Prostate Cancer

Description

Alternative Names

Options if Treatments Fail

Indications of Persistent Cancer after Initial Treatment

Rising PSA Levels. If prostate cancer has been eliminated, PSA levels should drop to 0.5 ng/mL or less after treatment. A sudden rise or persistently elevated PSA levels after treatment are often indications that prostate cancer persists:

• If PSA levels are above 2.0 ng/mL, then cancer is most likely still present.
• If PSA levels are between 0.5 and 2.0 ng/mL, the situation is less clear. One study indicated that measuring free PSA may help determine the status of the cancer in such patients. An average free PSA of 27% indicated that cancer had been eliminated, while an average of 15% meant that cancer was still present.

Note: It is common for PSA levels to temporarily rise following radiation seed implantation without signaling cancer recurrence.

General Prognosis with Recurrence or Failure

Rising PSA levels do not necessarily mean that the cancer has spread or even that the cancer will recur during a mans lifetime. An actual cure is still possible if the cancer is localized within the prostate. In one study, 64% of patients with rising PSA levels after surgery still had cancer confined to the prostate. Indications of a poorer outlook in this study included the following:

• Cancer penetration of the prostate capsule.
• Positive surgical margins (microscopic evidence of cancer cells at the very edge of the resected specimen.
• Invasion of nearby vessels or lymph nodes.

Still, among the men in the study, after seven years only 3% of patients had actually died of prostate cancer. After fifteen years, only 19% had evidence of recurrence. Other markers for persistent cancer are under investigation. For example blood tests that show low levels of acid phosphatase (ACP) before treatments may predict a higher chance for recurrence-free survival.

Treatment Options for Recurring or Persistent Prostate Cancer After Local Treatment

Treatments for cancer that has recurred after initial therapy is not always clear-cut. If the cancer recurs locally, cure may still be possible:

• Surgery and androgen-suppression therapy may be considered for patients who were first treated with radiation receive.
• For patients who were initially treated with surgery, radiation or androgen-suppression therapy are both options.

If the disease has already spread or if the physician suspects that it may have spread, the patient is typically given androgen-suppression therapy. Chemotherapy agents in combination with hormonal agents are being investigated for patients who fail surgery or radiation.

Androgen-Suppression Therapy. Treatments that block or suppress androgens (male hormones) are often the appropriate response to rising PSA levels after treatment failure. There has been some debate over whether to start this therapy as soon as PSA levels rise or wait until symptoms develop. Some studies indicate there is no increased survival from early treatment, and patients have a better quality of life if therapy is started only after symptoms have occurred. A major analysis in 2002, however, reported that early intervention prolonged survival over a 10-year period.

Salvage Prostatectomy. Salvage prostatectomy is sometimes performed after unsuccessful radiation treatment if the cancer is still local. The odds of the procedures success are only 10% to 64%. Many experts recommend against salvage prostatectomy in most cases of radiation failure. Severe complication rates for salvage prostatectomy are very high: 10 times that of men who have not had radiation. For example, incontinence after salvage prostatectomy is often untreatable with medications, collagen implants, or other standard treatment measures.

Salvage Cryosurgery. Salvage cryosurgery may be effective in certain patients who fail external beam radiotherapy. The best candidates are those with Stage II cancer or less and PSA levels below 10 ng/mL.

Adjuvant and Salvage Radiation. Radiation is proving to be beneficial in patients who still show detectable levels of PSA after surgery (generally 2 ng/mL or less), and may even be useful years after surgery if PSA levels rise. Depending on timing, radiation after treatment failure is referred to as follows:

• Adjuvant radiation is radiation therapy performed within 6 months of surgery. One area of controversy is whether to use adjuvant radiation after surgery on patients whose PSA levels are very low or undetectable but who have other test results that indicate the cancer is likely to spread. Patients with adverse findings and low PSA have to weigh the potential complications of radiation therapy against the odds of recurrence without it, which are about 20% to 30%.
• Salvage radiation is radiation therapy more than 6 months after surgery.