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Best Treatment For Recurrent Prostate Cancer

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Which Treatment Should I Have

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Your doctor will recommend a treatment based on the location of your cancer and which treatment you had before.

When the cancer is only in your prostate:

  • If you had surgery before: You can now have radiation therapy, sometimes combined with hormone therapy. Or you might get hormone therapy on its own.
  • If you had radiation therapy before: Your options include cryotherapy and surgery. Doctors don’t recommend getting radiation a second time because it can cause severe side effects. Brachytherapy may still be an option if you had external beam radiation the last time.

If cancer has spread to other parts of your body:

  • Hormone therapy is often the treatment for recurrent prostate cancer that is advanced. You may get chemotherapy, too.

Timing And Duration Of Adt

Physicians wishing to treat BCR prostate cancer patients with ADT face 2 key timing questions: 1) whether to initiate ADT immediately upon PSA recurrence or to defer its use until after clinical/radiographic progression occurs, and 2) whether to use continuous administration of ADT or intermittent cyclic administration of ADT. As of December 2012, the American Society of Clinical Oncology had not provided definitive guidelines addressing either of these questions. We will review the relevant clinical trial data that may guide clinicians with respect to these 2 issues.

Additional Treatment After Surgery

Additional treatment can come with one of two approaches: treatment given as adjuvant therapy , or as salvage therapy . In the modern era, most additional treatment is given as salvage therapy because firstly this spares unnecessary treatment for men who would never experience recurrence, and secondly because the success rates of the two approaches appear to be the same.

Regardless of whether an adjuvant or salvage therapy approach is taken, the main treatment options following biochemical recurrence are:

  • Radiotherapy this is the commonest approach. Because scans dont show metastatic deposits until the PSA is more than 0.5 ng/ml and because radiotherapy is more effective when given before this level is reached, the radiotherapy energy is delivered to the prostate bed. This is because we know that this is the commonest site of recurrence in most men, and that 80% of men treated in this way will be cured.
  • Active surveillance this is appropriate for a very slowly-rising PSA in an elderly patient who has no symptoms.
  • Hormonal therapy in many ways this is the least appealing option as it causes symptoms but does not cure anyone, although it does control the recurrence and lower the PSA.

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Considering Complementary And Alternative Methods

You may hear about alternative or complementary methods that your doctor hasnt mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctors medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be harmful.

Be sure to talk to your cancer care team about any method you are thinking about using. They can help you learn what is known about the method, which can help you make an informed decision.

Detecting Prostate Cancer Recurrence

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If you have recurrent prostate cancer, its usually detected during follow up appointments. Once you undergo initial prostate cancer treatment, youll need to see your urologist once every few months to monitor your PSA levels and discuss any new symptoms. If your PSA levels begin to rise, it can be an indication that the cancer has returned. Your doctor will use imaging tests to try and locate the cancer and determine the best course of action for a second round of treatment. Tools for detection are continually improving, so be open to suggestions from your doctor.

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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.

Prostate Cancer Is A Disease In Which Malignant Cells Form In The Tissues Of The Prostate

The prostate is agland in the malereproductive system. It lies just below the bladder and in front of the rectum . It is about the size of a walnut and surrounds part of the urethra . The prostate gland makes fluid that is part of the .

Prostate cancer is most common in older men. In the U.S., about 1 out of 8 men will be diagnosed with prostate cancer.

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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

What Is Advanced Prostate Cancer

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Most prostate cancers are slow growing. However, during the illness, prostate cancer may progress. When PSA starts to rise in the months or years following surgery or radiation therapy for localized prostate cancer, it means that cancer cells remain in the body and there may be a recurrence of the disease. This is called advanced prostate cancer. At this time, advanced prostate cancer is generally not curable, although a variety of treatments can control the cancer, reduce symptoms, and improve and maintain quality of life.

Locally advanced prostate cancer is cancer that has grown through the outer wall of the prostate gland and into neighboring tissue and has returned after attempts at local treatment. Locally advanced prostate cancer has not spread into lymph nodes or to other organs.

Metastatic prostate cancer is prostate cancer that has spread to other parts of the body, particularly the bones or lymph nodes.

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Frequent Urination Burning With Urination And Difficulty Urinating

These are the most common complaints. Occasionally the urinary stream will weaken. Generally these symptoms are managed with medications to help the bladder function better or eliminate burning. Rarely, your doctor may order a urine test. Symptoms will resolve after the end of treatment. Contact your doctor if you see blood in your urine or if you are unable to urinate.

Repurposed Antidepressant Could Be A New Treatment For Recurrent Prostate Cancer

A new interdisciplinary USC study shows that an antidepressant in use for decades, repurposed to fight prostate cancer, could help patients whose disease has returned following surgery or radiation.

The drug an MAO inhibitor called phenelzine represents a potential new treatment direction with fewer side effects for men with recurrent prostate cancer, researchers said.

To our knowledge, this study is the first clinical trial of an MAO inhibitor in cancer patients, said senior author Jean Shih, PhD, a University Professor at the USC School of Pharmacy who has studied the enzyme MAO, or monoamine oxidase, for four decades.

The research appears in the journal Prostate Cancer and Prostatic Diseases.

If our findings are confirmed, this could part of a new avenue for patients that could avoid undesirable side effects of standard therapies, said first author Mitchell Gross, MD, PhD, a medical oncologist and research director at the Lawrence J. Ellison Institute for Transformative Medicine of USC. Gross and Shih have been collaborating for several years to bring her research out of the lab and into the clinic.

In this study, 11 of 20 participants had a measurable decline in their PSA levels after 12 weeks of twice-a-day treatment, with the greatest decline in PSA being a 74% drop. PSA stands for prostate-specific antigen its a biomarker for prostate cancer circulating in the blood.

How MAO inhibitors can help prostate cancer patients

Antidepressant lowers PSA levels

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Side Effects Of Radiation Therapy

Compared to earlier radiation methods, these modern techniques reduce the chance of urinary and bowel problems.

With several treatment options available, your doctor will work with you to develop and oversee a treatment plan that precisely addresses your prostate cancer while minimizing the risk to surrounding tissues.

This is why it is important to choose an experienced radiation oncologist who specializes in the management of prostate cancer. High volume centers where practitioners have significant experience and treat large numbers of patients with prostate cancer may be associated with good outcomes and fewer lasting problems related to treatment. The majority of patients who undergo radiation do not have permanent effects on bowel or urinary function, and patients who develop erectile difficulty after these therapies can often be treated successfully with medications such as sildenafil or tadalafil.

Radical Prostatectomy vs. Radiation: How to Compare the Results

Making a decision about prostate cancer treatment is not easy. When considering radiation therapy or radical prostatectomy, one of your top concerns is seeking reassurance that your cancer will be cured following treatment.

Comparison Of Curative Treatments

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Active surveillance, radiation therapy, and surgery all have advantages and disadvantages .13,2427 A randomized controlled trial of 1,643 men in Great Britain compared active surveillance, radical prostatectomy, and external beam radiation therapy for treatment of clinically localized prostate cancer over a median of 10 years.24 There were 17 prostate cancerspecific deaths overall: eight in the active-surveillance group , five in the radical prostatectomy group , and four in the EBRT group . There were no significant differences among groups in prostate cancerspecific mortality or all-cause mortality. Surgery and radiation therapy were associated with lower incidences of disease progression than active surveillance. No trials have compared treatment outcomes by race or ethnicity.

Summary of Curative Treatment Options for Localized Prostate Cancer

Radical prostatectomy

Information from references 13, and 24 through 27.

Summary of Curative Treatment Options for Localized Prostate Cancer

Radical prostatectomy

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Fewer Doses In More Places

At the same time, over at The Institute of Cancer Research in London, a team of researchers funded jointly by Movember and Prostate Cancer UK is exploring whether a particular type of radiotherapy called stereotactic body radiotherapy can nip recurrence in the bud.

Unlike traditional radiotherapy, which might be done in around 20 small doses over several weeks, SBRT delivers larger doses of radiation in around five visits, making the process a lot less stressful for men undergoing the treatment.

The team has previously found that using SBRT on the prostate is safe and effective so they now want to improve it further. They have just begun a new trial called PACE-NODES to see whether giving the treatment to the lymph nodes and the prostate, rather than just the prostate, can reduce the risk of the cancer returning.

If successful, this research could give men the option of a more convenient new treatment that also reduces the risk of their cancer coming back.

What Are The Symptoms

The symptoms depend on where the cancer is and how large it is. The most common places for breast cancer to spread are within the breast or to the nearby chest wall or to the liver, lungs, or bones. Common symptoms include a lump in your breast or on your chest wall, bone pain, and shortness of breath.

Or you may not have any symptoms. Sometimes recurrent or metastatic breast cancer is found with an X-ray or a lab test.

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Castration Resistant Or Hormone

Treatment of prostate cancer with ADT may control the growth of the cancer for several years. Eventually, however, most prostate cancers stop responding to ADT and begin to grow again. Cancers that grow in spite of ADT are called hormone-refractory and if widespread are referred to as metastatic castration resistant prostate cancer . Treatment options for CRPC may include additional ADT, precision cancer medicines, chemotherapy, immunotherapy or local radiation therapy for the purpose of alleviating symptoms, or participation in clinical studies evaluating new treatments. The choice of treatment is influenced by the types of previous therapy received, the overall health of the individual and the goals of therapy.

Diarrhea Flatulence Or Painful Defecation

Tracking Recurrent Cancer | Ask a Prostate Expert, Mark Scholz, MD

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.

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Are There Side Effects Of The Combination Approach

There is a slightly higher chance that patients who receive the combined therapy will have rectal irritation or urinary side effects. This is common with prostate cancer radiation therapy because the radiation can damage cells in the tissues surrounding the prostate. But at MSK, we routinely use sophisticated computer-based planning techniques that help us reduce the dose given to normal tissues such as the rectum, bladder, and urethra, lessening the chances of side effects and complications. We have also found that, when treating with the combined approach, using the high-dose-rate brachytherapy compared to low-dose-rate brachytherapy may have less in the way of side effects.

In addition, at MSK, we routinely use a rectal spacer gel, which we inject between the prostate and the rectum while the patient is under mild anesthesia, to create a buffer between these two tissues. By creating this space, we can further reduce the dose of radiation the rectum is exposed to. This leads to fewer side effects for the patient. The rectal spacer gel is biodegradable and dissolves on its own within the body after a few months.

Remission And The Chance Of Recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.

A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someone’s risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.

When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA recurrence or biochemical recurrence.

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What The Results Showed

What Chesnut and his colleagues wanted to know was if the mens pre-operative findings were consistent with tumor details in their surgically removed prostates. And that turned out to be the case. The men truly did have treatable index lesions without other aggressive cancer, meaning that the biopsy and MRI results had accurately predicted PGA eligibility. Moreover, six additional men were found to be eligible for PGA based on tumor slide analysis, even though the pre-operative and MRI evidence had suggested otherwise.

Given that, the authors concluded that 21 of the initial 77 men, or 27% in all, had recurring prostate cancer that was amenable to PGA.

While the results are promising, the authors also cautioned that, given the small number of men evaluated and other study limitations, they are currently unable to recommend PGA as treatment for recurring prostate cancer outside of clinical trials.

The authors have addressed a very important problem and one that has no easy answers, which is what to do about recurrent or persistent prostate cancer following radiation therapy, says Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

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