Radical Prostatectomy For Prostate Cancer
Defined as radiation treatment for suspected recurrent malignant disease after a period of observation after prostatectomy.
This is to be distinguished from adjuvant radiation treatment directly after prostatectomy in patients potentially without residual disese and with an undetectable PSA.
Randomized trials have shown adjuvant radiation therapy provides benefit, whereas salvage radiation therapy evidence is lacking .
For 635 patients who underwent radical prostatectomies for T1 and T2 disease with PSA relapse, only, were randomized to local salvage radiation alone or in combination with hormonal therapy-397 men did not receive salvage radiation , 160 received salvage radiation alone and 78 received salvage radiation plus hormonal therapy: salvage radiotherapy for biochemical relapse at a median follow-up of 6 years resulted in a threefold lesser risk for prostate associated deaths, hormonal therapy did not lead to significantly longer prostate cancer specific survival associated with salvage radiotherapy, survival benefit with salvage radiation benefit was limited to men with PSA doubling time of less than 6 months and if salvage radiotherapy was initiated more than 2 years after recurrence was not associated with survival prostate cancer specific survival, and finally if PSA did not become undetectable after salvage radiotherapy there was no benefit .
Surgery is often followed by adjuvant radiotherapy to the prostate bed.
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Can I Lower The Risk Of Prostate Cancer Progressing Or Coming Back
If you have prostate cancer, you probably want to know if there are things you can do that might lower your risk of the cancer growing or coming back, such as exercising, eating a certain type of diet, or taking nutritional supplements. While there are some things you can do that might be helpful, more research is needed to know for sure.
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Understanding The Recurrent Prostate Cancer
Recurrent prostate cancer is when prostate cancer returns after the initial treatment or partial to complete remission has occurred. This is due to the reemergence of surviving prostate cancer cells that have grown large enough to be detected.
Following a prostatectomy, your prostate-specific antigen levels being to decrease. Eventually, they are no longer detectible, which is an indication that prostate cancer is no longer present. However, there is no clear reference for a normal PSA. It differs between men and can be affected by a number of factors. Following your initial prostate cancer treatment, PSA levels should stabilize and be low enough to where theyre not detected on blood tests. In some cases, PSA levels begin to rise again, indicating a need for further tests.
Even if youve had a prostatectomy, prostate cancer can recur in the immediately surrounding tissue, lymph nodes, seminal vesicles, muscles that control urination, the rectum, the wall of the pelvic, or metastasize into lymph nodes and bones further away.
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Good Prostate Cancer Care
Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.
You should be able to talk with a named specialist nurse about treatment options and possible side effects to help you make a decision.
You should also be told about any clinical trials you may be eligible for.
If you have side effects from treatment, you should be referred to specialist services to help stop or ease these side effects.
Are There Different Types Of Hormone Therapy For Prostate Cancer
Yes. There are several different ways to block the secretion of testosterone, including the surgical removal of the testes, drugs known as LHRH agonists, and drugs called LHRH antagonists. These are considered standard hormone therapy. Another class of medications that can be used in combination with standard hormone therapy is called antiandrogens.
In the past decade, newer medicines called androgen directed therapies have been approved for certain states of advanced prostate cancer.
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What Is Intermittent Hormone Therapy
With intermittent hormone therapy, the LHRH agonist is used for 612 months, during which time a low PSA level is maintained. The drug is stopped until the PSA rises to a predetermined level, at which point the drug is restarted. During the drug holidays in between cycles, sexual function and other important quality of life measures might return. However, this approach is not right for all patients, and a patient-by-patient approach should be used based on response to and tolerability of hormone therapy.
Why Is A Simple Prostatectomy Performed
There are varying degrees of prostate enlargement.
If your prostate grows only slightly, many minimally-invasive surgeries can remove part of the gland, such as transurethral resection of the prostate .
However, if your prostate becomes very large , your surgeon will need to perform a simple prostatectomy. This involves removing the inner core of your prostate gland. Most men who undergo this type of surgery are age 60 or older.
Special diets, changes in drinking habits, and medications are often tried before surgery is recommended.
Your doctor may recommend a simple prostatectomy if your prostate is very large and you are suffering from:
- extremely slow urination
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Symptoms Of Prostate Cancer Recurrence
In many cases, symptoms of a recurring prostate cancer are similar to those you experienced with the original diagnosis. They can include:
- Urinary frequency, urinating often, even during the night
- Urinary urgency, the sudden need to urinate
- Urinary hesitancy, with delays in starting or stopping flow of urine
- Blood in your urine, called hematuria
- Bone pain near the prostate region
Risks Of Prostate Surgery
The risks with any type of radical prostatectomy are much like those of any major surgery. Problems during or shortly after the operation can include:
- Reactions to anesthesia
- Blood clots in the legs or lungs
- Damage to nearby organs
- Infections at the surgery site.
Rarely, part of the intestine might be injured during surgery, which could lead to infections in the abdomen and might require more surgery to fix. Injuries to the intestines are more common with laparoscopic and robotic surgeries than with the open approach.
If lymph nodes are removed, a collection of lymph fluid can form and may need to be drained.
In extremely rare cases, a man can die because of complications of this operation. Your risk depends, in part, on your overall health, your age, and the skill of your surgical team.
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What If My Cancer Comes Back Again
If your cancer comes back again after treatment that aims to get rid of it, you will be offered hormone therapy to control your cancer, though you may not need to start it straight away. Hormone therapy can keep your cancer under control for many months or years before you need to think about other treatments.
But over time, your cancer may start to grow again. You may continue having your original hormone therapy, but there are also other treatments available. Read more about treatment options after your first hormone therapy. Some men decide they would like to take part in a clinical trial of a new treatment or a new combination of existing treatments.
How Does Hormone Therapy For Prostate Cancer Work
LHRH, or luteinizing-hormone releasing hormone, is one of the key hormones released by the body that initiates the production of testosterone.
LHRH Agonists: One of the most common hormone therapies in prostate cancer involves blocking the release of LHRH through the use of agonists . LHRH agonists cause a testosterone flare reaction, which is an initial transient rise in testosterone that happens over the first week or two after the first treatment.
LHRH Antagonists: These are a class of medications that can block LHRH from stimulating testosterone production without causing an initial testosterone surge.
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Do I Need Additional Treatment After Prostate Surgery
After surgery, one of the most important questions to ask is whether you may benefit from additional therapy, such as adjuvant radiation . The decision to use radiation to lower your risk of recurrence and dying from prostate cancer after surgery is based on whether the cancer has spread to your seminal vesicles, whether there were positive margins, and whether the cancer spread beyond the prostate capsule. In addition, it is important to allow time to recover your urinary function before considering radiation therapy after surgery, as radiation to this region increases the risk of urinary strictures, leakage, and high urination frequency.Many, but not all men, often can safely avoid adjuvant radiation therapy, and closely monitor their PSA to determine if they will need early salvage radiation therapy .
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.
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Even When Prostate Cancer Returns Most Survive
By Anne Harding, Reuters Health
5 Min Read
NEW YORK – Men who show signs that their disease has returned after prostate cancer treatment are still more likely to die of other causes, a new study in US veterans shows.
Nevertheless, researchers say the study underscores the need to find a better way to identify the minority of men who will die of prostate cancer after disease recurrence.
We often dont know what to tell these men in terms of their risk of dying of prostate cancer, Dr. Timothy Daskivich of the University of California, Los Angeles, told Reuters Health.
Detecting prostate cancer is most often done with a blood test that measures concentrations of prostate-specific antigen, or PSA, a protein made in the prostate that becomes elevated in men with prostate cancer.
After treating prostate cancer with surgery or radiation, PSA levels are monitored. If PSA levels begin to increase, this can serve as an early indicator of disease recurrence. But the effect of a rising PSA after treatment — also known as biochemical recurrence — on mens subsequent risk of dying from prostate cancer is not clear.
To investigate, Dr. Edward M. Uchio of the VA Connecticut Healthcare System in West Haven and Yale University School of Medicine in New Haven and his colleagues looked at 623 men who had been diagnosed with prostate cancer between 1991 and 1995 and were followed for up to 16 years after treatment.
During follow up, 420 men died, but only 86 died of prostate cancer.
What Does Rising Psa Mean
When the PSA is rising or cancer spreading despite a low level of testosterone, prostate cancer is called castration-resistant, or hormone-refractory. Despite this name, some hormonal therapies may still work. But prostate cancer in this setting will inevitably progress and become more aggressive and resistant, and you should be prepared to discuss more aggressive treatment strategies with your doctor. This is the time when a medical oncologist, if not already involved in your care, gets involved. These doctors specialize in systemic treatments for prostate cancer, which is useful at this time given that your disease is typically systemic, meaning that it is not confined to only one location. Cancer cells in this situation have typically spread through the blood stream or lymphatics to other places in the body, and localized treatments are rarely helpful except in circumstances where urination becomes difficult. You should talk to your doctor about these systemic therapies, when to start chemotherapy, and clinical trials that may be available.
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What Do The Test Results Mean
PSA tests can be difficult to interpret. Tests can also vary from laboratory to laboratory. To ensure accurate comparison, its important to use the same lab each time youre tested.
If your PSA level is low and not rising after repeated tests, its probably not a cancer recurrence. Thats because other cells in your body can produce small amounts of PSA.
Ideally, your post-prostatectomy PSA will be undetectable, or less than 0.05 or 0.1 nanograms of PSA per milliliter of blood . If thats the case, your doctor may call it a remission.
If the result is greater than or equal to 0.2 ng/mL and its risen on two separate tests taken at least two weeks apart, its called a biochemical relapse. You still have PSA in your bloodstream. Theres a chance that cancer has recurred.
A PSA level higher than that may indicate a locally advanced tumor.