Recurrent Prostate Cancer

There are six treatment options for prostate cancer,HIFU (high intensity focused ultrasound), Cryoablation(freezing),Radiation,Surgery,Active Surveillance (AS) and androgen deprivation therapy (ADT). The last two,AS and ADT (“hormone shots”) are NOT definitive treatment options while HIFU,cryo,radiation and surgery are DEFINITIVE TREATMENT OPTIONS for localized prostate cancer. These are the same four definitive treatment options available to men when first diagnosed with localized prostate cancer and these options are also available to treat a localized RECURRENCE of prostate cancer. None of these four definitive treatment options can guarantee a cancer free status indefinitely and in addition, all four options have SIMILAR SURVIVAL BENEFITS. Therefore,if one treatment option fails one of the others may still bring about a cure of the prostatic cancer recurrence. Ideally, when considering a treatment option,as well as looking at survival benefits, we should be taking a hard look at the complications associated with the various treatments and their quality of life (QOL) impact.
The risk of recurrence of your prostate cancer depends predominantly on the tumor volume (the amount of prostate cancer and the number of positive biopsy needle cores) as well as your tumor Gleason score and whether or not the margins of your prostate are clear of tumor. Your risk for progression of prostate cancer can be categorized into low,intermediate or high (D’Amico) based on the amount of cancer,the number of positive cores,the Gleason score,the PSA as well as your stage of disease based on imaging studies such as CT scans and bone scans.

After definitive therapy for presumed localized prostate cancer,about 1/3 will develop a rise in their PSA or a biochemical rise which means a return of the prostate cancer although in many men it will be a very slow return without significant impact. Men in the high risk category have about a 50% risk of developing a recurrence as measured by a rising PSA,usually within about 5 years of treatment.

Urologists will take particular note of a PSA doubling time (PSADT). The speed at which the PSADT occurs has some predictive value for prostate cancer recurrence. For example,men with a PSADT of 3 months or less are at extremely high risk for adverse outcomes while those with a PSADT of greater than 15 months are at low risk of death from prostate cancer. Other studies have suggested that the time span for metastases after a PSA rise was about 8 years and the additional time span from metastases to death was an additional 5 years.

All men treated for prostate cancer require lifelong follow up with regular PSA monitoring. After total treatment of the prostate for cancer with HIFU, cryo, radiation or surgical removal,your PSA should nadir at about 0.1 to 0.2. A progressive rise in your PSA after a definitive treatment should be evaluated with a prostate biopsy especially if the PSA should rise to 1.0ng/ml. These biopsies may be done in the office once more or as an outpatient under sedation. All prostate biopsy slides should have their reading validated by an outside reference laboratory for confirmation of the diagnosis.
A rising PSA may not always mean a prostate cancer recurrence or an incomplete treatment of your prostate cancer. After a radiation procedure it is not uncommon to see a temporary PSA rise,”bump” or “bounce” by about 18 months after completion of treatment and this PSA rise will eventually settle once more. A prostate biopsy will confirm that this rise was a benign event.

Also,a PSA rise can be seen in those men who have undergone focal or sub total (by design) treatment of their prostate cancer with HIFU or cryo. The rise in PSA may simply reflect PSA production from the residual untreated benign portion of the prostate. A prostate biopsy will help resolve this dilemma.
Should your PSA rise within 3 months or so of total definitive treatment of your prostate cancer then this likely represents an incomplete treatment and progression of the cancer. Again,all persistent and sustained rises in PSA after treatment demand early evaluation with a prostate biopsy.
Prostate cancer recurrences may be localized (within the prostate),regional (outside but close to the prostate) or distant (more advanced). In many men,these prostate cancer recurrences are still localized to the prostate or prostatic bed and cure is still possible with an alternative definitive treatment option. These alternative definitive treatment options for localized recurrent prostate cancer are definitively preferable over the long term ADT (“hormone shots”) that are being offered by most urologists or radiation oncologists for a prostatic cancer recurrence after radiation as these physicians lack the expertise in HIFU or cryo. Long term ADT can have considerable downsides with bone wasting and metabolic syndrome events as well as a negative impact onQOL.

If you have had a SURGICAL treatment (conventional,perineal,laparoscopic or robotic) for your prostate cancer and have a localized recurrence,it may be treatable with HIFU or cryo if a nodule is palpable and the biopsy is positive for cancer. I have seen where the nodule was benign and the cause for a PSA rise after surgery. If a nodule is not palpable,then radiation therapy to the prostatic bed and pelvic lymph nodes is preferred. In about 20-40% of all men who elect primary surgical removal (including robotically) of their prostate for cancer the pathology report will indicate positive margins which means some cancer was left behind and radiation is usually offered as an adjunct (some weeks post operatively) or as salvage (at a later date after the PSA rises) to these men.

If a prostatic recurrence occurs after RADIATION (all types including external beam options,brachytherapy or combinations thereof,proton beam) a definitive treatment with HIFU or cryo may be offered by those few urologists who possess expertise with these techniques. Surgical removal is attempted by some after finding a recurrence after radiation but this option has even more complications and negative impact on QOL than when surgery is attempted primarily for prostate cancer.
If one has a documented localized prostatic cancer recurrence after CRYO,the patient may choose as a definitive treatment an additional outpatient cryo or a HIFU procedure or radiation treatments or even surgical extirpation with all of it’s associated complications and negative QOL issues.
If you have a recurrence after HIFU,the HIFU may be repeated as an outpatient treatment or you may choose cryo,radiation or as a last resort,surgery with it’s attendant complications.

For localized prostate cancer and the definitive treatment options of surgery or radiation,each of these can be offered only but once. Only HIFU and cryo can be offered repeatedly and are non radiation but of these two outpatient definitive treatment options for localized prostate cancer,HIFU is the most precise and with the lowest incidence of complications as well as superior QOL.

All men who undergo a secondary definitive treatment option for their recurrent localized prostate cancer must continue regular follow up and with monitoring of their PSA’s in the same fashion as when they were followed up after their first definitive treatment.