Immediate Radiation When Psa Levels Spike After Prostate Cancer Surgery Helps Reduce Risk Of Recurrence
- By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
Following surgery to remove a cancerous prostate gland, some men experience a biochemical recurrence, meaning that prostate-specific antigen has become detectable in their blood. Since only the prostate releases PSA, removing the gland should drop this protein to undetectable levels in the body. Detecting PSA could signify that prostate cancer cells are lingering, and forming new tumors before they can be seen with modern imaging technology. PSA isnt always reliable for cancer screening, but it is a very sensitive marker of new cancer growth after initial treatment.
Doctors usually treat biochemical recurrence by irradiating the prostate bed, or the area where the gland used to be. Studies have shown that this treatment, which is called salvage radiation, helps to minimize the risk that prostate cancer will return and spread, or metastasize. But when to initiate salvage radiation has been open question, since PSA will also rise if small amounts of benign prostate tissue have been left behind after surgery. Many times, doctors dont know if biochemical recurrence is really cancer, so they wait to see if the PSA levels will rise any further.
In this newer era of ultra-sensitive PSA testing we didnt know if giving salvage radiation at lower levels would make a difference or not, Tendulkar said. Now we know that it does.
Apccc 201: Management Of Men With Psa Recurrence Or Persistence After Prostatectomy
- PSA 0-0.19 ng/mL: 33%
- PSA 1-1.99 ng/mL: 75%
- PSA 2ng/ml: 95%
- PSA persistence > 0.1 ng/mL has a poor prognosis but salvage radiation therapy is beneficial.
- PSA recurrence has several definitions the new EAU guidelines move from absolute value to risk groups.
- New imaging has a relevant and evolving role.
- EAU low risk is at a small risk of metastatic progression or cancer-specific mortality.
- Salvage radiation therapy with ADT should be given in EAU high-risk patients.
- Salvage surgical approaches are immature and should be considered cautiously.
What If A Screening Test Shows An Elevated Psa Level
If a man 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 man continue with PSA tests and DREs at regular intervals to watch for any changes over time.
If a mans PSA level continues to rise or if a suspicious lump is detected during a DRE, the doctor may recommend additional tests to determine the nature of the problem. A urine test may be recommended to check for a urinary tract infection. The doctor may also recommend imaging tests, such as a transrectal ultrasound, x-rays, or cystoscopy.
If prostate cancer is suspected, the doctor will 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. Most often, the needles are inserted through the wall of the rectum . A pathologist then examines the collected tissue under a microscope. The doctor may use ultrasound to view the prostate during the biopsy, but ultrasound cannot be used alone to diagnose prostate cancer.
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What Factors Influence Cancer Predictions If The Psa Level Is Elevated
As previously noted, PSA rising after surgery can mean many different things in terms of the status of prostate cancer. These different prognoses are based on several different factors, outlined below:
- Gleason Score of Prostate Cancer: The Gleason score is a measure of how aggressive the cells of prostate cancer are. The higher the score, the more aggressive cancer. Men with higher Gleason scores who experience PSA recurrence are at greater risk for metastasis of prostate cancer than those men with lower Gleason scores. Is the Gleason Score 7 or less or is it 8 or higher?
- Time from Surgery: How soon after surgery the PSA reappears is one indicator specialists use to determine the aggressiveness of cancer. Generally, the longer the time between surgery and PSA recurrence, the less likely cancer is aggressive and going to spread. In turn, the better rate of survival will be. Is the time greater or less than 2 years?
- PSA Doubling Time: The term refers to the time it takes for the PSA to double in value. The value measures the rate at which the PSA rises, and can be a very significant indicator of the aggressiveness of cancer. Men with a shorter PSA doubling time postoperatively are more likely to have more aggressive disease. In these cases, a more aggressive secondary treatment plan may be advised. Is the PSA doubling in less or greater than 10 months?
Im Worried About All The Side Effects From Prostate Cancer Medications What Can I Do
Carefully review the side effect profile of the different hormone therapy regimens, and discuss with your health care team potential ways to minimize the effects. In the end, its important that you not only understand the value of the therapy in the management of your prostate cancer, but also that you learn how to live your life as best as possible while fighting the disease.
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What Research Has Been Done To Study Prostate Cancer Screening
Several randomized clinical trials of prostate cancer screening have been carried out. One of the largest is the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, which NCI conducted to determine whether certain screening tests can help reduce the numbers of deaths from several common cancers. In the prostate portion of the trial, the PSA test and DRE were evaluated for their ability to decrease a mans chances of dying from prostate cancer.
The PLCO investigators found that men who underwent annual prostate cancer screening had a higher incidence of prostate cancer than men in the control group but the same rate of deaths from the disease . Overall, the results suggest that many men were treated for prostate cancers that would not have been detected in their lifetime without screening. Consequently, these men were exposed unnecessarily to the potential harms of treatment.
A second large trial, the European Randomized Study of Screening for Prostate Cancer , compared prostate cancer deaths in men randomly assigned to PSA-based screening or no screening. As in the PLCO, men in ERSPC who were screened for prostate cancer had a higher incidence of the disease than control men. In contrast to the PLCO, however, men who were screened had a lower rate of death from prostate cancer .
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 and the stage of your cancer. 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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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:
What Causes An Elevated Psa Level
Prostate cancer is the main cause of an elevated PSA level. But PSA levels increase with age and can reflect different prostate conditions. Other factors that may raise a persons PSA level include:
- Prostate enlargement and inflammation .
- Urinary tract infection.
- Urinary catheter placement.
Your healthcare provider will also consider whether your medications affect PSA levels. For example, 5-alpha reductase blockers treat enlarged prostates and will lower PSA levels.
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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.
What Is The Psa Test
Prostate-specific antigen, or PSA, is a protein produced by normal, as well as malignant, cells of the prostate gland. The PSA test measures the level of PSA in a mans blood. For this test, a blood sample is sent to a laboratory for analysis. The results are usually reported as nanograms of PSA per milliliter of blood.
The blood level of PSA is often elevated in men with prostate cancer, and the PSA test was originally approved by the US Food and Drug Administration in 1986 to monitor the progression of prostate cancer in men who had already been diagnosed with the disease. In 1994, FDA approved the use of the PSA test in conjunction with a digital rectal exam to test asymptomatic men for prostate cancer. Men who report prostate symptoms often undergo PSA testing to help doctors determine the nature of the problem.
In addition to prostate cancer, a number of benign conditions can cause a mans PSA level to rise. The most frequent benign prostate conditions that cause an elevation in PSA level are prostatitis and benign prostatic hyperplasia . There is no evidence that prostatitis or BPH leads to prostate cancer, but it is possible for a man to have one or both of these conditions and to develop prostate cancer as well.
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Tips To Get The Most From Your Follow
Write down any questions or concerns beforehand
It’s easy to forget what you want to say once youre at your appointment.
Bring someone with you
It can be hard to take everything in at your appointments. Some people find it helpful to take someone with them, to listen and discuss things with later. If your appointment is on the phone, you could ask a friend or family member to listen with you.
It can help to write things down during or after your appointment. Theres space for this in the appointment diary in our booklet, Follow-up after prostate cancer treatment: What happens next?
Ask to record your appointment
You could do this using your phone or another recording device. You have the right to record your appointment if you want to because its your personal data. But let your doctor or nurse know if you are recording them.
Ask for help
If there is anything bothering you, let your doctor or nurse know.
Ask for copies of any letters
If your appointment is at the hospital, ask for a copy of the letter that is sent to your GP. This will happen automatically at some hospitals. It will help to remind you of what was said at your appointment. If you don’t understand the letter, call your main contact at the hospital or contact our Specialist Nurses.
Is The Psa Test Recommended For Prostate Cancer Screening
Until about 2008, some doctors and professional organizations encouraged yearly PSA screening for men beginning at age 50. Some organizations recommended that men who are at higher risk of prostate cancer, including African-American men and men whose father or brother had prostate cancer, begin screening at age 40 or 45. However, as more was learned about both the benefits and harms of prostate cancer screening, a number of organizations began to caution against routine population screening. Most organizations recommend that men who are considering PSA screening first discuss the risks and benefits with their doctors.
Currently, Medicare provides coverage for an annual PSA test for all Medicare-eligible men age 50 and older. Many private insurers cover PSA screening as well.
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Risks Of The Procedure
As with any surgical procedure, certain complications can occur. Somepossible complications of both the retropubic and perineal approaches to RPmay include:
Some risks associated with surgery and anesthesia in general include:
Reactions to medications, such as anesthesia
Difficulty with breathing
One risk associated with the retropubic approach is the potential forrectal injury, causing fecal incontinence or urgency.
There may be other risks depending on your specific medical condition. Besure to discuss any concerns with your doctor prior to the procedure.
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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Psa Surveillance After Surgery
We used laboratory files within the VA Corporate Data Warehouse to identify the date and value of PSA tests after surgery. We started the surveillance period 60 days after surgery through 31 December 2012 and defined guideline concordance as receiving at least one PSA test within each 12-month period. Each patient was eligible for at least 4 years of follow-up. Next, we determined the maximum PSA value in the preceding year for each person-year of follow-up.
Lastly, we used administrative and pharmacy claims data to identify salvage radiotherapy or ADT after surgery. We censored patients at receipt of these treatments since our primary objective for this study was to understand surveillance patterns and quality after surgery, but before treatment for recurrence. Patients being treated for recurrence typically follow with medical or radiation oncologists, rather than primary care providers as might happen after surgery. Given the risk of ascertainment bias due to patients receiving salvage treatment outside of the VA, we also performed a sensitivity analysis in which patients were not censored in this fashion. We also censored patients at death.
What Does Rising Psa Mean
When the PSA is rising or cancer 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 will inevitably progress and become more aggressive and resistant, and you should be prepared to discuss more aggressive 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 systemic treatments for prostate cancer, which is useful at this time given that your disease is typically systemic, 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 urination becomes difficult. You should talk to your doctor about these systemic therapies, when to start chemotherapy, and clinical trials that may be available.
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