Rising Psa After Prostatectomy Should You Worry
Dr. David Samadi says that elevated levels of the PSA after prostatectomy are very rare incidents that come up every once in a while.
The main benefit of surgery is that you can remove entire cancer, while the patients know exactly what type of cancer they have and how much cancer, so the PSA after surgery should be undetectable or zero. This is why it is better to choose surgery over radiation.So, first, you need to have the surgery, and only if the PSA levels come back after the prostatectomy, which can happen 5% to 10% of the time, only then radiation should be used as a form of treatment for persistent PSA after prostatectomy. It is very difficult to have surgery after radiation. Prostate surgery outcomes are usually positive in the hands of an experienced surgeon.
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.
Salvage Radiotherapy And Androgen Deprivation Therapy
GETUG-AFU 16 was the first randomized trial comparing SRT vs. SRT and short ADT as salvage treatment for biochemical recurrent prostate cancer after radical prostatectomy and was presented in abstract form at the American Association of Clinical Oncology 2015 Annual Meeting. The trial randomized 743 patients most of them having high intermediate risk features . The 5-year PFS was 62.1% vs. 79.6% for SRT and SRT + ADT, respectively . The 5-year OS was 94.8% for RT vs. 96.2% for SRT + ADT . Cause of death was progressive disease in 2.1% of the patients on SRT arm vs. 0.8% in the SRT + ADT arm. Acute toxicities occurred more frequently in SRT + ADT arm . This trial will require longer follow-up to see if the benefits observed in progression-free survival translate into the same OS benefit .
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What Are The Side Effects Of Hormone Therapy For Prostate Cancer
Because androgens affect many other organs besides the prostate, ADT can have a wide range of side effects , including:
- loss of interest in sex
Studer UE, Whelan P, Albrecht W, et al. Immediate or deferred androgen deprivation for patients with prostate cancer not suitable for local treatment with curative intent: European Organisation for Research and Treatment of Cancer Trial 30891. Journal of Clinical Oncology 2006 24:18681876.
Zelefsky MJ, Eastham JA, Sartor AO. Castration-Resistant Prostate Cancer. In: Vincent T. DeVita J, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenbergs Cancer: Principles & Practice of Oncology, 9e. Philadelphia, PA: Lippincott Williams & Wilkins 2011.
Smith MR, Saad F, Chowdhury S, et al. Apalutamide and overall survival in prostate cancer. European Urology 2021 79:150158.
Larry B. Levy, MSOncology
- Biochemical failure is not justificationper se to initiate additionaltreatment. It is not equivalent to clinicalfailure. It is, however, an appropriateearly end point for clinical trials.
- No definition of PSA failurehas, as yet, been shown to be a surrogatefor clinical progression or survival and
Deficiencies in theASTRO Definition
Persistent Psa After Radical Prostatectomy How To Interpret The Data
Although PSA should be 0 after surgery, some patients are faced with one of two scenarios: PSA recurrence or PSA persistence.
Since other cells in the body can produce small quantities of PSA, the test would raise no concerns if the PSA is 0.1 after prostatectomy. However, any results higher than this can lead to one of the aforementioned scenarios.
Persistent PSA after radical prostatectomy is the detection of a PSA higher than 0.1 nanograms of PSA per milliliter of blood . The distinction is that the PSA has not recurred, but rather persisted after surgery.
The key difference this small distinction makes is the prediction of the course the disease will take. A persistent PSA after radical prostatectomy or other forms of treatment can, unfortunately, mean cancer has progressed and metastasized. In many cases, the best course of secondary treatment is hormone therapy with the purpose of shrinking the size of cancer tumors.
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Psa Levels 5 Years After Radiation Therapy Predict Survival From Prostate Cancer
The level of prostate-specific antigen in the blood of prostate cancer patients five years after radiation treatment can help predict their disease-free survival for the next several years, according to the October 2002 issue of the International Journal of Radiation Oncology, Biology and Physics, the official journal of ASTRO, the American Society for Therapeutic Radiology and Oncology.
Researchers have discovered that patients who maintain very low five-year PSA levels have a very low probability of relapse at 10 years and beyond.
The study identified 328 men treated with external beam radiation therapy to the prostate who were biochemically disease-free five years after treatment. The median follow-up was 7.4 years. The patients were divided into four groups according to their PSA values five years after treatment: PSA less than or equal to 0.5, 0.5 to 1.0, 1.0 to 2.0 and 2.0 to 4.0 ng/mL. PSA progression-free rates were calculated in each subgroup at 10 years after treatment.
Researchers concluded that when PSA levels remain low five years after external beam radiation therapy, the great majority of patients will be biochemically disease-free at 10 years. The hazard rates of biochemical progression in the 6 to 10 years after treatment are low and are comparable to rates seen when prostatectomy is the chosen treatment modality.
How Are Hormone Therapies For Prostate Cancer Administered
LHRH agonists, the most commonly used drug class for hormone therapy, are given in the form of regular shots: once a month, once every three months, once every four or six months, or once per year. These long-acting drugs are injected under the skin and release the drug slowly over time. LHRH antagonists include degarelix and relugolix, an oral form.
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What Other Tests Do I Need
After prostatectomy, youll probably have a PSA test in about six weeks or so. Your doctor will recommend a follow-up schedule, usually every three months for two years. Depending on the results, you may need to test once or twice a year thereafter. Testing may be more frequent if it appears to be rising.
If your PSA levels are high and you have symptoms such as bone pain, imaging tests can be used to determine if cancer has spread. These may include bone scans and CT scans. If a mass is found, a biopsy can determine if its cancerous.
You might not need treatment right away. If youve had multiple PSA tests and it appears that your PSA level is rising, a number of other factors determine the next steps. These factors include:
- age and life expectancy
- if cancer has spread and where
- previous treatments
Radiation therapy after prostatectomy, also known as salvage radiotherapy, can be quite effective after a prostatectomy. External beam radiation can be delivered directly to the area around where the prostate was. The goal is to destroy prostate cells that may have been left behind after surgery. This lowers the risk of recurrence and metastasis, or of the cancer spreading.
Metastatic prostate cancer may not be curable, but there are treatments to slow progression and manage symptoms. Treatments may include:
Theres More To Know About Rising Psa After Treatment
The goal is to help you focus on what you need to know about rising PSA levels so you can hold meaningful, regular dialogues with all members of your health care team as you find the treatment path thats right for you. Here are some questions you may have about the complexities of treatment in these casesand some answers that will help prepare you for the ongoing discussions and decisions to be made to keep your prostate cancer under control.
Common Thoughts And Feelings
You may feel all sorts of things after you finish treatment. Some men are relieved and feel ready to put the cancer behind them and get back to normal life. But others find it difficult to move on. Adjusting to life after cancer can take time.
For some men, the emotional impact of what they have been through only hits them after they have finished treatment. You might feel angry for example, angry at what you have been through, or about the side effects of treatment. Or you might feel sad or worried about the future.
Follow-up appointments can also cause different emotions. You might find it reassuring to see the doctor or nurse, or you may find it stressful, particularly in the few days before your appointments.
Worries about your cancer coming back
You may worry about your cancer coming back. This is natural, and will often improve with time. There are things you can do to help manage your concerns, such as finding ways to reduce stress. Breathing exercises and listening to music can help you relax and manage stress. Some people find that it helps to share what theyre thinking with somebody else, like a friend. If you are still struggling, you can get help for stress or anxiety on the NHS you can refer yourself directly to a psychological therapies service or ask your GP.
If youre worried about your PSA level or have any new symptoms, speak to your doctor or nurse. If your cancer does come back, you’ll be offered further treatment.
How Long Will Hormone Therapy Keep My Cancer In Check
Hormone therapy typically is effective for only a few years, but this period can range from several months to many decades. For many men who were using an antiandrogen in combination with an LHRH agonist or antagonist, stopping the antiandrogen, or antiandrogen withdrawal, is the most common first step in secondary hormone therapy. Between 10%30% of men will respond to anti-androgen withdrawal, which lasts on average 3 to 5 months. However, inevitably, additional therapies will need to be added even if this withdrawal response occurs. Continuing the LHRH agonist or antagonist and adding a new therapy in combination can improve survival and maintain or improve quality of life.
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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.
An Increased Psa Level
A biochemical relapse is when your PSA level rises after having treatment that aims to cure your cancer.
You might not need to start treatment straight away. Your doctor will continue to monitor your PSA levels regularly to see if your PSA rises quickly or stabilises. You might have a scan if your PSA rises quickly.
The choice about whether to have treatment and what treatment to have will depend on:
- the treatment you have already had
- your general health
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During Watchful Waiting Or Active Surveillance
If you choose observation or active surveillance, your PSA level will be monitored closely to help decide if the cancer is growing and if treatment should be considered.
Your doctor will watch your PSA level and how quickly it is rising. Not all doctors agree on exactly what PSA level might require further action . Again, talk to your doctor so you understand what change in your PSA might be considered cause for concern.
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, or if it rises for three PSA tests in a row within six months, 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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Cancer That Clearly Has Spread
If the cancer has spread outside the prostate, it will most likely go to nearby lymph nodes first, and then to bones. Much less often the cancer will spread to the liver or other organs.
When prostate cancer has spread to other parts of the body , hormone therapy is probably the most effective treatment. But it isnt likely to cure the cancer, and at some point it might stop working. Usually the first treatment is a luteinizing hormone-releasing hormone agonist, LHRH antagonist, or orchiectomy, sometimes along with an anti-androgen drug or abiraterone. Another option might be to get chemotherapy along with the hormone therapy. Other treatments aimed at bone metastases might be used as well.
The Risk Of Your Cancer Coming Back
For many men with localised or locally advanced prostate cancer, treatment is successful and gets rid of the cancer. But sometimes not all the cancer is successfully treated, or the cancer may have been more advanced than first thought. If this happens, your cancer may come back this is known as recurrent prostate cancer.
One of the aims of your follow-up appointments is to check for any signs that your cancer has come back. If your cancer does come back, there are treatments available that aim to control or get rid of the cancer.
Your doctor cant say for certain whether your cancer will come back. They can only tell you how likely this is.
When your prostate cancer was first diagnosed, your doctor may have talked about the risk of your cancer coming back after treatment. To work out your risk, your doctor will have looked at your PSA level, your Gleason score, the stage of your cancer and your Cambridge Prognostic Group . If your prostate has been removed, it will have been sent to a laboratory for further tests. This can give a better idea of how aggressive the cancer was and whether it is likely to spread. If you dont know these details, ask your doctor or nurse.
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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.
Radiation Therapy After Radical Prostatectomy: What Has Changed Over Time
- 1Urology Unit, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
- 2Department of Urology, Medical University Innsbruck, Innsbruck, Austria
- 3Division of Surgery and Interventional Science, University College London, London, United Kingdom
- 4Department of Urology, University College London Hospital, London, United Kingdom
- 5Department of Urology, Ludwig-Maximilians-University of Munich, Munich, Germany
- 6Department of Urology, San Giovanni Battista Hospital, University of Turin, Turin, Italy
- 7Department of Radiation Oncology, Udine General Hospital, Udine, Italy
- 8Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
- 9Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- 10Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- 11Department of Urology and Pediatric Urology, Mainz University Medicine, Mainz, Germany
- 12Department of Urology, CHUV Lausanne, Lausanne, Switzerland
- 13Department of Urology, Antonius Hospital, Utrecht, Netherlands
- 14Department of Urology, University Hospital Essen, Essen, Germany
- 15Division of Nuclear Medicine, IEO European Institute of Oncology IRCCS, Milan, Italy
- 16University Hospital Zürich, Zurich, Switzerland
- 17Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
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