Radical Prostatectomy: Conclusions And Recommendations
When faced with an initial detectable PSA after radical prostatectomy, repeat evaluation of serum PSA is warranted to rule out laboratory error. If, on repeat testing, the serum PSA remains in the detectable range, our initial evaluation would consist of a thorough history and digital rectal examination. We do not routinely perform biopsy of the vesicourethral anastomosis due to both the lack of beneficial information obtained and the potential morbidity of the procedure itself.
In men felt to be at risk for distant recurrence based on either pathologic features or PSA kinetics, a radiographic evaluation for early signs of metastatic disease is warranted. Although there is a low probability of finding significant disease in men with PSA levels under 10 ng/mL, we feel that these studies function as an initial baseline study with which to compare subsequent studies. These studies are then repeated on an annual basis in the asymptomatic patient or earlier if there are signs or symptoms suggestive of distant disease. Unless the patient is being considered for possible adjuvant local therapy, cross-sectional imaging of the abdomen and/or pelvis is not routinely performed.
Medical Procedures Can Cause Psa To Rise
“Anything that traumatically interferes with the architecture around the prostate gland can make PSA go up,” says Dr. Milner. “One of the most common causes of significantly high PSA from this type of trauma is the placing of a catheter into the bladder.”
Another cause is a prostate or bladder exam that involves passing a scope or taking a biopsy.
“Since it takes about two to three days for PSA to go down by half, you should wait two to three weeks after this type of trauma to do a PSA test,” Milner says.
Radical Prostatectomy Perineal Approach
YouÃ¢ll be placed in a supine position in which the hips and knees will be fully bent with the legs spread apart and elevated with the feet resting on straps. Stirrups will be placed under your legs for support.
An upside-down, U-shaped incision will be made in the perineal area .
The doctor will try to minimize any trauma to the nerve bundles in the prostate area.
The prostate gland and any abnormal-looking tissue in the surrounding area will be removed.
The seminal vesicles may be removed if thereÃ¢s concern about abnormal tissue in the vesicles.
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Psa Increases After Surgery
If your PSA is elevated after prostate cancer surgery, it can be a false positive result. It may take some time for your blood to show the results of the surgery. During your recovery, your physician will monitor the level closely. Since results immediately after surgery can be skewed, any test results should be repeated after you have fully healed and recovered. Since each patient is different, this recovery time may take a few weeks or even up to a few months. During that time, your physician will let you know how often to test your PSA. Once you fully recover, your physician may ask for further tests to determine the cause of the elevated PSA and formulate a plan for any additional treatment.
What Do The Test Results Mean
PSA tests can be difficult to interpret. Tests can also vary from laboratory to laboratory. To ensure accurate comparison, its important to use the same lab each time youre tested.
If your PSA level is low and not rising after repeated tests, its probably not a cancer recurrence. Thats because other cells in your body can produce small amounts of PSA.
Ideally, your post-prostatectomy PSA will be undetectable, or less than 0.05 or 0.1 nanograms of PSA per milliliter of blood . If thats the case, your doctor may call it a remission.
If the result is greater than or equal to 0.2 ng/mL and its risen on two separate tests taken at least two weeks apart, its called a biochemical relapse. You still have PSA in your bloodstream. Theres a chance that cancer has recurred.
A PSA level higher than that may indicate a locally advanced tumor.
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Should You Panic About Prostate Cancer If You Learn That Your Psa Is Shockingly High
Is it at all possible for a man who does not have prostate cancer to have a VERY high PSA?
Absolutely. Many benign conditions can cause a very elevated PSA, including recent surgeries, trauma or catheterization due to urinary retention, says Michael Herman, MD, director of urologic oncology at South Nassau Communities Hospital in Oceanside, NY.
The most common benign cause of a very high PSA is a urinary tract infection or prostatitis.
Also, some people simply have an elevated PSA without prostate cancer. Just because someone has a high PSA does not mean they have prostate cancer, but it does need to be evaluated very carefully.
PSA stands for prostate specific antigen. High levels are correlated to the likelihood of prostate cancer, but its not 100 percent reliable.
This is why a man can have a PSA in the normal range and still be diagnosed with the disease.
Not All Psa Recurrences Can Mean Recurrent Prostate Cancer
And although experiencing rising PSA after prostatectomy can be frightening, all hope is not lost. Many reoccurrences are still manageable and a cure is possible with the right treatment plan. An important point to remember is that while radiation is possible secondary treatment after surgery, the opposite is not true.
Surgery is rarely possible after radiation as primary treatment. For this reason, choosing the right initial treatment for prostate cancer is crucial in your long-term care. Speak to your urologist about your specific risk factors if you have a PSA recurrence after prostatectomy and map out the right course of treatment for you.
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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
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.
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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.
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When Should I Get A Psa Test
The guidelines below are adapted from the NCCN Clinical Practice Guidelines In Oncology for Prostate Cancer Early Detection. Please use these guidelines to have a discussion with your physician about your personal risk and make a plan for screening.
- If you are between ages 45 and 75:
- Discuss the risks and benefits of prostate cancer screening with your doctor, have a baseline PSA, and consider a baseline DRE
- If your PSA is below 1 ng/mL and your DRE is normal, repeat testing every 2-4 years
- If your PSA is between 1 and 3 ng/mL and your DRE is normal, repeat testing every 1-2 years
- If your PSA is greater than 3 ng/ML or your DRE is very suspicious, your doctor may suggest additional testing or a biopsy
Standard Care Post Treatment
After radiation treatment, doctors typically measure the PSA level every three months in a patient for the first year, and every six months thereafter. During the first year or two, patients normally experience a decline in their PSA blood test score. If the PSA level steadily decreases and stays relatively level after reaching its low point, then the treatment is considered a success.
However, if the PSA reaches a low point and then begins to steadily rise, the patient may be having a reoccurrence of the cancer, which could require additional treatments such as a hormonal blockade.
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Sites Of Highest Concentrations
PSA is found primarily in prostate epithelial cells and in the seminal fluid. The exact mechanism by which PSA gains access to the serum is unknown, but a possible mechanism has been suggested.
The lumen of the prostate gland contains the highest concentration of PSA in the body. A number of barriers exist between the glandular lumen and the capillaries, including the basement membrane of the glands, the prostatic stroma, and the capillary endothelial cell. Diseases such as infection, inflammation, and cancer may produce a breakdown in these barriers, allowing more PSA to enter the circulation.
PSA levels can rise dramatically with a prostate infection, but they return to the reference range after the infection has healed. A vigorous prostate massage also can produce a brief elevation of the PSA level.
Low concentrations of PSA have been identified in urethral glands, endometrium, normal breast tissue, breast milk, salivary gland tissue, and the urine of males and females. PSA also is found in the serum of women with breast, lung, or uterine cancer and in some patients with renal cancer.
Risk Prostate Cancer And Being 70 To 80 Years Of Age
So a relatively new article in Reviews in Urology caught your Sitemasters eye this morning and worried him because it seemed to be communicating a conclusion of questionable accuracy, which we will explore below. And if we have misinterpreted the data provide in the paper, we are more than willing to be corrected.
The new paper by Shah and Ioffe is based on a retrospective analysis of data from 5,100 patients of between 70 and 80 years, all of whom received radiation therapy of some type for the treatment of prostate cancer over a 10-year period from 2005 to 2015. The authors state that:
Multiple studies in peer-reviewed journals document that men 70 years and older have more prevalence of prostate cancer, more high-grade disease, more metastases, and more prostate cancer-specific deaths compared with men under 70 years.
That they have a higher prevalence of prostate cancer and more prostate cancer-specific deaths than men of < 70 years is probably undisputed, for the simple reason that they are older, incidence of prostate cancer is well understood to be age-related, and many such patients may well have at least micrometastatic disease by the time they are initially diagnosed . Whether they really have more high-grade disease at time of diagnosis, however, is not quite as clear.
So the first thing that worries us about this study is that it appears to include exclusively men who received treatment for prostate cancer. The authors state this very clearly:
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What Is Done If A Screening Test Shows An Elevated Psa Level
If someone who has no symptoms of prostate cancer chooses to undergo prostate cancer screening and is found to have an elevated PSA level, the doctor may recommend another PSA test to confirm the original finding. If the PSA level is still high, the doctor may recommend that the person continue with PSA tests and digital rectal exams at regular intervals to watch for any changes over time .
If the PSA level continues to rise or a suspicious lump is detected during a DRE, the doctor may recommend additional tests to determine the nature of the problem. These may include imaging tests, such as magnetic resonance imaging or high-resolution micro-ultrasound.
Alternatively, the doctor may recommend a prostate biopsy. During this procedure, multiple samples of prostate tissue are collected by inserting hollow needles into the prostate and then withdrawing them. The biopsy needle may be inserted through the wall of the rectum or through the perineum . A pathologist then examines the collected tissue under a microscope. Although both biopsy techniques are guided by ultrasound imaging so the doctor can view the prostate during the biopsy procedure, ultrasound cannot be used alone to diagnose prostate cancer. An MRI-guided biopsy may be performed for patients with suspicious areas seen on MRI.
Prostate Cancer Surgery Wont Boost Survival In Men With Early
Men with early-stage prostate cancer often face a difficult choice as to treatment: Do they opt for radiation, surgery or watchful waiting to see if the cancer gets worse.
A new study in the New England Journal of Medicine finds men who opt to surgically remove their prostate gland a procedure called a radical prostatectomy are no less likely to die than men who choose wait and monitor their symptoms to see if the cancer progresses.
The study adds to the ongoing debate surrounding prostate-specific antigen testing and whether the tests pick up cancers that may be too slow-growing to ever cause a problem.
In May, the U.S. Preventive Services Task Force, a panel of advisors on government medical guidelines, reviewed existing research and reported in its final recommendation that healthy men of all ages should not take a PSA test because the potential harms from a positive test outweigh the benefits from catching the cancer early.
The study tracked 731 men with early-stage prostate cancer found through PSA testing, average age of 67, who agreed to be randomized to either receive radical prostatectomy or just observation from a doctor between November 1994 through January 2002. The men were followed-up with by January 2010 to see how they fared.
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What Is Considered Rising Psa After Prostatectomy
After radical prostatectomy, it takes the PSA quantities in patients blood to drop to undetectable levels in four to eight weeks. Within this timeframe, the doctors will perform the first PSA test after prostatectomy in order to determine whether there are any signs left of prostate cancer.
So, the question is: Can you have a PSA reading after the surgical removal of the prostate gland? Since PSA is a type of protein produced only by prostate cells and prostate cancer cells, when you eliminate one of the two sources of PSA, any trace of PSA presence can indicate the only source left: a prostate tumor.
This usually happens when the tumor is advanced at the time of surgery and could have already spread its cancer cells to other parts of the body.
It is considered elevated PSA after prostatectomy a PSA greater than 0.2 ng/ml. If the prostate cells are grown enough to generate detectable levels of PSA, this could be an alarming point both for the patient and the doctor.
It is important to note that a 0.2 ng/ml level of PSA is not alarming when first diagnosed with prostate cancer. Thats because the prostate gland generates a certain level of PSA by itself, even in healthy men. However, the same reading becomes a reason for concern after a radical removal of the prostate gland. The PSA level after prostatectomy is expected to be zero or at undetectable levels unless the prostate cancer cells had already spread to other parts of the body.
What Is Screening For Prostate Cancer
Some men get a PSA test to screen for prostate cancer. Talk to your doctor, learn what is involved, and decide if a PSA test is right for you.
Cancer screeningexternal icon means looking for cancer before it causes symptoms. The goal of screening for prostate cancer is to find cancers that may be at high risk for spreading if not treated, and to find them early before they spread.
There is no standard test to screen for prostate cancer. Two tests that are commonly used to screen for prostate cancer are described below.
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What Is A Psa Test
PSA is a protein that is made by all prostate cells, whether they are normal or cancerous. A PSA test measures the level of PSA in a mans blood and generally reflects the volume of prostate tissue in the body.
Since prostate cancer can increase the level of PSA in the blood as it is progressing, a high PSA is associated with higher risk of having the disease. Therefore, many doctors have used the test to help determine whether a man is harboring the disease. Since the test was developed, several professional organizations have recommended that men over age 50 undergo PSA testing, often in addition to a digital rectal exam, to aid in early detection of the disease.
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What Your Psa Numbers Mean
The PSA test measures the level of prostate-specific antigen in your blood. The lab will report your results in nanograms of PSA per milliliter of blood.
Only the prostate gland releases PSA, so your numbers should drop to almost zero within 4 weeks after your surgery. A test result above 0.2 ng/mL a few months after your procedure could be a sign that your prostate cancer has come back. This is called a biochemical recurrence.
If your number is higher than it should be, it doesn’t mean you definitely have cancer. Results can vary from person to person and from lab to lab. A more accurate way to find out if you have cancer is to test how quickly your PSA levels rise.
A PSA velocity test measures the change in your PSA levels over time. PSA doubling time tests calculate how long it takes for your PSA levels to double. If they rise quickly, it could be a sign of cancer. Knowing how fast yours is rising can help your doctor predict whether your cancer will spread, and if — or when — you’ll need treatment.
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