A Rising PSA Post-treatment

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The following is a clinical perspective from Dr. Espinosa, whose recent book on prostate cancer (Thrive Don’t Only Survive) is available and recommended.

A 63-year-old patient who is one year after prostate cancer surgery recently came to see me at my clinic following his recent diagnosis of recurrence PSA. He looked at me strangely, so I asked him, “What’s wrong?” He responded with “I thought I didn’t have ever to worry about prostate cancer again since I had it taken out. I expected my PSA to be zero forever. I’m confused.”

Men who opt for aggressive treatment of prostate cancer such as a radical prostatectomy, radiation therapy, and so on unfortunately believe they are “home free” after treatment. If this were to be true, why are patients required to return to their urologist every 3 to 6 months for a PSA test after surgery or radiation? 

Men after prostatectomy or radiation even more so need to make lifestyle changes to reduce their risk of prostate cancer recurrence. Here are two reasons why:

  1. 1. Up to 40% of men experience biochemical recurrence (PSA recurrence) after initial treatment. (Freedland et al. 2007)
  2. Men treated initially with Radiation Therapy (RT) have a higher chance of getting secondary bladder cancer or rectal cancer (Nieder et al. 2008)

What do biochemical recurrence (BCR) and PSA recurrence mean? PSA recurrence is defined by a PSA of 0.2 ng/ml to 0.4 ng/ml after removal of the cancerous prostate. 

PSA recurrence after Radiation therapy (RT) is harder to determine as PSA initially increase’s (known as PSA bounce) after treatment and does not reach its lowest level for up to 18 months. There is no consensus on the definition of treatment failure but most agree that the lowest PSA value after RT plus 2 is the cut-off.

For men who undergo RT as primary treatment for prostate cancer the most common treatment after PSA recurrence is cryotherapy (freezing the prostate). Cryotherapy in this patient population can induce close to 100% impotence but not worsen urinary incontinence. 

Does PSA recurrence mean this is the beginning of the end for me? Not necessarily. The average time from PSA recurrence to prostate cancer death is 16 years (Freeland et al. 2007). Most men with PSA recurrence, however, die of other causes than from prostate cancer, i.e. heart disease. Importantly, PSA increase after prostatectomy may be due to benign, non-cancerous prostate tissue left behind after surgery (Djavan et al., 2005).

These statistics do not include men on a thoughtful cancer-specific lifestyle approach after initial treatment. None of these studies monitored lifestyle changes or integrative modalities in their statistics which clinically shows PSA stabilization plus optimal overall health benefits in prostate cancer patients. 

Here’s a doozy, however: Men with a high rapid PSA doubling time (PSADT) after treatment are at the highest risk of disease progression. This is the scenario when the harder drugs such as Zytiga, Xtandi or the chemo drug Taxotere come into play, especially if cancer spreads to the bone. 

Once there’s PSA increase after prostatectomy, your physician may decide to consider radiation therapy (RT) at any point after the PSA increase. Studies suggest RT may be a good idea in men with a PSA of ≤ 2.0ng/ml after prostate removal. Every physician has a different point when the “pull the trigger” and suggest RT after surgery (also known as salvage radiation.)

When does hormone therapy come into play? The term hormonal therapy (also known as Androgen Deprivation Therapy (ADT)) refers to treatments meant to eliminate testosterone production by surgical removal of the testicles or chemically castrate the patient with drugs such as Lupron.

The negative impact on quality of life in men on ADT can be significant. Such symptoms include hot flashes, bone loss, increased fracture risk, sexual dysfunction, loss of libido, memory loss, increased fat deposition, loss of muscle mass and other metabolic changes that may increase the risk for heart disease. 

Men on ADT are encouraged to include weight resistant exercises, three times a week and to consume a group of that can help support bone, heart and brain health. 

Lastly, not everybody with BCR (PSA recurrence) needs treatment. A man with a detectable and low PSA level of 0.05 ng/ml after RP may have a persistently detectable PSA without significant change for a long time. Such a patient is unlikely to progress and suffer prostate cancer-related death because as Djavan et al. showed, there can be benign prostate tissue left behind. 

Bottom line: Every prostate cancer recurrence situation is different, and the treatment approach should be individualized. 

The takeaway:

  1. Biochemical recurrence (PSA increase) after prostate treatment is more common than people think.
  2. Men tend to be, intentionally or unintentionally naïve about the possibility of biochemical recurrence. 
  3. Not all men with rising PSA after prostate cancer die from this disease. Most die from other causes. About a third of men with cancer recurrence of the prostate do die from prostate cancer.
  4. A cancer-specific lifestyle not only helps with the reduction of prostate cancer recurrence but also with a lessened chance of dying young from heart disease. 


References:

Nieder AM, Porter MP, Soloway MS. Radiation therapy for prostate cancer increases subsequent risk of bladder and rectal cancer: a population based cohort study. J Urol. 2008 Nov;180(5):2005-9;

Djavan B., Milani S., Fong Y. K. (2005). Benign positive margins after radical prostatectomy means a poor prognosis – pro. Urology 65, 218–220.

Freedland S. J., Humphreys E. B., Mangold L. A., Eisenberger M., Dorey F. J., Walsh P. C., Partin A. W. (2005). Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. JAMA 294, 433–439.

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