Early Versus Delayed Treatment
For men who need hormone therapy, such as men whose PSA levels are rising after surgery or radiation or men with advanced prostate cancer who dont yet have symptoms, its not always clear when it is best to start hormone treatment. Some doctors think that hormone therapy works better if its started as soon as possible, even if a man feels well and is not having any symptoms. Some studies have shown that hormone treatment may slow the disease down and perhaps even help men live longer.
But not all doctors agree with this approach. Some are waiting for more evidence of benefit. They feel that because of the side effects of hormone therapy and the chance that the cancer could become resistant to therapy sooner, treatment shouldnt be started until a man has symptoms from the cancer. This issue is being studied.
What Symptoms Should I Look Out For
If your cancer does come back, the first sign is likely to be a rise in your PSA level, rather than any symptoms. And problems will often be side effects of treatment rather than a sign that your cancer has come back.
However, its important to let your doctor or nurse know if you do get any new symptoms or side effects, or are worried that your cancer might have come back. If your cancer has come back and has spread from the prostate to other parts of the body, it can cause symptoms, such as extreme tiredness ” rel=”nofollow”> fatigue), bone pain and problems urinating.
Your doctor or nurse can help find out what might be causing your symptoms and help you manage any side effects. They can also look at your PSA level and do other tests to see whether or not your cancer might have come back.
What other tests might I have?
If your doctor or nurse is concerned about your PSA level or if you have new symptoms that suggest your cancer might have come back, they may recommend that you have some other tests, such as a prostate biopsy, MRI scan, CT scan, bone scan or PET scan.
Your doctor or nurse will explain these tests to you if you need them, or you can get in touch with our Specialist Nurses for more information.
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 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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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.
What Should My Psa Level Be After Treatment
Following surgery , your PSA number should be undetectable after about a month. This is effectively zero PSA, but may not get all the way to zero, given the sensitivity of the test and the fact that other proteins may be misread as PSA proteins. The most widely accepted definition of a prostate cancer recurrence after surgery is a PSA of 0.2 ng/mL or greater on at least two separate occasions.
If youve had radiation therapy, your PSA will likely not drop to zero, as there is some normal, healthy prostate tissue that remains after treatment. Instead, there is a different low PSA level for each patient, called a nadir. The most widely accepted definition is a PSA that has risen from nadir by 2 ng/mL or more. Either way, its important to always use the same lab, if possible, for all of your PSA tests because PSA values can fluctuate somewhat from lab to lab. Defining failure after other forms of therapy like brachytherapy seeds or cryotherapy is more challenging, but similar to that used with external radiation.
If your PSA is rising but doesnt quite meet these definitions, your doctor may recommend an evaluation to see whether your prostate cancer has recurred.
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What Is Prostate Cancer
Prostate cancer develops in the prostatea small gland that makes seminal fluid. It is the second most common type of cancer in men. Prostate cancer usually grows over time and in the beginning stays within the prostate gland, where it may not cause serious harm. While some types of prostate cancer grow slowly and may need minimal or no treatment, other types are aggressive and can spread quickly.
Prostate cancer that is caught early has a better chance of successful treatment.
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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.
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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:
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 byCT, 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.
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Rise In Psa After Radiation And Hormone Treatment
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Results Side Effects And Whats Next
According to their results, the more intensive treatments led to better outcomes. Just over 70% of men in group 1 were still avoiding disease progression after five years, compared with 80.3% of men in group 2 and 87.4% of men in group 3. More specifically, 145 of the men in group 1 developed further PSA elevations during the follow-up period, compared with 104 men in group 2 and 83 men in group 3. Similar trends were observed with respect to how many men developed metastases, or cancer that becomes resistant to hormonal therapy after it begins to spread.
The more intensive treatments also had more short-term side effects, especially diarrhea. But differences in side effects between the three groups disappeared after three months.
The authors emphasized that longer follow-up is still needed to confirm whether adding ADT and pelvic node radiation to PBRT actually lengthens survival. Moreover, the study did not evaluate a newer therapeutic strategy for biochemical relapse, where doctors use novel imaging methods to find exceedingly small metastases throughout the body that they treat directly with radiation.
About the Author
Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
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Diarrhea Flatulence Or Painful Defecation
These symptoms usually occur after the second or third week of treatment. Symptoms will resolve after the treatment ends. During radiation, dietary modification usually helps reduce the frequency and severity of diarrhea. Try to avoid or reduce fried foods, greasy foods and highly spiced foods. Reduce foods with insoluble fiber, such as lettuce and cauliflower, and increase low-fiber and soluable-fiber foods, such as bananas, mashed potatoes, applesauce, white rice, canned or cooked fruits and vegetables.
Maintain your intake of lean proteins, such as turkey, chicken and fish, and increase your fluid intake to avoid dehydration. Using moist toilet paper, baby wipes or sitz baths may help relieve rectal irritation. Your doctor may recommend anti-diarrheal medications. Contact your doctor if you see blood in your stool, if the diarrhea worsens or if you become light-headed or dizzy.
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 Rosenberg’s 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.
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Psa After Radiation For Prostate Cancer
Larry B. Levy, MSOncology
The introduction of prostate-specific antigen as a reliabletumor marker for prostate cancer brought significant changes in theend points used for outcome reporting after therapy. With regard to adefinition of failure after radiation, a consensus was reached in 1996that took into account the particular issues of an intact prostate aftertherapy. Over the next several years, the consensus definition issued bythe American Society for Therapeutic Radiology and Oncology was used and studied. Concerns and criticisms were raised.The sensitivity and specificity of this definition vs other proposals hasbeen investigated, and differences in outcome analyzed and compared.Although the ASTRO definition came from analysis of datasets on external-beam radiation and most of the work on this topic has been withthis modality, failure definitions for brachytherapy must be exploredas well. The concept of a universal definition of failure that might beapplied to multiple modalities, including surgery, should also be investigated,at least for comparative study and research purposes.
- 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
Comparing Failure Definitions
Salvage Androgen Ablation Therapy
Hormonal manipulation is likely to be the therapy most commonly administered to patients with recurrent prostate cancer and yet it has been the least well studied to date. A total of 54% of urologists and radiation oncologists in one study recommended androgen ablation or observation with delayed androgen ablation for patients with recurrent prostate cancer.22 Certainly, androgen ablation is not a curative intervention, and therefore the optimal timing of its application is uncertain. The cancer-specific survival after androgen ablation administered upon identification of local-only recurrence in one series of 72 patients was 70 and 84 months.23 Although this relatively short survival may be a reflection of the advanced stage of disease of these patients or the intrinsic response rate of prostate cancer to hormonal therapy, the more morbid attempts at salvage therapy, such as radical prostatectomy, cryoablation, and brachytherapy, should demonstrate improved survival beyond that of androgen ablation in order to be reasonably administered to patients with recurrent prostate cancer.
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Study Reveals Importance Of Testing Psa Level During 1st Months After Radiotherapy
Shared by Will Sansom
San Antonio The success or failure of radiation therapy for prostate cancer may be predicted as early as three months after completion of therapy, rather than waiting one to two years as conventional wisdom indicates, a new study from The University of Texas Health Science Center at San Antonio suggests.
The research also found that men whose blood PSA values stayed above important threshold levels three months after radiotherapy were 30 percent more likely to suffer a recurrence of cancer than men whose PSA values sank lower. The authors studied the prognostic value of early PSA changes in order to establish a model for analyzing improvements in radiation therapy, including intensity-modulated radiation therapy, a rapidly developing technique that pinpoints tiny radiation beams to destroy tumors but spare surrounding healthy tissues.
Dr. Cavanaugh and his co-authors studied blood samples of 855 men treated at the Cleveland Clinic with external beam radiotherapy. They compared the early PSA response to the clinical outcome of the patients. The average patient in the study was followed for more than six years. None of the men underwent hormone therapy, which may lower PSA levels. The study also did not examine men whose cancers had spread outside the prostate and who have a much worse prognosis for survival.
Side Effects Of Treatment
Treatments for prostate cancer can cause side effects, which might carry on after your treatment has finished. Some side effects can even start several months or years after treatment finishes.
Side effects will affect each man differently you may not get all the possible side effects from your treatment.
Read more about:
Managing side effects
Side effects can affect your day-to-day life, but there are treatments for them, as well as things you can do to manage them yourself. Its important to speak to your doctor, nurse or GP about them.
If youre having problems with a side effect, you might have a meeting with your doctor or nurse to work out what support you need. They may refer you to someone who can give you more advice and support.
Read more about managing the side effects of prostate cancer treatment.
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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.