Neha Vapiwala, MD
Last Modified: February 25, 2007
Dear OncoLink "Ask the Experts,"
Even though he is 61 years old and has had extensive blood work done twice a year, my husband never had a PSA drawn until two months ago. His PSA was elevated, and he was found to have prostate cancer. He had a radical retropubic prostatectomy. The cells were found to be poorly differentiated, and the cancer was high grade. The urologist said the prostate was totally consumed with the tumor. There were no signs of metastases at this point. The stage was T2c, margin-defined. Should we have expected our family doctor to be monitoring his general health with no PSA for 10 years? What is his probable future?
Neha Vapiwala, MD Senior Editor of OncoLink and Assistant Professor in the Department of Radiation Oncology at the Hospital of the University of Pennsylvania responds:
Although there is a lot of controversy regarding PSA screening, the typical recommended age for men without family history to get their first baseline PSA is 50 years old. Some advocate obtaining the first baseline PSA at around age 40-45 years old for those that have a strong family history of prostate cancer diagnosed at an early age.
A digital rectal examination is also recommended in conjunction with the PSA for prostate cancer screening. The combination of serum PSA level and digital rectal exam should be performed on a yearly basis along with one's routine physical examination.
Despite not having his PSA checked until age 61, your husband appears to have a localized cancer from the limited information that you have provided. According to the current AJCC (American Joint Committee on Cancer) staging system, clinical/ pathological stage T2c means involvement of both lobes of the prostate, but no invasion outside of the capsule).
The bottom line is that this is a curable cancer with the surgery that you described. Of course, there is no guarantee that the cancer will not come back in the surgical bed or in the bones, but with negative surgical margins, the chances are very good that there was no spread. The two potential confounding factors could be the high grade nature of the tumor and the original PSA level. If the tumor is truly high grade (i.e. Gleason score of 8 or 9), and the PSA prior to surgery was greater than 20, the chances are not as promising that the cancer is all gone. Ultimately, the best and only way to know whether the surgery cured the cancer once and for all is to follow the PSA regularly over time. As the prostate has been surgically removed, his PSA should be zero or undetectable forever. Any rise in the PSA, or failure of the PSA to drop to zero after surgery, indicates that there may be residual cancer. Treatment options at that time include hormonal therapy, radiation therapy, and/or chemotherapy.
Please consult our section on prostate cancer for more information.