Recurrent Cancer

After your initial treatment for localised or locally-advanced prostate cancer is complete, the next stage of your recovery is monitoring and checking that all the cancer has been eradicated from the body. Some prostate cancer cells might have been able to spread outside the treatment areas before they could be removed or killed. At some point these cells may begin to multiply and produce enough PSA to become detectable by a blood test. Monitoring for recurrence or ‘relapse’ typically involves regular PSA tests, which are usually repeated every 6 months for the first 5 years, then yearly. A DRE prostate exam is sometimes performed every year but may be omitted if the PSA level is undetectable. If your PSA starts to rise, it could be a sign of your cancer returning, or it could be a sign of something else, dependent on which treatment you have had.

Surgery

If you had the prostate removed by surgery, your PSA should be undetectable with a reading of less than 0.01ng/ml, which is effectively zero, but by definition can never get all the way to zero. Following a prostatectomy, the most recognised confirmed PSA reading relating to recurrence is >0.20ng/ml. It is important to use the same lab for measuring your PSA result, as PSA levels can fluctuate from lab to lab dependent on machine calibration.

Radiation Therapy

Following radiation therapy, your consultant will need to look for confirmation from several PSA tests, because PSA can jump or ‘bounce’ for a short period, before returning to its low level, which is called your ‘baseline’ reading (as measured on two consecutive tests). PSA bounces can typically occur between 12 months and 2 years following the end of your initial therapy. If your PSA rises more than 2.0ng/ml above your baseline reading, that can be an indication of cancer recurrence.

The rate (or velocity) at which your PSA rises after prostatectomy or radiation therapy can be a significant factor in determining how aggressive your cancer is and can therefore be useful in deciding how aggressively it might need to be treated.

Recurrent Prostate Cancer after Surgery

Should your PSA start to rise after surgery, then ‘salvage’ radiation therapy could be right for you. EBRT is delivered to the area that the prostate used to occupy (called the prostate bed), the object being to eradicate any cancer cells that were left behind after surgery. Approximately 80% of men with a rising PSA after surgery have a regrowth contained within the prostate bed.

If the cancer has spread to other areas of the body and become metastatic then salvage radiation therapy is unlikely to be the best choice, as it will only target the prostate bed and potentially the nearby lymph nodes. Salvage radiation therapy (like all salvage therapies) is likely to cause an increase in side effects on top of those previously experienced with surgery.

Recurrent Prostate Cancer after Radiotherapy

Many patients now have a course of Hormone treatment in addition to radiation (EBRT), but should your PSA start to rise after this treatment has finished, there are options. Low dose-rate brachytherapy (seed implant), can treat the prostate provided there is no spread outside the gland. Likewise, it would be possible to have cryotherapy (freezing), although men with higher-grade disease do not respond well to treatment. Surgery to remove the prostate is difficult after EBRT and very few surgeons would take this on, it would depend on several factors such as age and aggressiveness of the tumour.

Salvage HIFU can be used after several first-line treatments such as EBRT, brachytherapy, cryotherapy; and also if HIFU itself has been used as a first treatment. Men with a rapidly rising PSA are likely in the first instance to be given Hormone treatment in order to arrest the cancer growth, and imaging scans will then detect any spread outside of the prostate bed.