Growing Body Of Evidence
The results are consistent with those of a clinical trial published last year that tested the addition of short-term androgen deprivation therapy to radiation therapy, noted Deborah E. Citrin, M.D., of NCIs Center for Cancer Research , who was not involved in either study. The findings of the 2016 trial indicated that radiation plus a course of androgen deprivation therapy for 6 months could be a treatment option for men who experience a biochemical recurrence after a prostatectomy.
Together, the results of these studies give us much more confidence in recommending this type of treatment for the appropriate patients, said Dr. Citrin, a senior investigator in CCRs Radiation Oncology Branch.
Now that we know theres a survival benefit, we need to determine who is likely to benefit most from the treatment and what the optimal duration of treatment is, Dr. Citrin continued. Some patients may achieve some of the benefits reported in the bicalutamide trial from shorter courses of androgen deprivation therapy, she noted.
Patients considering treatment with androgen deprivation therapy and radiation therapy should discuss the option with their doctors to find a balance between the potential benefits and the risks, including side effects, Dr. Citrin added.
Radiation Therapy Prolongs Life In Men With Recurrent Prostate Cancer
Men whose tumors recur after prostate cancer surgery are three times more likely to survive their disease long term if they undergo radiotherapy within two years of the recurrence. Surprisingly, survival benefits were best in men whose new tumors were growing fastest, according to results of a “look-back” study of 635 men by Johns Hopkins Medical Institutions researchers reported June 18 in the Journal of the American Medical Association.
Previous studies of radiation therapy for recurrent prostate cancer found that it reduced disease progression, but this study demonstrates that it significantly prolongs survival as well, according to Bruce J. Trock, Ph.D., associate professor of urology, epidemiology, oncology, and environmental health studies, and director of the Division of Epidemiology in the Brady Urological Institute at Johns Hopkins.
“What this new study tells us is that even men with aggressive disease that has recurred after surgery appear to benefit from radiation therapy. It also means that we may be able to give radiation selectively to those who are really likely to benefit from it,” advises Trock.
PSA, or prostate specific antigen, is the blood-based protein shed by the organ that signals the likely presence of cancer. Rapid rises in PSA levels after surgical removal of the prostate signal the recurrence of cancer and often convey a poor prognosis.
Table : Predictors Of Biochemical Recurrence At Time Of Diagnosis
Although a number of clinical factors contribute to your risk of relapse after treatment, the parameters below provide a simpler assessment of your chances of biochemical recurrence, based on your clinical profile at the time of diagnosis. For more sophisticated estimates, based on specific risk factors, see Figures 1 through 3.
Low risk Gleason score less than or equal to 6and Cancer stage T2c or more
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Prognostic Factors In Psa
Pre- and post-treatment prognostic factors allow physicians to assign risk levels and use those risk groupings to help determine whether to start treatment immediately or to defer it. Pretreatment factors that have shown prognostic value include absolute baseline PSA, tumor stage , and pathologic findings . All of these parameters are prognostic of development of distant metastases and prostate-specific mortality, with Gleason score providing the greatest prognostic value with advanced T-stage and absolute PSA value also contributing to accuracy of prognosis. Gleason score continues to have prognostic value following local therapy but it is joined by other factors, of which PSADT is likely the most important prognostic factor for metastasis-free survival and overall survival. Time to biochemical recurrence has been shown to be a prognostic factor in some studies, but not in others. In a landmark study, Pound and associates found that time to biochemical recurrence after RP was as effective as PSADT and Gleason score as a prognostic factor for metastasis. However, a recent multivariate analysis using updated information from these same patients showed that time to biochemical recurrence does not add measurably to the prognostic value of PSADT and Gleason score. Finally, changes in PSADT after initiation of therapy in the setting of clinical trials has also been shown to be prognostic of metastasis-free survival in patients with BCR disease following local therapy.
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
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Timing And Duration Of Adt
Physicians wishing to treat BCR prostate cancer patients with ADT face 2 key timing questions: 1) whether to initiate ADT immediately upon PSA recurrence or to defer its use until after clinical/radiographic progression occurs, and 2) whether to use continuous administration of ADT or intermittent cyclic administration of ADT. As of December 2012, the American Society of Clinical Oncology had not provided definitive guidelines addressing either of these questions. We will review the relevant clinical trial data that may guide clinicians with respect to these 2 issues.
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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Side Effects Of Radiation Therapy
Compared to earlier radiation methods, these modern techniques reduce the chance of urinary and bowel problems.
With several treatment options available, your doctor will work with you to develop and oversee a treatment plan that precisely addresses your prostate cancer while minimizing the risk to surrounding tissues.
This is why it is important to choose an experienced radiation oncologist who specializes in the management of prostate cancer. High volume centers where practitioners have significant experience and treat large numbers of patients with prostate cancer may be associated with good outcomes and fewer lasting problems related to treatment. The majority of patients who undergo radiation do not have permanent effects on bowel or urinary function, and patients who develop erectile difficulty after these therapies can often be treated successfully with medications such as sildenafil or tadalafil.
Radical Prostatectomy vs. Radiation: How to Compare the Results
Making a decision about prostate cancer treatment is not easy. When considering radiation therapy or radical prostatectomy, one of your top concerns is seeking reassurance that your cancer will be cured following treatment.
Why Does Breast Cancer Come Back After Treatment
Even with the best treatment, cancer can come back. If just a few cancer cells remain in your body after your initial treatment, those cells can spread through the blood or lymph system and grow. This may happen from a few months to many years after the first diagnosis.
If your breast cancer has come back, you may second-guess your previous treatment choices. But the fact is, there is no guarantee with any treatment. Now it is time to make new decisions and explore other treatment options.
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Who Is More Likely To Have Prostate Cancer Recurrence
In general, the further your cancer has spread and the more aggressive it is, the more likely it is to recur. Specific factors include:
- Tumor size: In general, the larger the tumor, the more likely it is to recur.
- Gleason score: A higher Gleason score means a more aggressive cancer and a higher rate of recurrence.
- Cancer staging: Staging refers to how far the cancer has spread. Higher stage cancers have spread further at initial treatment and have higher rates of recurrence.
- Involvement of the lymph nodes: Prostate cancer that has entered the lymph nodes prior to treatment is more likely to recur.
What Do I Need To Know About Axumin
- As with all diagnostic imaging tests such as x-rays, bone scans and computed tomography scans, it is possible that the physician that reviews your Axumin PET/CT scan can interpret your results incorrectly. This means that a negative Axumin PET/CT scan does not rule out that you have recurrent prostate cancer, and a positive Axumin PET/CT scan does not confirm that you have recurrent prostate cancer.
- How well Axumin works seems to be affected by PSA levels. As PSA levels go up, an Axumin PET/CT scan is better able to identify recurrent prostate cancer.
- Serious reactions including anaphylaxis, a severe, potentially life-threatening allergic reaction, may occur in patients who receive Axumin.
- Axumin adds to your long-term overall radiation exposure, which can lead to an increased risk of cancer.
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What Are The Symptoms
The symptoms depend on where the cancer is and how large it is. The most common places for breast cancer to spread are within the breast or to the nearby chest wall or to the liver, lungs, or bones. Common symptoms include a lump in your breast or on your chest wall, bone pain, and shortness of breath.
Or you may not have any symptoms. Sometimes recurrent or metastatic breast cancer is found with an X-ray or a lab test.
Salvage Radiation For Psa
Three large retrospective studies provide evidence that early salvage radiation therapy, delivered to patients with rapid PSADT, or while the PSA levels remain below 2.0 ng/mL, impacts survival of prostate cancer patients with BCR. A study at Duke University examined 519 patients who experienced BCR after prostatectomy, of which 219 patients received salvage radiation therapy. That study stratified the patients by PSADT . Salvage radiation therapy significantly improved overall survival in both groups at a median follow-up of 11.3 years, with all-cause mortality hazard ratios for death of 0.53 and 0.52 for those with faster and slower PSADT, respectively.
Although another large retrospective trial has not shown overall survival benefits from salvage radiation treatment after prostatectomy, the 2 studies described above provide adequate evidence that salvage radiation therapy may positively alter the progression of the disease when administered within 2 years of BCR and while the absolute PSA remains below 2 ng/mL . The finding of improved prostate cancerâspecific survival in men with PSADT less than 6 months is provocative , and should be confirmed by additional studies.
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Recurrent Prostate Cancer After Radiation Therapy
Once a patient has received radiation therapy to the prostate gland, more radiation therapy typically cannot be given to the same area safely. Systemic treatment with ADT is the mainstay of treatments for individuals with recurrent prostate cancer following primary treatment with radiation. Rarely, surgeons have removed the prostate gland for persistent cancer after radiation therapy. Other surgeons have used cryosurgery, which is a local treatment where the prostate gland is frozen with a probe. Complications of surgery or cryosurgery, however, tend to be more frequent in patients previously treated with radiation therapy. If a patient is not a candidate for these types of local therapies or ADT other systemic treatments like chemotherapy or immunotherapy are used.
Research Needs And Future Directions
Ongoing Clinical Trials. Several ongoing clinical trials will help to clarify the magnitude and impact of ART or SRT, the relative value of combining RT with hormone and other therapies, and potentially make clear which patients are more likely to benefit from specific therapies, therapy combinations, and therapeutic contexts.
RTOG 0534 is randomizing post-prostatectomy patients with Gleason scores 9, with or without positive margins, and with post-RP PSA of 0.1 ng/mL to < 2.0 ng/mL to prostate bed RT, prostate bed RT plus short-term ADT or pelvic lymph node RT plus prostate bed RT plus short-term ADT. Patients are stratified by SVI status, Gleason score 7 or 8-9, pre-RT PSA of 0.1 to 1.0 ng/mL or > 1.0 to
The RAVES trial was a phase III multi-center trial taking place in Australia and New Zealand comparing ART with early SRT in patients with positive margins or EPE. The primary trial aim was to determine whether surveillance with early SRT results in equivalent biochemical control and improved QoL when compared with ART. Secondary outcomes include QoL, toxicity, anxiety/depression, bRFS, OS, CSS, time to distant failure, time to local failure, time to initiation of hormone therapy, quality adjusted life years, and cost-utility. The rate of participant accrual diminished over time, and the trial closed prematurely with entry of 333 of the 470 patients planned.
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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.
How Can You Handle Your Feelings About Having Breast Cancer Again
It’s common to have a wide range of emotions. It may be hard to stay hopeful when you are fighting cancer for the second or third time. These ideas may help:
- Get the support you need. Spend time with people who care about you, and let them help you.
- Take good care of yourself. Get plenty of rest, and eat nourishing foods.
- Talk about your feelings. Find a support group where you can share your experience.
- Stay positive. Do things each day that will help you stay calm and relaxed.
If your emotions are too much to handle, be sure to tell your doctor. You may be able to get counselling or other types of help.
You may want to think about planning for the future. An advance care plan lets doctors know what type of life-support measures you want if your health gets much worse. You can also choose a substitute decision-maker to make decisions in case you aren’t able to. If you put your wishes in writing, you can make it easier for your loved ones and others to know what you want.
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How Is Hormone Therapy Used To Treat Hormone
Hormone therapy may be used in several ways to treat hormone-sensitive prostate cancer, including:
Early-stage prostate cancer with an intermediate or high risk of recurrence. Men with early-stage prostate cancer that has an intermediate or high risk of recurrence often receive hormone therapy before, during, and/or after radiation therapy, or after prostatectomy . Factors that are used to determine the risk of prostate cancer recurrence include the grade of the tumor , the extent to which the tumor has spread into surrounding tissue, and whether tumor cells are found in nearby lymph nodes during surgery.
The use of hormone therapy before prostatectomy has not been shown to be of benefit and is not a standard treatment. More intensive androgen blockade prior to prostatectomy is being studied in clinical trials.
Relapsed/recurrent prostate cancer. Hormone therapy used alone is the standard treatment for men who have a prostate cancer recurrence as documented by CT, MRI, or bone scan after treatment with radiation therapy or prostatectomy.
Hormone therapy is sometimes recommended for men who have a “biochemical” recurrencea rise in prostate-specific antigen level following primary local treatment with surgery or radiationespecially if the PSA level doubles in fewer than 3 months.
Side Effects Of Treatment
Cancer and its treatments can be painful, but cancer pain can almost always be controlled. If you are having ongoing problems with managing pain, ask to see a pain specialist.
There are also many things you can do at home to help manage side effects of treatment. But talk to your doctor about any bothersome symptoms. Working together with your doctor can help you have the best possible quality of life.
You can find more information about treating breast cancer online at the:
- Canadian Cancer Society website at www.cancer.ca.
- U.S. National Cancer Institute website at www.cancer.gov.
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What Factors Determine The Likelihood Of Recurrence
Several signs can point to a prostate cancer that has come back or spread, including:
- Lymph node involvement. Men who have cancer cells in the lymph nodes in the pelvic region may be more likely to have a recurrence.
- Tumor size. In general, the larger the tumor, the greater the chance of recurrence.
- Gleason score. The higher the grade, the greater the chance of recurrence. Your doctor can tell you your score when the biopsy results come back from the laboratory.
- Stage. The stage of a cancer is one of the most important factors for selecting treatment options, as well as for predicting future outlook of the cancer.