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
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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What Are Male Sex Hormones
Androgens are required for normal growth and function of the prostate, a gland in the male reproductive system that helps make . Androgens are also necessary for prostate cancers to grow. Androgens promote the growth of both normal and cancerous prostate cells by binding to and activating the androgen receptor, a protein that is expressed in prostate cells . Once activated, the androgen receptor stimulates the expression of specific genes that cause prostate cells to grow .
Almost all testosterone is produced in the testicles a small amount is produced by the adrenal glands. Although prostate cells do not normally make testosterone, some prostate cancer cells acquire the ability to do so .
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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.
Who Is At Risk For Advanced Prostate Cancer
The exact cause of prostate cancer isnt clear. Your risk of developing this particular cancer increases after you reach age 50.
Certain groups are more likely to develop aggressive forms of prostate cancer, including African-American men and men who carry certain inherited genetic mutations such as BRCA1, BRCA2, and HOXB13.
Most men with prostate cancer dont always have a family history of the disease. But having a father or brother with prostate cancer more than
You probably wont need all of these tests. Your doctor will choose the tests based on your symptoms and physical exam.
If any of the images reveal abnormalities, it doesnt necessarily mean that you have cancer. Additional testing may be necessary. If they find a mass, your doctor will probably order a biopsy.
For a biopsy, your doctor will use a needle to remove samples from the suspicious area. A pathologist will then analyze the removed cells under a microscope to see if theyre cancerous. The pathologist can also determine if you have an aggressive form of prostate cancer.
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Radiation As Adjuvant Or Salvage Therapy After Surgery
Several randomized trials have evaluated the use of adjuvant radiation therapy to the prostatic bed following surgery for patients at high risk of recurrence . Those include EORTC 22911, SWOG 8794, ARO 96-02/AUO AP 09/95, and FinnProstataX, as well as the ongoing RAVES, GETUG-AFU 17, and RADICALS-RT studies. Recent research has further highlighted the role of early salvage radiation therapy with concomitant ADT for those with biochemical recurrence after prostatectomy, to avoid overtreatment associated with adjuvant radiotherapy. This is reflected in the current AUA/ASTRO guidelines.
Focal Therapy For Prostate Cancer Recurrance Post Radiotherapy
Overview byChair in Urology and Consultant Urological SurgeonImperial College NHS TrustProfile
Focal treatment for recurring prostate cancer after radiotherapy.
Following radiotherapy for prostate cancer, there is a 1 in 5 chance of recurrence where the cancer returns inside the prostate. Most men in this situation have been traditionally treated with a palliative strategy with watchful waiting and hormones. Hormones that suppress testosterone, the male hormone, keep the cancer in control for 2-3 years but long term use can lead to diabetes, heart disease, bone thinning as well weight gain, tender enlarged breasts and tiredness.
The alternative of surgical removal prostatectomy carries significant problems. Treating prostate cancer that recurs locally in the prostate following radiotherapy can be problematic as the tissue becomes sticky. Surgery results in side effects including incontinence and bowel damage requiring a stoma and subsequent major open surgery and total loss of erectile function. More radiotherapy can also increase toxicity with the same result and because the cancer has resisted radiotherapy once, there is concern further radiotherapy may not work a second time. Having said that there is work is starting on using MR guided Linac to treat recurrence, but this is its very early stages.
Meanwhile, less than 1 in 100 patients experienced significant complications. 0.3% suffered some rectal injury.
How it works
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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.
What Is Advanced Prostate Cancer
When prostate cancer spreads beyond the prostate or returns after treatment, it is often called advanced prostate cancer.
Prostate cancer is often grouped into four stages, with stages III and IV being more advanced prostate cancer.
- Early Stage | Stages I & II: The tumor has not spread beyond the prostate.
- Locally Advanced | Stage III: Cancer has spread outside the prostate but only to nearby tissues.
- Advanced | Stage IV: Cancer has spread outside the prostate to other parts such as the lymph nodes, bones, liver or lungs.
When an early stage prostate cancer is found, it may be treated or placed on surveillance . Advanced prostate cancer is not curable, but there are many ways to treat it. Treatment can help slow advanced prostate cancer progression.
There are several types of advanced prostate cancer, including:
With biochemical recurrence, the prostate-specific antigen level has risen after treatment using surgery or radiation, with no other sign of cancer.
Castration-Resistant Prostate Cancer
Non-Metastatic Castration-Resistant Prostate Cancer
Prostate cancer that no longer responds to hormone treatment and is only found in the prostate. This is found by a rise in the PSA level, while the testosterone level stays low. Imaging tests do not show signs the cancer has spread.
Metastatic Prostate Cancer
- Lymph nodes outside the pelvis
- Other organs, such as liver or lungs
Metastatic Hormone-Sensitive Prostate Cancer
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What Types Of Hormone Therapy Are Used For Prostate Cancer
- reducing androgen production by the testicles
- blocking the action of androgens throughout the body
- block androgen production throughout the body
Treatments that reduce androgen production by the testicles are the most commonly used hormone therapies for prostate cancer and the first type of hormone therapy that most men with prostate cancer receive. This form of hormone therapy includes:
Treatments that block the action of androgens in the body are typically used when ADT stops working. Such treatments include:
Treatments that block the production of androgens throughout the body include:
How Common Is Recurrence
The recurrence of prostate cancer depends on when it was caught and treated the first time. If your doctor was able to remove the cancer while it was still confined in the prostate gland, your chances of recurrence are fairly low. If your cancer spread before treatment, such as in the case of about 10% of men, recurrence is more likely to occur. Recurrence, therefore, occurs if not all of the cancer cells were treated the first time or if the cancer was more advanced than originally believed.
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Testing Options For Prostate Cancer
There is no one age for prostate cancer testing, but the American Cancer Society makes recommendations about prostate cancer screenings. According to the ACS, patients in any of these groups should consider asking their doctor about testing:
- Men age 50 or older who have an average risk of prostate cancer and a life expectancy of at least 10 more years
- Men age 45 or older with a high risk, including African-American men and those with a first-degree relative who had prostate cancer before age 65
- Men age 40 or older who have a higher risk, such as more than one first-degree relative diagnosed with prostate cancer at an early age
Expert cancer care
Ive Had A Prostatectomy Am I At Risk Of Cancer Returning
Although all forms of cancer are technically a cellular mutation that cannot necessarily be prevented or controlled, there are factors that may increase the risk of prostate cancer recurrence, even after surgery. These include, but are not limited to, the following:
- Stage of Prostate Cancer
- If the prostate cancer was detected in a later stage, or if cancerous tissue or tumor growth is significantly progressed, a prostatectomy may be slightly less effective for the purposes of controlling future susceptibility to recurrence.
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Surgery In Metastatic Disease
Physicians have suggested that the benefits seen from radiation to the prostate point to the benefits of local therapy, raising the question of whether radical prostatectomy might have the same results. Trials are ongoing, and at present the use of surgery should be considered investigational and conducted only within the context of a trial. However, transurethral resection is sometimes needed in men who develop obstruction secondary to local tumor growth. Bilateral orchiectomy can be used to produce androgen deprivation in patients with widely advanced and metastatic prostate cancer.
Since the introduction of LHRH agonist and antagonist therapies, surgical intervention has been practiced less often. An indication for immediate bilateral orchiectomy is spinal cord compression, because it avoids the potential flare response that can occur during the first 3 weeks of treatment with an LHRH agonist.
Basics Of Prostate Cancer Pet Imaging And Available Tracers
PET is currently performed in combination with CT or MR for attenuation correction and anatomic localization of PET findings. The vast majority of clinical PET scanners currently are PET/CT systems, although PET/MRI is in clinical use with an increasing installation base. In PET imaging for prostate cancer, a positron-emitting radiopharmaceutical is administered intravenously, and images are acquired through the detection of coincident gamma rays of 511 keV that result from the annihilation of a positron with an electron in a tissue . PET images can provide quantitative localization of radioactivity throughout the body at a single or multiple time points after tracer injection.
The timing of imaging acquisition after PET tracer administration varies depending on the pharmacokinetics of the tracer. In some cases, image acquisition within 5 minutes after PET tracer administration is desirable to minimize the concentration of radioactivity in the urinary bladder and ureters. PET provides higher spatial and temporal resolution than conventional single photon computed tomography . However, one of the limitations of PET is resolution, with decreased sensitivity of the detection and characterization of PET tracer uptake in lesions less than 8 mm. Additionally, PET tracers are expensive compared to CT and MRI contrast agents, and reimbursement for PET studies can be challenging even when the PET tracers are approved by the Food and Drug Administration .
Table 1Table 2
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After Surgery To Remove The Prostate
Following a prostatectomy, the course of treatment generally follows a similar path for all patients, with variations and adjustments made as needed based on test results, physical response, and overall progression of recovery, from both a provider and patient perspective. Almost universally among post-operative men who have had a cancerous prostate removed, levels of PSA are expected to drop, and this decrease is seen in a measurable way that follows suit.
However, prostate cancer is not limited to the borders of the gland itself, and it is commonly found to metastasize in the tissues directly surrounding the prostate, or in the nearby seminal vesicles . If cancer spreads after a prostatectomy, it is likely going to be found in one or both of these areas. It can also cause the affected individual to exhibit elevated levels of PSA, which, as youll recall, should be steadily dropping or fully depleted after surgery has been completed.
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What Is An Elevated Psa Level
After your initial prostate cancer treatment, you likely had regular checkups with your doctor. These checkups usually include a blood test to monitor your prostate specific antigen .
If your blood test shows that your PSA has gone up after surgery, radiation, or hormone therapy, your doctor will likely order another PSA test to confirm the results.
If your PSA is still elevated after the test, recurrent prostate cancer is indicated. Imaging tests may then be scheduled to locate where the prostate cancer has returned in your body.
By learning about my recurrent prostate cancer and talking with my urologist, I can be my own best advocate.
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What Can Prostate Cancer Feel Like
Fatigue: This can be both because of the treatment or the presence of cancer itself. The process has a mental and an emotional toll as well, so it is important to keep a check on your therapy, diet, physical activity and sleeping routine.
Pain: You may feel severe or no pain depending on the location of the tumor. A stinging pain is characteristic specifically to when the cancer is spread in the bones. This may weaken them, making them vulnerable to fractures or soreness. So, if you are wondering if prostate cancer hurts, the answer is yes. However, the degree of severity can vary. The sensations can be burning, stabbing, tingling, or numbing.
Issues in Bowel Movement: This includes constipation, diarrhea, the urgency to excrete feces, or no control over fecal excretion thus causing leakage.
Lack of Sexual Drive: Prostate cancer in men affects a body part that is deemed very personal. The inactivity signals aging, which is a source of stress, but it is actually more than that. One of the signs of prostate cancer is erectile dysfunction the odds of which are elevated after getting treatment for this cancer. Androgen Deprivation Therapy is when this cancer is ought to be treated by decreasing the levels of testosterone, and that can affect your sex life adversely.
Radiation Therapy Plus Androgen Ablation Therapy
Androgen ablation has been shown to improve survival in men with localized disease who are treated with external radiation. DAmico et al reported higher overall survival with the combination of radiation therapy and 6 months of ADT in men with intermediate-risk prostate cancer. Median follow-up was 7.6 years.
A study by Jones et al found that for patients with stage T1b, T1c, T2a, or T2b prostate cancer and a PSA level of 20 ng/mL or less, short-term ADT increased overall survival in intermediate-riskbut not low-riskmen. The 10-year rate of overall survival was 62% with combination therapy, versus 57% with radiation therapy alone 10-year disease-specific mortality was 4% and 8%, respectively. In this study, ADT was given for 4 months, starting 2 months before radiation therapy.
In a study by Pisansky et al of 1489 intermediate-risk prostate cancer patients, disease-specific survival was not significantly different whether total androgen suppression was given for 8 weeks or for 28 weeks prior to radiation therapy. Patients in the study were randomized to 8 or 28 weeks of TAS with LHRH agonist, along with a daily nonsteroidal antiandrogen, prior to radiation treatment. This was followed in both groups by an additional 8 weeks of androgen suppression, administered concurrently with radiotherapy.
Taken together, radiation therapy is generally given for 4-36 months, depending on the risk group of the patient.
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