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
Choosing A Prostate Cancer Surgeon
When you are choosing a surgeon to treat your prostate cancer, it is important to select someone you trust and have confidence in. He or she should have enough experience to not only perform the operation you need but also to make an informed clinical judgment and change course, if necessary.
The prostate cancer experts at Fred Hutch recommend choosing a surgeon who has done at least 250 prostatectomies total and who does at least 40 a year.
As you consider your options, you might want to ask your surgeon these questions.
Neoadjuvant Or Adjuvant Androgen Deprivation Therapy For Rp
Neoadjuvant or adjuvant ADT with RP may have benefits in some patients with local or locally advanced PCa, where there is evidence that this approach provides a significant survival advantage . The European Association of Urology guidelines recommend that adjuvant ADT be offered upon detection of nodal involvement during RP .
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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.
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.
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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
After Prostate Cancer Has Been Diagnosed Tests Are Done To Find Out If Cancer Cells Have Spread Within The Prostate Or To Other Parts Of The Body
The process used to find out if cancer has spread within theprostate or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The results of the tests used to diagnoseprostate cancer are often also used to stage the disease. In prostate cancer, staging tests may not be done unless the patient has symptoms or signs that the cancer has spread, such as bone pain, a high PSA level, or a high Gleason score.
The following tests and procedures also may be used in the staging process:
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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:
Some Patients May Still Benefit From Treatment With Adt
Newer hormonal medications that inhibit the synthesis of androgen and block androgen receptor signaling are FDA-approved for the treatment of advanced prostate cancer.2-5
Xtandi targets multiple steps in the androgen-receptorsignaling pathway, interfering with molecular pathways that help the prostate cancer grow. Whats more, the drug does not cause side effects commonly associated with chemotherapy, such as nausea and hair loss. Xtandi has been shown to improve survival, reduce the risk of cancer progression, and delay the need for additional chemotherapy in men with HRPC.3,5
Zytiga® is an oral targeted agent that blocks the production of androgens not only by the testes, but also by the adrenal glands and the tumor itself. Zytiga when administered with prednisone has been shown to improve quality of life and delay patient-reported pain progression in HRPC patients. Although this medication is generally well-tolerated, side effects may include fatigue, high blood pressure, and electrolyte or liver abnormalities and patients need to be monitored regularly.6
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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:
Immediate Versus Deferred Adt
When BCR patients experience clinical/radiographic metastatic disease, immediate initiation of ADT reduces further metastatic progression, improves pain , and reduces the development of skeletal-related events . Immediate ADT in the metastatic setting also reduces prostate cancerâspecific mortality, but does not necessarily improve overall survival because of increases in deaths from other causes.24,26 For nonmetastatic BCR patients, timing of ADT is controversial. Many men in the BCR setting choose to defer the initiation of hormonal therapy and prefer to allow their physician to monitor their PSA kinetics, bones scans, and CT scans on a regular basis. Two ongoing clinical trials are exploring the timing of ADT initiation after BCR following radiation, the Australian and New Zealand Timing of Androgen Deprivation trial and the Canadian Early vs. Late Androgen Ablation Therapy trial .
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The Grade Group And Psa Level Are Used To Stage Prostate Cancer
The stage of the cancer is based on the results of the staging and diagnostic tests, including the prostate-specific antigen test and the Grade Group. The tissue samples removed during the biopsy are used to find out the Gleason score. The Gleason score ranges from 2 to 10 and describes how different the cancer cells look from normal cells under a microscope and how likely it is that the tumor will spread. The lower the number, the more cancer cells look like normal cells and are likely to grow and spread slowly.
The Grade Group depends on the Gleason score. See the General Information section for more information about the Gleason score.
- Grade Group 1 is a Gleason score of 6 or less.
- Grade Group 2 or 3 is a Gleason score of 7.
- Grade Group 4 is a Gleason score 8.
- Grade Group 5 is a Gleason score of 9 or 10.
The PSA test measures the level of PSA in the blood. PSA is a substance made by the prostate that may be found in an increased amount in the blood of men who have prostate cancer.
What Side Effects Can Second
Any cancer treatment can cause side effects. For example, hormone therapy side effects include erectile dysfunction, hot flashes, and breast tissue tenderness.
You’re more likely to have side effects after second-line treatments, because the first treatment you had might have already damaged the tissue around your prostate. The side effects can also be more severe during the second round of treatment.
Just because a treatment can cause a side effect doesn’t mean it will affect you that way. Ask your doctor or nurse what types of side effects to expect, and what to do if you have any.
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An Emerging Treatment Option For Men With Recurring Prostate Cancer After Radiation Therapy
- By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
Prostate cancer is often a multifocal disease, meaning that several tumors can be present in different parts of gland at the same time. Not all of these tumors are equally problematic, however. And its increasingly thought that the tumor with the most aggressive features called the index lesion dictates how a mans cancer is likely to behave overall. That concept has given rise to a new treatment option. Called partial gland ablation , and also focal therapy, it entails treating only the index lesion and its surrounding tissues, instead of removing the prostate surgically or treating the whole gland in other ways. Emerging evidence suggests that PGA controls prostate cancer effectively, but with fewer complications such as incontinence.
In February, researchers at Memorial Sloan Kettering Cancer Center in New York published findings that could pave the way for focal therapy in men with reoccurring prostate cancer. They focused specifically on men whose cancer had returned three to four years on average after initial treatment with radiation.
Their findings, while preliminary, suggest that MRI and biopsy results can allow doctors to select which patients with reoccurring prostate cancer might be eligible for PGA. The research was headed by Dr. Gregory Chesnut, an MSKCC urologist.
How Do I Know That My Cancer Has Come Back
Recurrent prostate cancer usually doesn’t cause symptoms unless it has spread to other parts of your body. Then you might have:
- Trouble urinating
Often, the first sign that your cancer has returned is rising levels of prostate specific antigen, or PSA, in a blood test. Regular PSA testing is one way your doctor monitors you for a recurrence.
This test can’t show for sure that your cancer is back. Your doctor can do a biopsy to confirm that your cancer has returned, or a CT or MRI scan to see if it has spread.
Doctors also have an imaging test called positron emission tomography, or a PET scan, that may be better than other scans. It uses a radioactive tracer to find out where the cancer has spread and predict which treatment might work best against it.
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Can I Do Radiation Therapy Again
Having radiation therapy a second time is usually not an option because there is an increased risk of serious side effects3. A second radiation treatment would do significant damage to the tissues around the prostate, such as the bladder and rectum1. Although in some cases, brachytherapy may be an option after external radiation3.
There Are Three Ways That Cancer Spreads In The Body
Cancer can spread through tissue, the lymph system, and the blood:
- Tissue. The cancer spreads from where it began by growing into nearby areas.
- Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
- Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.
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Certain Factors Affect Prognosis And Treatment Options
The prognosis and treatment options depend on the following:
- The stage of the cancer .
- The patients age.
- Whether the cancer has just been diagnosed or has recurred .
Treatment options also may depend on the following:
- Whether the patient has other health problems.
- The expected side effects of treatment.
- Past treatment for prostate cancer.
- The wishes of the patient.
Most men diagnosed with prostate cancer do not die of it.
Is Prostate Cancer A Hereditary Cancer
It can be.
Hereditary cancer occurs when a gene mutation is passed down from parent to child. People with hereditary cancer mutations in their family are more likely to have relatives with the same type or other related types of cancer.
Hereditary prostate cancer is generally more aggressive than non-hereditary types, which means that early detection, along with new treatment options, can be lifesaving. Having hereditary cancer can also mean a higher risk for developing more than one cancer and those cancers often occur at an earlier age.
If you do have hereditary prostate cancer, you want to find out early. The answers are in your genes.
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Radiation Therapy And Radiopharmaceutical Therapy
External-beam radiation therapy
Candidates for definitive radiation therapy must have a confirmed pathologic diagnosis of cancer that is clinically confined to the prostate and/or surrounding tissues . Staging laparotomy and lymph node dissection are not required.
Radiation therapy may be a good option for patients who are considered poor medical candidates for radical prostatectomy. These patients can be treated with an acceptably low complication rate if care is given to the delivery technique.
Long-term results with radiation therapy are dependent on stage and are associated with dosimetry of the radiation.
Evidence :
Evidence :
Brachytherapy
Diagnostic Evaluation After Psa Recurrence
No formal guidelines have been published defining the frequency of diagnostic evaluations for patients following BCR who choose to undergo surveillance rather than initiating early hormonal therapy. In the authorsâ opinion, it is reasonable to monitor serum PSA every 3 months and to perform annual technetium-99 bone scans and bi-annual computed tomography scans in patients at high risk of metastatic progression as determined by PSA levels and/or a rapid PSADT of 9 months or less. In one retrospective study describing the natural history of untreated PSA-recurrent prostate cancer after prostatectomy, it was observed that men with a PSADT of 9 months or less had a median metastasis-free survival of 2 years after biochemical recurrence.8 Another analysis from this same population reported that the median PSA value at the time of first radiographic metastasis was 31.4 ng/mL .20 These figures may help to determine whether a particular patient might be at a more imminent risk of metastasis, allowing for more frequent PSA evaluations or imaging tests to be obtained at the treating physicianâs discretion.
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