How to handle a relapse after treatment for prostate cancer

Marc B. Garnick, M.D., discusses what biochemical recurrence means and what your options are

“Am I going to die?” This is the first question a patient usually asks me when a follow-up blood test reveals that his prostate-specific antigen (PSA) level has risen after he has already undergone treatment for prostate cancer (usually a radical prostatectomy or radiation therapy). The fear is understandable: When PSA levels rise to a certain threshold after prostate cancer treatment, the patient has suffered what is known technically as a biochemical recurrence, sometimes also referred to as a biochemical relapse or stage D1.5 disease. Whatever term is used, it means that prostate cancer remains within the prostate after radiation therapy, that it survived outside the excised area after radical prostatectomy, or that it has reappeared in metastatic form in other tissues and organs. In most cases the cancer remains at a microscopic level, and many years will pass before any physical evidence of it is detectable on a clinical exam or any abnormalities are seen on a bone scan or CT scan.

That’s usually of small comfort to the patient whose PSA has risen. It’s emotionally traumatic to go through treatment for prostate cancer, thinking it is cured, and then learn that it might have come back. For many men, it’s as if they’re dealing with another diagnosis of cancer, except this time it’s much worse because there is less likelihood of getting cured. A man’s confidence and sense of safety may be shattered, especially because the popular misconception is that when prostate cancer recurs, it is deadly.

Which brings me back to my patient’s question: “Am I going to die?”

The simple answer is yes, eventually — we all do — but you may not die from prostate cancer. Of course, with prostate cancer, nothing is simple. This may be one disease, but it can appear in multiple forms, so every diagnosis or recurrence requires individualized assessment and intervention. To start thinking about the salient issues, see “Four key questions.”

Four key questions

If your PSA rises after prostate cancer treatment, answering four key questions will help you and your doctor determine next steps:

  • What were your risk characteristics, such as Gleason score, PSA, and cancer stage, at the time of diagnosis? (See Table 1.)
  • What type of treatment did you have? That will help determine your next treatment options.
  • How long has it been since you underwent initial therapy for prostate cancer? This helps indicate how aggressive follow-up treatment needs to be.
  • How fast is your PSA rising, as determined from several evaluations?

In practical terms, biochemical recurrence means that you are now dealing with a chronic disease, like diabetes, so that your clinical monitoring will have to increase and you may need to choose or adjust treatment to meet new challenges. Unfortunately, we don’t yet have sufficient research to provide clear guidance about when a second therapy (referred to as salvage therapy) should be considered after biochemical recurrence, and which type of salvage therapy is most effective in particular circumstances. (Salvage therapy is a terrible term, but I use it in this article because it is the standard name for follow-up therapy.)

For those who have already suffered a biochemical recurrence after being treated for prostate cancer — or dread each follow-up blood test because it might signal such a recurrence — this article explains what a rising PSA after treatment really means and what your treatment options are.

Table 1: Predictors of biochemical recurrence at time of diagnosis

Although a number of clinical factors contribute to your risk of relapse after treatment, the parameters below provide a simpler assessment of your chances of biochemical recurrence, based on your clinical profile at the time of diagnosis. For more sophisticated estimates, based on specific risk factors, see Figures 1 through 3.

Low risk (33% chance of biochemical recurrence within five years) Gleason score less than or equal to 6
and
PSA less than or equal to 10 ng/ml
and
Cancer stage T1c or T2a
Intermediate risk (50% chance of biochemical recurrence within five years) Gleason score of 7 (if 3+4)
and/or
PSA greater than 10 but no greater than 20 ng/ml
and/or
Cancer stage T2b
High risk (85% chance of biochemical recurrence within five years) Gleason score of 7 (if 4+3), or 8 or more
and/or
PSA greater than 20 ng/ml
and/or
Cancer stage T2c or more

Defining biochemical recurrence

As you are probably aware, both normal prostate cells and prostate cancer cells manufacture PSA. That is why the PSA level should fall to undetectable levels in men treated with radical prostatectomy, in which the prostate is removed, but is not likely to drop to zero in men treated with radiation therapy, even when treatment is successful. This is because after radiation therapy the prostate gland remains intact and can recover some function. This is also true if you received hormone therapy as part of your radiation treatment: As you recover, testosterone levels rise, and so does your PSA.

The real challenge is defining what constitutes a biochemical recurrence after a particular type of therapy. There is no consensus on this issue, but the working guidelines are summarized in Table 2.

Table 2: Guidelines for determining biochemical recurrence

Initial therapy PSA threshold Comments
Radical prostatectomy 0.2 ng/ml on at least two successive tests Some physicians continue to use a higher threshold of 0.4 ng/ml or greater
Radiation therapy (external beam or brachytherapy) Three successive elevations in PSA compared to nadir (low point), regardless of actual reading, according to the American Society for Therapeutic Radiology and Oncology Many oncologists use a working definition that biochemical recurrence has occurred if PSA levels are greater than 1–2 ng/ml 12 to 18 months following initial treatment.

Ideally, post-treatment PSA levels should be less than 0.5 ng/ml, but this is rare; levels of 0.6–1.4 ng/ml may occur.

Neoadjuvant hormone therapy and radiation therapy Unknown

Further muddying the water, it is not clear what PSA levels should be in men who have undergone neoadjuvant hormone therapy in addition to radiation therapy. Hormone therapy suppresses levels of testosterone; once the therapy is stopped, testosterone levels rise, and PSA generally increases rapidly until the hormonal environment stabilizes.

Moreover, some men who have undergone external beam radiation therapy or implantation of radioactive seeds (brachytherapy) experience a phenomenon known as PSA bounce, a temporary spike in PSA that does not necessarily indicate recurrence. Studies offer varying conclusions about how common this phenomenon is, probably because they use different definitions of what constitutes a “bounce.” Until more is known, if you have had some form of radiation therapy for prostate cancer and experience a spike in your PSA level, it is wise to ask your physician whether this could be a PSA bounce.

A common challenge

Rising PSA after initial treatment often comes as a shock to the person affected, but it’s actually a common problem. Studies indicate that biochemical recurrence affects roughly 15%–30% of men initially thought to be curable with localized treatment of prostate cancer. Certainly if you find yourself in this situation, you are not alone.

For example, a study published in the Journal of Urology, which followed 3,478 men who underwent radical prostatectomy for prostate cancer, found that 32% were likely to suffer a biochemical recurrence within 10 years. (The study actually followed patients an average of a little more than five years, but used actuarial tables to predict outcome at 10 years.) Another study, published in the Journal of the American Medical Association, examined the outcomes for 1,997 men who underwent radical prostatectomy and were followed for an average of a little more than five years, and found that 15% experienced biochemical recurrence in that time. (For further details about these studies, see “Biochemical recurrence after surgery,” below.)

Biochemical recurrence after surgery

Pound CR, Partin AW, Eisenberger MA, et al. Natural History of Progression after PSA Elevation Following Radical Prostatectomy. Journal of the American Medical Association 1999;281:1591–7. PMID: 10235151.

Roehl KA, Han M, Ramos CG, et al. Cancer Progression and Survival Rates Following Anatomical Radical Retropubic Prostatectomy in 3,478 Consecutive Patients: Long-Term Results. Journal of Urology 2004;172:910–14. PMID: 15310996.

Other studies indicate that a similar (or perhaps slightly higher) percentage of men treated with radiation therapy will experience a biochemical recurrence (see “Biochemical recurrence after radiation therapy,” below). For example, a study of 1,449 men with prostate cancer treated with brachytherapy, published in the Journal of Urology, found that anywhere from 19% to 26% experienced biochemical recurrence within 12 years, depending on the definition of recurrence. It should be noted that nearly half the men were also treated with either neoadjuvant hormone therapy or a combination of brachytherapy and external beam radiation therapy, which may have increased the success of treatment or delayed recurrence. And a study comparing the outcomes of 393 men who received different doses of external beam radiation therapy for prostate cancer, published in the Journal of the American Medical Association, found that 19.6% of those who underwent high-dose radiation therapy experienced biochemical recurrence within five years, while 38.6% of those who underwent conventional-dose radiation therapy did.

Biochemical recurrence after radiation therapy

Potters L, Morgenstern C, Calugara E, et al. 12-Year Outcomes Following Permanent Prostate Brachytherapy in Patients with Clinically Localized Prostate Cancer. Journal of Urology 2005;173:1562–6. PMID: 15821486.

Zietman AL, DeSilvio ML, Slater JD, et al. Comparison of Conventional-Dose vs High-Dose Conformal Radiation Therapy in Clinically Localized Adenocarcinoma of the Prostate: A Randomized Controlled Trial. Journal of the American Medical Association 2005;294:1233–9. PMID: 16160131.

Assessing your personal risk

Several factors contribute to your risk profile. One important factor is whether you have localized or more advanced disease at the time of biochemical recurrence. As indicated in Table 1, your pretreatment numbers such as Gleason score and pathological cancer stage will provide some indication of whether the recurrence is local or metastatic. Also important is how much the PSA increased within a given time period (known as the PSA velocity) before treatment, and how long it takes for PSA to double in value (known as PSA doubling time) after treatment.

For example, two studies that looked at the relationship between PSA velocity and post-treatment outcomes in men treated for early-stage prostate cancer found that men with a PSA velocity of 2 ng/ml or less in the year before diagnosis had a much better prognosis than those whose PSA velocity was greater than 2 ng/ml per year (see “PSA velocity and prognosis,” below). In a study of 1,095 men treated with surgery, published in the New England Journal of Medicine, investigators found that men with a PSA velocity greater than 2 ng/ml in the year preceding diagnosis were 50% more likely to experience biochemical recurrence than the men whose PSA velocity was less than that. These men were also likely to experience biochemical recurrence faster and faced a greater likelihood of dying from prostate cancer than the other men. In the second study, involving 358 men treated with external beam radiation therapy, published in the Journal of the American Medical Association, researchers found that men with a PSA velocity greater than 2 ng/ml in the year preceding diagnosis were 80% more likely to experience biochemical recurrence than the others, and less likely to survive (see Table 3). Similarly, post-treatment PSA doubling time can also be used to assess the likelihood that disease is local or metastatic and provide insight into prognosis.

Table 3: PSA velocity before diagnosis and estimated chances of survival

An analysis of PSA velocity in the year preceding diagnosis reveals that it can predict the likelihood of survival seven years after external beam radiation therapy. (Similar findings have been reported for an analysis of men who underwent radical prostatectomy.)

Overall risk profile (based on PSA, Gleason score, cancer stage) When PSA velocity is less than or equal to 2 ng/ml per year When PSA velocity is greater than 2 ng/ml per year
Low risk 100% 81%
High risk 96% 76%
Source: Journal of the American Medical Association, July 27, 2005.

When the post-treatment PSA level doubles in less than six months, for example, and certainly when it doubles in less than three months, the cancer has most likely spread and therefore requires systemic treatment. Research has also shown that the length of time it takes PSA to double can be used to estimate likelihood of whether disease will become clinically evident (detected by symptoms and scans) following biochemical recurrence (see Table 4).

Table 4: PSA doubling time and outcome five years after biochemical recurrence

A study involving 2,809 men who were treated with surgery and subsequently experienced biochemical recurrence (defined as a PSA of 0.4 ng/ml or more) found a clear relationship between PSA doubling time and eventual clinical outcomes.

PSA doubling time Percentage of men without prostate cancer*
Less than 6 months 38%
6–11 months 46%
12 months–9 years, 11 months 62%
10 years or more 87%
*No clinical indication of local or systemic disease, based on digital rectal examination, transrectal ultrasonography, biopsy, or bone scan.

Source: Mayo Clinical Proceedings, June 2001.

Of course, estimates of average likelihood of progression are simply that — estimates — and may not indicate what is going on in your own case. So to better determine whether your cancer recurrence is localized to the prostate or has spread elsewhere, your doctor will not only look at your pretreatment numbers, but also restage the disease by repeating some of the tests you had at the time of your initial diagnosis. You will likely undergo a bone scan and an abdominal pelvic CT scan. You may also undergo a ProstaScint scan, which uses monoclonal antibodies tagged with a radioisotope to identify metastatic prostate cancer in lymph nodes and other areas in the pelvis. It’s important to note, however, that not all doctors recommend such tests because in most men who experience rising PSA, these scans will usually not reveal any clinical evidence of metastases.

PSA velocity and prognosis

D’Amico AV, Chen MH, Roehl KA, Catalona WJ. Preoperative PSA Velocity and the Risk of Death from Prostate Cancer After Radical Prostatectomy. New England Journal of Medicine 2004;351:125–35. PMID: 15247353.

D’Amico AV, Renshaw AA, Sussman B, Chen MH. Pretreatment PSA Velocity and Risk of Death from Prostate Cancer Following External Beam Radiation Therapy. Journal of the American Medical Association 2005;294:440–7. PMID: 16046650.

Knowing whether and when to act

If your PSA indicates that biochemical recurrence has occurred — or if you are tracking your PSA closely, to determine whether you may need to consider treatment — you probably want to know what your options are. But as you evaluate options, consider not only what to do, but whether and when to act.

Unfortunately, experts don’t agree about when salvage treatment for recurrent prostate cancer should begin, or which salvage treatments are best. Of course, if you experience biochemical recurrence and the cancer appears aggressive — as indicated by your pretreatment risk profile (see Table 1) or a PSA doubling time of less than six months — your physician is likely to recommend immediate treatment, probably with hormone therapy, to delay metastases.

But many other men will find themselves in a gray area, with clinical profiles and PSA doubling times that are not sufficient to trigger immediate salvage therapy. If you are in this category, your physician may recommend waiting to treat until your PSA rises to a particular level. That means you may have more frequent PSA testing, which can be nerve-racking but is necessary to detect progression earlier. (For more insight into what this feels like, see “A couple’s story: Tracking PSA,” below.)

Although many men diagnosed with biochemical recurrence will want to take immediate action to stop the cancer, going ahead with therapy for the sake of simply doing something may cause more harm than good. The risks and complications of surgery or radiation, already high when delivered after an initial diagnosis of prostate cancer, may become even greater when these therapies are delivered as salvage after biochemical recurrence. Data are sparse on the side effects of salvage therapy, simply because not many studies have been done on the topic, but I always advise patients in this situation to consider that any complications of the initial therapy may be increased if their abdominal and pelvic areas are subjected to a second therapy. For example, some research indicates that the likelihood of developing urinary incontinence after prostatectomy is greater following salvage treatment (where it may affect 20%–60% of men) than when it is the first mode of treatment (where it may affect 2%–15% of men).

It’s also wise to consider the impact of further treatment if you have other diseases besides prostate cancer, such as diabetes, cardiovascular disease, or a pulmonary disease such as emphysema. If you do, it is likely that you are on medications for these disorders, and are already dealing with significant health challenges and risks. Undergoing additional treatment for prostate cancer may add to these risks, or may require that you readjust medications you are taking.

Finally, remember that you have time to make an informed decision about whether and when to undergo additional treatment for prostate cancer following biochemical recurrence. The evidence shows that you can expect to live for many more years. For example, the Journal of the American Medical Association study cited earlier, which reported that 15% of men experienced biochemical recurrence in a little over five years, also analyzed what happened to the men afterward. The authors found that it took an average of eight years for the cancer to metastasize to the bones, and the men survived another five years after that — for a total of 13 years, on average, after biochemical recurrence.

Remember that average survival times are based on studies of men treated in the past, and sometimes as long as 10 or 20 years ago. What’s more, some of these studies (including the Journal of the American Medical Association study cited above) included men who did not undergo further treatment after biochemical recurrence occurred. It’s likely that these men would have survived for a longer time if they had received additional treatment after biochemical recurrence was detected (although longer survival would come at the cost of treatment side effects). For these reasons, the “average” chances may be much better for a man treated today. And such averages can never predict what will happen in your particular case. That’s why, when I talk with patients about studies like this one, I encourage them to make decisions based on their own risk profile. As shown in Figures 1 through 3, your particular risk will vary, depending on factors such as PSA level at diagnosis, PSA doubling time, and Gleason score. Finally, when it comes to evaluating your options, much will depend on whether you were treated initially with surgery or radiation therapy, with or without hormone therapy.

Figure 1. Preoperative PSA level and freedom from relapse

Preoperative PSA levels and freedom from relapse

Source: Journal of Urology, 2004

Figure 2. Gleason score and freedom from metastases

Gleason score and freedom from metastases

Source: Journal of the American Medical Association, 1999

Figure 3. PSA doubling time and freedom from metastases

PSA doubling time and freedom from metastases

Source: Journal of the American Medical Association, 1999

Options for men who had surgery

How long after treatment it took for the PSA to rise and how quickly it rose provide important clues to whether it’s likely that your cancer is localized or metastatic. Generally speaking, the prognosis is worse for men whose PSA never becomes undetectable after surgery, or rises quickly a short time after treatment. Prognosis is better for men whose PSA rises slowly and begins to rise a long time after treatment. A few scenarios will help clarify what the options are in each situation.

Some men learn right away that they have residual disease. The surgeon sends any tissue excised during the operation to a pathologist for analysis. If the pathologist finds positive margins — meaning that he found cancer cells at the borders, or margins, of the excised tissue — this means that you may need to undergo radiation treatment to eradicate the cells remaining in the prostate area.

Scenario 1. Sometimes the PSA level never becomes undetectable after a prostatectomy. This situation, which is fortunately rare but among the most challenging to treat, means either that some cancer cells remained in the prostatic fossa (tissue left behind during surgery in the area once occupied by the prostate gland), or — more likely — that micrometastases had already spread beyond the prostate. A man in this situation may need additional therapy right away. The options offered may be radiation or hormone therapy, or both, or an investigational therapy.

Scenario 2. Sometimes the PSA falls to undetectable levels for several months following radical prostatectomy, and then begins to creep up. Typically, a man in this situation learns during one of his follow-up tests that he has experienced a biochemical recurrence. If the PSA level rises within the first year after surgery, it usually indicates metastatic disease. The treatment option most often offered is hormone therapy (either intermittent or continuous).

Scenario 3. The PSA does not begin to rise until a year or more after surgery. This is more likely to indicate localized disease, although it is possible that the disease has spread. Your treatment options depend on the PSA doubling time — how quickly PSA is increasing. If your PSA doubles in less than six months, and certainly less than three months, your doctor may recommend treating the area again, but this time with radiation or hormone therapy, in order to eradicate the disease.

Scenario 4. The PSA rises a year or more after surgery, but the doubling time is slow (a year or longer). This is probably the best scenario of all, as it indicates that the cancer may be localized and not aggressive. In this situation, you may opt for active surveillance — monitoring PSA and periodically having other tests, but not necessarily choosing an active intervention right away.

Salvage options after radical prostatectomy

Most men who experience a biochemical recurrence after prostatectomy and decide to undergo treatment have three options. The best strategy depends on your risk profile and comfort with side effects.

Radiation therapy

Many men opt to undergo salvage radiation therapy. Although few studies have been done to evaluate long-term results, many men do respond to salvage treatment. One study involving 368 men who had initially undergone radical prostatectomy, for example, found that five years after undergoing salvage radiation therapy, 46% remained free of biochemical recurrence, and 92% were still alive; at eight years, 35% remained free of biochemical recurrence, and 80% were still alive. Other studies have reported that salvage radiation therapy is likely to be most effective in men whose Gleason score, PSA level and doubling time, and other clinical features indicate less aggressive disease (see “For more information: Salvage radiation therapy,” below).

Side effects. Be aware that radiation therapy delivered after a prostatectomy markedly increases the likelihood of impotence and may increase the likelihood of incontinence. If you are already incontinent after surgery, then having radiation therapy is likely to make the problem permanent. For that reason, most men who become incontinent after surgery will wait until they regain control over their bladder or rectum before undergoing postoperative radiation therapy.

For more information: Salvage radiation therapy

Buskirk SJ, Pisansky TM, Schild SE, et al. Salvage Radiotherapy for Isolated Prostate Specific Antigen Increase after Radical Prostatectomy: Evaluation of Prognostic Factors and Creation of Prognostic Scoring System. Journal of Urology 2006;176:985–90. PMID: 16890677.

Sengupta S, Christensen CM, Zincke H, et al. Detectable Prostate Specific Antigen Between 60 and 120 Days Following Radical Prostatectomy for Prostate Cancer: Natural History and Prognostic Significance. Journal of Urology 2006;176:559–63. PMID: 16813889.

Stephenson AJ, Shariat SF, Zelefsky MJ, et al. Salvage Radiotherapy for Recurrent Prostate Cancer after Radical Prostatectomy. Journal of the American Medical Association 2004;291:1325–32. PMID: 15026399.

Radiation with hormone therapy

Another option is to undergo hormone treatment while undergoing salvage radiation therapy, because this may increase the effectiveness of radiation therapy.

Hormone therapy

If the PSA doubling time is less than six months, indicating that the cancer is aggressive, radiation therapy may not be adequate, as it is likely the cancer has already spread. In that case, a better option is a full course of hormone therapy, which can delay the time of onset to bone metastasis.

But other considerations also come into play. If you are sexually active and want to remain so, hormone therapy may not be the right option for you. Or you can opt for erectile-sparing hormone therapy, which involves a single agent like bicalutamide (Casodex), or bicalutamide and finasteride (Proscar) (see “For more information: Erectile-sparing hormone therapy,” below). Another option is to go on intermittent hormone therapy, in effect taking occasional “holidays” from treatment. This allows men to recover some quality of life while at the same time reducing levels of testosterone, which fuels the cancer.

If you are elderly (defined as having less than 10 years of life expectancy), you may not want the full spectrum of hormone therapy because it causes other complications.

For more information: Erectile-sparing hormone therapy

Boccardo F, Rubagotti A, Barichello M, et al. Bicalutamide Monotherapy Versus Flutamide Plus Goserelin in Prostate Cancer Patients. Journal of Clinical Oncology 1999;17:2027–38. PMID: 10561254.

Salvage options after radiation therapy

If your initial cancer treatment was radiation therapy and you experience a biochemical recurrence, the salvage treatment you choose depends on whether you received external beam radiation therapy or brachytherapy, as well as whether you also received hormone therapy.

Salvage prostatectomy

When one of my patients experiences biochemical recurrence following radiation therapy, the first question I expect to hear is, “Can we just go in and take it out?” Salvage prostatectomy is a possibility for some men, but it is not used often, simply because it’s such a difficult operation. Radiation therapy causes scar formation and the development of fibrous tissue in the treated area, so that a surgeon may be unable to distinguish among different types of tissue. It may be difficult, for example, to distinguish the specific boundaries of the rectum and the bladder because of prior radiation scarring. Some highly skilled surgeons can perform a salvage prostatectomy, but the larger consideration is whether it is worth doing at all.

One could make a strong argument that in most cases, rising PSA after radiation therapy indicates systemic disease, and any type of local therapy — even salvage prostatectomy — is not going to solve the larger problem of cancer cells that have metastasized elsewhere. For those cells, you need hormone therapy.

Salvage radiation therapy

In certain unusual circumstances, if recurrent cancer is found only in a limited part of the prostate gland, it may be possible to place radioactive seeds in the area to eradicate the cancer. The techniques for performing this are still under investigation, and long-term data on effectiveness are not yet available. Be aware that it is not known whether this additional radiation will increase the risk of other types of cancers.

Cryotherapy

Another option, also appropriate only when a localized area of cancer is found, is cryotherapy. This freezes the prostate gland to kill any remaining cancer cells. This highly specialized treatment is not practiced widely, and substantial complications have been reported.

Metastatic disease: Hormone therapy

If your doctor determines that you have a metastatic rather than a localized recurrence, hormone therapy is your best option — and it is appropriate whether you initially underwent a radical prostatectomy or radiation therapy. Before a man who has experienced biochemical recurrence decides to have hormone therapy, however, the first question is whether he has had it before. Some men who were at intermediate or high risk of relapse (see Table 1) and decided to have radiation therapy initially probably also had hormone therapy beforehand because this increases the chances that initial therapy will succeed. If the patient had a hard time of it, in terms of side effects, he may not want to consider hormone therapy again.

Hormone therapy works by reducing testosterone levels. Because testosterone fuels the growth and development of prostate cancer, reducing levels of this fuel helps stop cancer from progressing — or at least slows the rate of progression.

Hope for the future

Experiencing biochemical recurrence can be emotionally devastating — there’s no doubt about it. But research continues about how best to treat men who experience a relapse following initial therapy for prostate cancer, and it is likely that new therapies will emerge in the coming years. In the meantime, stay informed about your treatment options and work with your doctor to determine whether it’s time to consider some type of salvage therapy.

A couple’s story: Tracking PSA

Joe and Patricia Shields* have been married nearly 25 years. Mr. Shields received a diagnosis of prostate cancer in 2001, at age 57, and underwent a radical prostatectomy. In the summer of 2004, a routine blood test revealed that Mr. Shields’ PSA had doubled, from 0.02 ng/ml to 0.04 ng/ml. It held steady for the next few months, then jumped to 0.1 ng/ml, where it’s remained for more than 15 months. Mr. Shields has not experienced a biochemical recurrence (see Table 2). Even so, the Shields are concerned about the fact that the PSA level has increased at all, and find themselves living in a gray area, where medical science can offer little guidance.

Joe Shields: I mostly put it out of my mind. The day I go in to have the test done is hard. The day I need to call in for my results is hard. But otherwise I try not to worry about it. It’s not that I’m cavalier about risk. But I could spend the next 10 years worrying about dying of cancer, and then die in a car crash.

Patricia Shields: I think there’s a gender difference in how we cope. Joe says, “This is the hand I was dealt, I can’t worry about it, I just need to get up and get on with life.” Meanwhile, I have a female, “protect the nest” outlook. There isn’t a day that goes by when I don’t think about it.

In some ways, learning Joe’s PSA increased was much worse than the initial diagnosis. The first time around, you’re in shock. Then you think it’s behind you. But now it feels like something hanging over us all the time.

Joe Shields: One aspect of this that has been difficult is the ambiguity. When I was evaluating my options the first time around, there were guidelines. I felt like I could make an intelligent choice. But with PSA elevation after surgery, there are no clear treatment recommendations.

*Note: Names and some biographical details have been changed to protect this couple’s privacy. All medical details are as reported.

Originally published April 1, 2007; last reviewed April 22, 2011.

Comments
16
Jack Stopforth

I had radical surgery in October 2012 and was told in my first post-op exam that my PSA had not been fully eradicated and was measured at 0.01. Six moths later (June 2013) I was told it had doubled, but at 0.02 was still very low and should be monitored: only if it shows growth after 3 quarterly blood tests would my physician recommend radiotherapy or other salvage treatment. I want rid of the cancer and would rather have immediate treatment. Should I insist?

Bob

I’ll be 70 in January 2014. I had open RP on 9/7/13 after Gleason 9 PC was discovered in 2 of 6 biopsy cores on 6/24/13. Pathology was not good: Gleason 9, SVI, pos. margin and extraprostatic extension at base with Gleason 7. No PC was found in the 10 lymph nodes removed.

PSA two months later is 0.1, which is not surprising and not bad IMHO, all things considered. I still have minor incontinence and have ED which I had prior to surgery. So I’m biding my time at this point waiting to talk to my surgeon.

Michael Heinlein

I had robotic surgery 4/6/2013 showed lesson 8 after surgery with positive margin cut in on area by left blood vessel and never which could not be saved 3 month blood test showed less than .oo6 psa before operation was 2.9. No lymp node involvement no semen or bladder either. 6 month psa was 0.014 9 months .023 and then a 6 week test showed .04. Doctor wants send me to radiation oncologist next week for his info. What’s my chances what should I be looking at? What questions should I ask and is radiation the way to go. Should I buy green bananas ? Anyone have similar experience and how it turned out.

Patrick Dawson

At 52 I had a Prostatectomy in Nov 2013 with a pre op PSA of 53 and eventual pathology report after surgery with Gleason 8
38mm tumor apex to base and both sides of the prostate with Margin and Extension..I chose not to have follow up Radiation because my first Post op PSA was undetectable….told the stats of chance of reoccurence by the Oncologist which are the same as here 85%…I guess some very nervous months await me!!

Jerry

I had Gleason 7 (4, 3) I think it was 4, 3 any ways, I remember the combo was the best combo with T1C added in. It was found after my PSA hit 12 and two very painful biopsies. I was treated in the fall of 2011, proton beam. For the last three months my PSA has gone from 1.2, 2.7 to 3.8. I’ve undergone a bone scan, nothing, prostate MRI, nothing and tomorrow, a spinal MRI. Dr. wants to conclude that a accident I had, which scarred my spine, is just that, a scar. After that a biopsy then a sit down to discuss options.

I’m 65 years old very disappointed and confused as to what my options are. I feel that someone just put a medical harness on me. They tell me that at my age and, moving forward, it will always be something.

Vinnie StJohn

I had a radical prostectomy Dec 2012. 9 months later, my PSA rose to.2. 6 months after that rise, to .3 I was sent to an oncologist who did a PET and MRI with contrast. Everything was completely clear with the exception of a 1.2cm lytic lesion in my right proximal humerus. How can I have mestastasis with a PSA of.3? Also it’s lytic and not blastic.
Oncologist wants to be “sure” at the expense of open surgical biopsy which 2 other doctors disagree on. Lesion is metabolically active with an SUV as high as 5.5, yet X-ray reveal non-aggressive. I’m in no man’s land.

Don Jay

Hi, Im 56 y/o, 2 years ago I had RP via the da vinci robotic system. My highest psa was 6.44. Post surg, my psa was undetectable for approx 15 mos. Subsequently in Oct 13 my psa was 0.03, in January 14 it increased to 0.07 in May14 it increased to 0.10 and one month later this June it remains 0.10.
Path post surg indicates 0.9cm intra- postive margin w/ gleason of 4+3 . My urologist has referred me to the radiation oncologist, whom I saw last week 6/5/14. He is recommending radiation therapy. Your thoughts on if I should have the treatment as rx’d or should I take the wait and see approach. Your time and comments would be most appreciated, thank you very much!!!

Bob

I was stage pt3b gl9 at pathology post RP. PSA at two, five and eight months post op was .1, .2, and .3 respectively so I started lupron and IMRT. My Uro and RO both think PCa is still in prostate bed, but I don’t know why they think so. So I have taken the plunge hoping for a cure this time. What else could I do? Standing pat and doing nothing seemed like giving up. I have no PCa symptoms but side effects of ADT have started, primarily hot flashes, fatigue , upset stomach and bowels, and muscle pain. Side effects of SET have not begun. Can’t wait for those bad boys! I’m not sure I’ll get another three month lupron shot.

jim

hi,,i had surgery in 2002 to remove my prostate. 11 years later my psa went up to .6 had radiation treatment. 33 hits..had another psa three months later and it was .8 ouch..four months later it was 1.2,,now i am worried. so the doctor put me on horomone treatment..so far no side effects..but what i would like to know is why the radiation did not work…i am 68 years old…

CJ

Jim- My best guess is because the cancer is not where the radiation was targeted. I assume the pelvic bed was irradiated — were there scans that indicated something was there? Hormone therapy can keep the cancer at bay for an unknown period of time. If you want to try to pinpoint where the PCa is, you might want to try a different type of scan — research C-11 PET scans on Google.

GB

I had high dose radiation treatment via SBRT for my PCa, gleason 6 (3+3), 5/12 cores, all on left side. I was 50 when diagnosed and treated. I get my first PSA test next month and the waiting for results is difficult to know if it worked. I think I have 93% shot of it working but as difficult as it is waiting to know the results, I feel for those of you who have gotten the results and know the initial treatment did not take care of it. My prayers are with you!

Bud

30 years ago I had PSA of 18. I had seed implant to prostate and 6 weeks of radiation. Not broad band. All was fine for for 25 years, PSA today is only 0.50 ,however, the radiation has caused scar to bladder and prostate that has been terrible for past 5 years.Broken scar tissue and blood clots blocking my urine off and on for 5 years.Finally I tried hyperbaric oxygen therapy for 80 hours and stopped the bladder blood clots.Now 3 years laterand years and 30 years after original treatment I have same problem with prostate blood clots. The oxygen treatment did not work this time.i pass clots on a regular basis praying they will not block me. Some have,most don’t I am 87 years old and very active or was until my activity caused scar tissue to break off.My doctor has no good answers.I say think twice before radiation. It comes home later and bites hard.

helen collins

Goodday
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me to wait for just 24 hours, after 24 hours, i went to the
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Jim

Like the other Jim (June comment) I had a radical prostatomy in 2003. Undetectable (<0.1) PSA until about 2010 then slow steady rise from 0.1 to 0.29 to mid-2014, now a jump to 0.42 in under 3 months. Abdominal CT and bone scans show nothing. I'm reluctant to start radiation so tomorrow I get a biopsy of (I think) the prostate bed. Then may have to weigh up risk vs reward – wait and see, or blast it before it goes any further? Can't say either option sounds good! I kind of hoped that the delayed and slow increase in PSA was a good omen but suspect that is probably unsubstantiated optimism.

john

Had a RPT on 8/31/10..Gleason of 4+3 and SI invasion. Went 3 years with an undetectable PSA. A recurrence of .07 to .1 ..Although still considereda low number to me any rise is not good..So..Had all scans they were all clear and opted for Radiation of the prostate bed with a total of 42 sessions over 2 months..after 3 months PSA was undetectable once again..Will follow up in 6 months but feel really good we might of got it for good..All it takes is a PMA..positive mental attitude to beat the dreaded rise in PSA..

zorro

Radical prostatectomy on 29March 2014.All margins clear.Psa pre-op 2.37.Psa post-op at 3 weeks forty-five.Psa at 6 weeks post-op seventeen.Psa 12 weeks post-op 1.29.Psa 18 weeks post-op 1.24.Decided to respond with treatment only when a doubling time excist.What tests can be done to be certain that the urologist did not leave prostate tissue behind during prostatectomy. Robotic da Vince surgery was executed.

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