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Recurrence Rate Of Prostate Cancer After Prostatectomy

What Is Hormone Therapy For Prostate Cancer

Recurrent Prostate Cancer Cases – 2021 Prostate Cancer Patient Conference

Hormone therapy is a key treatment strategy for prostate cancer that has recurred following treatment for localized disease. Testosterone is a male hormone that fuels the growth of prostate cancer cells. The goal of hormone therapy is to stop the production and/or interfere with the effects of testosterone. However, not all prostate cancer cells are sensitive to decreases in testosterone levels, and, over time, the cancer can adapt to survive in a low-testosterone environment. Therefore, hormone therapy is a treatment for prostate cancer but does not cure the disease. The decision to start hormone therapy is individualized, based on your PSA, the PSA doubling time, whether the cancer has spread visibly or caused symptoms, and the potential side effects and risks involved with this type of therapy.

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.

How Prostate Cancer Recurrence Is Detected

Following surgery for prostate cancer removal, the majority of patients will have regular appointments to check in and assess recovery progress with their healthcare provider or preferred oncologist. At each of these visits, your doctor will draw blood to run tests on various levels of biomarkers, hormones, and immunological markers, including PSA. You may also undergo minor physical assessments as part of your post-prostatectomy preventive maintenance care plan.

If prostate specific antigen levels are found to be rising, staying the same as pre-operative quantities, or slowing their rate of decrease in an unexpected way, your provider may suggest imaging tests or an X-ray of the prostate and pelvic area. A few other alternative options for detecting prostate cancer recurrence are available, although some are in the early stages of development or are not yet widely available, so should not be used as a default or go-to option for determining whether metastatic resurgence is a clear and present health risk.

Are you a practicing healthcare provider or oncologist who would like to learn more about alternative options for localized detection of recurrent prostate cancer?

Check out the full infographic here.

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Salvage Androgen Deprivation Therapy

Recurrence following RP can potentially be managed with salvage ADT, although data supporting this use is generally obtained from retrospective studies . Not all patients with BCR after primary curative treatment benefit from salvage ADT however, a favourable effect is observed in a high-risk group, which may be defined as having a short PSA-DT and/or by tumour characteristics . Factors that may favour ADT after RP include a very high risk of clinical recurrence, good recovery of continence, long life expectancy, and the patient being anxious about the future or not being ready to accept the idea of sRT.

The National Cancer Institute of Canada PR-7 trial compared intermittent with continuous ADT in men with BCR and no evidence of metastatic disease after definitive or salvage RT and RP. OS in the intermittent arm was not inferior to that in the continuous arm, and intermittent therapy was associated with beneficial effects on certain domains of QoL. Salvage ADT for BCR may therefore be most appropriately delivered in an intermittent fashion, with the possible exception of patients with a Gleason score of 8 or higher .

Final Thoughts: Preventive Maintenance Is Always A Good Idea

Salvage Radical Prostatectomy for Recurrent Prostate Cancer Urology o

Prostate cancer is never an easy diagnosis to receive, and if youve already endured the physical and mental toll of a prostatectomy surgery, you certainly would like to hope it has been effective in its removal of the diseased tissue. However, approximately one-twentieth of men who undergo this procedure may not be completely free of the cancer.

If you or a loved one has reason to believe that prostate cancer recurrence is at play, or an increased risk of onset is likely, please contact HIFU Prostate Services today to discuss your options for noninvasive treatment. For more patient guides, healthcare resources, and medical news updates, please feel free to explore all of our articles on the official HIFU blog.

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What Is Prostate Cancer Recurrence

Prostate cancer recurrence is the return of cancer after treatment and a period when no cancer activity could be detected. Local therapies with radical prostatectomy or radiation therapy are the two main ways to eliminate localized prostate cancer.

Both options are definitive treatments because they can cure prostate cancer altogether. However, local treatments are ineffective if cancer has spread outside the prostate gland. Here, other types of treatment are needed to target cancer cells located in other parts of the body.

Cancer cells remain after curative treatments because of positive surgical margins or metastasis if the disease is more advanced than initially thought. Prostate cancer cells can start to grow again from these sites.

Treatment relapse increases the possibility of developing advanced incurable disease that needs complex treatment decisions to manage. However, current clinical methods for treating recurred prostate cancer can result in both over-treatment and under-treatment due to a lack of adequate biomarkers to predict response.

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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.

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How We Treat Prostate Cancer

The prognosis for metastatic prostate cancer can be discouraging, but some treatment centerslike the Johns Hopkins Precision Medicine Center of Excellence for Prostate Cancerspecialize in innovative, individualized therapy with the potential to improve outcomes.

Treating Prostate Cancer That Doesnt Go Away Or Comes Back After Treatment

Prostate Cancer (Part 14): Recurrence After Prostatectomy

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.

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Prognosis And Survival For Prostate Cancer

If you have prostate cancer, you may have questions about yourprognosis. A prognosis is thedoctorâs best estimate of how cancer will affect someone and how it willrespond to treatment. Prognosis and survival depend on many factors. Only adoctor familiar with your medical history, the type and stage and otherfeatures of the cancer, the treatments chosen and the response to treatment canput all of this information together with survival statistics to arrive at aprognosis.

A prognostic factoris an aspect of the cancer or a characteristic of the person that the doctorwill consider when making a prognosis. A predictive factor influences how acancer will respond to a certain treatment. Prognostic and predictive factorsare often discussed together. They both play a part in deciding on a treatmentplan and a prognosis.

The following are prognostic and predictive factors for prostatecancer.

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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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.

Treatment Of Rising Psa

The Role of Prostate

If PSA levels are rising slowly or by a small amount, a person may not need treatment. A doctor usually considers an individuals overall health, medical history, and age when giving advice on treatment.

Doctors often use active surveillance if PSA levels are rising. Active surveillance is a series of regular tests and health checks, with treatment only if necessary. Prostate cancer often progresses very slowly, so it may be many years before a person needs treatment.

If a person has had a prostatectomy, a doctor may also recommend radiation therapy, which kills cancer cells using high-energy particles.

Radiation therapy is not suitable for everyone who has had a prostatectomy. If a person had radiation therapy before surgery, they cannot usually have this treatment again. Having radiation therapy a second time can cause side effects.

Doctors may also use hormone therapy to shrink a persons tumors. This can make other treatments such as radiation therapy more effective.

It is not always possible to prevent PSA levels from rising. The best way to safeguard health after having a prostatectomy is by undergoing regular medical checks.

  • stopping smoking or using tobacco products
  • exercising regularly
  • eating a healthful diet, with plenty of fruits and vegetables
  • limiting alcohol intake to a moderate amount

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What Are The Side Effects Of Hormone Therapy For Prostate Cancer

Testosterone is the primary male hormone and plays an important role in establishing and maintaining the male sex characteristics, such as body hair, muscle mass, sexual desire, and erectile function. Most men who are on hormone therapy experience at least some effects related to the loss of testosterone, but the degree to which you will be affected by any one drug regimen is impossible to predict. Side effects from testosterone-lowering therapies include hot flashes, breast enlargement or tenderness, loss of bone mineral density , weight gain , higher cholesterol, and a higher risk of diabetes and heart attack. Some men experience fatigue, memory loss, and/or depression. Dont be afraid to discuss these issues with your doctors. Maintaining a healthy lifestyle through good nutrition and exercise can help reduce the impact of these side effects.

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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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.

Advancing Prostate Cancer Care

Cancer Recurrence After Prostatectomy

At Memorial Sloan Kettering, we tailor multimodal approaches to the individual features of each patients cancer. Radical prostatectomy is a complex procedure that requires a high level of technical precision. We provide state-of-the-art surgical techniques, including minimally invasive robotic and nerve-sparing surgery. Over the past few decades, we have dramatically reduced surgical complications by incorporating imaging test results in surgical plans to ensure the avoidance of other structures and the minimization of the risk of incontinence and erectile dysfunction. Our multidisciplinary prostate cancer team includes radiation oncologists who provide the latest radiotherapy approaches, including image-guided and intensity-modulated radiation therapy, stereotactic radiosurgery, proton therapy, and brachytherapy.

The field of prostate cancer care is evolving rapidly. We continue to explore new ways to improve outcomes and safety and effectiveness through clinical trials, in which we are testing new drugs and drug combinations, surgery and radiation therapy techniques, diagnostic approaches, and strategies for improving quality of life for men undergoing treatment for prostate cancer.

Disclosure: Peter Scardino sits on a clinical advisory board for OPKO Health outside the submitted study he also holds a patent issued by OPKO.

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Effect Of Gleason Score On Anisotropy And Capra

Gleason score is an important component of CAPRA-S, with 03 points out of the total possible 011 CAPRA-S points sourced from the Gleason grades. The observation that the overall performance of CAPRA-S and GS in our cohort was comparable, led us to study the performance of anisotropy and CAPRA-S at various GS ranges to determine added value. These results are summarized in and . In , we show the results from the AUC analysis comparing CAPRA-S and anisotropy at the GS ranges 56 7 , 7 and 810.

Figure 4: Gleason-score adjusted performance of Anisotropy and CAPRA-S.

At Gleason scores of 56, both anisotropy and CAPRA-S show poor performance at identification of recurrent individuals. However, the probability of recurrence at this stage is 3% and CAPRA-S outperforms anisotropy due to its ability to identify 100% of the non-recurrent cases. At Gleason score of 7 , anisotropy and CAPRA-S show comparable performance. The probability of recurrence at this stage was 16%. At Gleason score of 7 , the probability of recurrence is 43%. CAPRA-S failed due to overestimation of the recurrence risk. Anisotropy was able to identify recurrence . At Gleason score of 810, the probability of recurrence is 64%. Anisotropy was able to identify the recurrent cases with a higher level of accuracy than CAPRA-S .

Multiple Imputation And Missing Data

We used multiple imputation to impute missing data taking the variables of T-stage and histopathologic grading, age, and treatment into account. Missing data were mostly confined to the grading parameter in the German data . For propensity score matched analyses and year-specific Cox regression analyses, we used PROC MI in SAS. In piecewise proportional hazard models, we applied the mice package in R. Matching results for the complete data are shown in Table S2, which indicate equal mean values and proportions between treatment groups.

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Psa Levels After Treatment

A continuous rise in your PSA level can be the first sign that your cancer has come back. This should be picked up by your regular PSA tests.

The exact change in PSA level that suggests your cancer has come back will depend on which treatment you had. Speak to your doctor or nurse about your own situation.

Your PSA level should drop so low that its not possible to detect it at six to eight weeks after surgery. This is because the prostate, which produces PSA, has been removed. A rise in your PSA level may suggest that you still have some prostate cancer cells.

After radiotherapy or brachytherapy, your PSA should drop to its lowest level after 18 months to two years. Your PSA level wont fall to zero as your healthy prostate cells will continue to produce some PSA.

Your PSA level may actually rise after radiotherapy treatment, and then fall again. This is called PSA bounce. It could happen up to three years after treatment. It is normal, and doesnt mean that the cancer has come back.

If your PSA level rises by 2 ng/ml or more above its lowest level, this could be a sign that your cancer has come back. Your doctor will continue to check your PSA level and will talk to you about further tests and treatment options.

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