Neha Vapiwala, MD
Last Modified: February 25, 2007
Dear OncoLink "Ask the Experts,"
I had a radical prostatectomy 4 years ago for and early stage prostate cancer. I am concerned that my PSA is slowly rising. What should be my next steps? Am I able to have more treatment if necessary?
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:
Early-stage prostate cancer patients who appear to have all of the disease confined to the prostate and who have negative margins of resection (margin refers to the rim of normal tissue surrounding the tumor when it is removed from the body - a safety margin, if you will) usually do very well with radical prostatectomy. In many studies, 70 - 95% of these patients will never develop any recurrence of the cancer after surgery. Patients who undergo radical prostatectomy successfully should have and maintain undetectable PSA levels, since the entire prostate, including all of the cancerous tissue, should have been removed.
However, if the serum PSA starts to rise to a detectable level in the absence of new clinical symptoms, one may have what is called a "PSA failure". A PSA failure, also called a biochemical failure, means that the PSA rises above zero but there is NO clinical proof that the cancer has come back on digital rectal exam or radiographic studies. A detectable PSA suggests that there may be prostate cancer present at the microscopic level. In these situations, further imaging studies of the abdomen and pelvis along with a biopsy of the vesicourethral junction may be indicated.
Treatment options in this scenario include no intervention but just continued interval checks of the PSA and periodic rectal examinations. Proper intervention may be necessary if you have more symptoms or if the PSA gets "high enough" (what defines "high enough" should be decided between the patient and his doctors).
One such intervention is external beam radiation therapy delivered to the area where the prostate used to be, called the prostate bed or prostatic fossa. This local therapy can be given for a second chance at cure (salvage radiation) if there is felt to be a relatively high risk of local recurrence based on pathologic factors and time since surgery. In contrast, if there appears to be a higher likelihood of distant recurrence at a site outside of the prostate bed, hormonal therapy is an option and can be given alone or concurrently with radiation therapy to the prostate bed. Hormonal therapy in prostate cancer refers to androgen ablation; these ablative drugs essentially cut off the stimulating effect of testosterone on prostate cancer growth.
Ultimately, it is very important that each patient discusses the details of his case in depth with his urologist and/or oncologist