(These subjects are frequent topics in QUEST. In addition to the Q&As below, please use the website search engine for additional coverage.)
1. Q: Where is the cancer when the PSA rises after a radical prostatectomy?
A: It is not possible to say for certain where the recurrent cancer is located, but there is about a 70% chance that it is in the bed of the prostate (where the prostate used to be). Accordingly, radiotherapy has a good chance of controlling it.
2. Q: After a prostatectomy, how can a man have a PSA level without a prostate gland? What is producing the PSA protein material that is in the blood stream if there is no prostate gland?
A: After the prostate gland has been completely removed, any PSA in the blood is produced by prostate cancer cells that have left the prostate gland and spread to other areas of the body. However, sometimes the PSA can appear to be elevated because of a laboratory error.
All elevated PSA levels after surgery should be re-checked to rule out a laboratory error. For practical purposes, it is very difficult to detect PSA when levels are less than 0.2 ng/ml. Therefore, we consider any PSA value less than 0.2 as being negligible. A value of 0.2 or 0.1ng/ml would be considered essentially zero. PSA above 0.2 or above is an indication of cancer recurrence, and treatments for recurrence should begin before the PSA reaches 1.0ng/ml.
3. Q: What kind of follow-up do you recommend after a radical prostatectomy?
A: With any cancer, not only prostate cancer, theres always a possibility that the cancer can come back and thats why patients need to have follow up visits. I recommend a PSA test every six months for 15 years after the operation.
That said, in the category of men who have a prostate cancer removed that is very small and totally contained within the prostate and all the margins are clear and it has not spread to any lymph nodes, the life expectancy is virtually equal to that of the normal population who have never had prostate cancer.
4. Q: How useful is a PSA test once a patient is diagnosed with cancer and in therapy?
A: PSA is an excellent marker for use during and after cancer therapy. Ninety-nine percent of the time, PSA lets a patient know how the cancer is responding to the treatment.
5. Q: What should I do when my PSA level begins to rise after a radical prostatectomy?
A: The two treatment options are postoperative radiotherapy, which should begin before the PSA rises above 1.0ng/ml, and intermittent or continuous hormonal therapy, which can be initiated immediately or delayed until the PSA rises to 4.0.
6. Q: What is follow-up (postoperative) radiotherapy and why would it be needed after a RRP?
A: Sometimes, it is strongly advised when the pathology report shows positive (cancerous) surgical margins or extension of the tumor beyond the prostate gland.
Also, it is sometimes advised when the PSA begins to rise after surgery.
There are two types of follow-up radiotherapy:
- Adjuvant radiotherapy is given as a precautionary measure in patients who have adverse features in their pathology report. This radiotherapy is usually given 3 to 4 months after the operation when urinary continence has returned. It may be delayed further if continence has not yet returned.
- Salvage radiotherapy is for a rising PSA, which means a recurrence of the cancer. This radiotherapy should be given before the PSA level rises about 1ng/ml.
7. Q: Is there any way of predicting if follow-up treatment will work once a PSA has started rising after initial prostate cancer treatment?
A: Not really, but the prospects are better if the PSA begins to rise after a long interval from radical prostatectomy and if the rise is gradual.
8. Q: Why check PSA values after a radical prostatectomy if a man has no prostate?
A: Some rogue cancer cells might escape from the prostate and not be noticed by the pathologist. Any PSA that they produce will be absorbed into the bloodstream and elevate the PSA level. (See www.drcatalona.com and search on postoperative PSA.)
9. Q: When testing for doubling time in a recurrence of prostate cancer after a radical prostatectomy, how often should a man take a PSA test after
the first test indicates a detectable rise?
A: Every 3 months.
However, men who are definitely going to need postoperative adiotherapy by virtue of the fact that they had adverse pathology findings in their final radical prostatectomy specimen should not wait around testing PSA levels to calculate a doubling time, in my opinion.
They should receive salvage radiation as soon as the PSA rises above 0.2.
10. Q: I am 59 and in an advanced stage of prostate cancer. When the PSA starts to rise, at what level does it metastasize?
A: Generally, not before the PSA reaches 50 ng/ml; however, some high grade tumors that do not produce much PSA might produce metastases
at lower PSA levels. The best way to be sure is to have a bone scan, at least yearly, if the PSA is rising. An abdominal and pelvic
CT scan is also helpful to determine whether there are metastases in lymph nodes or other internal organs.
The important point is that with intermittent hormonal therapy, if the PSA level is maintained between zero and four, there is a very low likelihood that the cancer will have spread.
11. Q: What treatments are available when chemo-therapy has failed and hormonal therapy has become ineffective?
A: There are alternative chemotherapy treatments and there are "investigational treatments." Most investigational treatments are at major medical centers or
collaborating hospitals. They are not at all standardized or proven to be safe and effective, and many of them will ultimately fall by the wayside.
So, they are often a gamble.
The best way to learn what is available is to call the medical oncology division at your region’s medical center and ask what clinical trials are available
for patients with prostate cancer that is no longer responding to chemotherapy.
My research group is trying to obtain a blood sample for DNA testing in men with advanced prostate cancer. If you or anyone you know is interested in participating, please contact me by email: firstname.lastname@example.org
12. Q: My husband has an elevated PSA after surgery. The recommendation is for radiation with nothing being said about hormonal therapy. Do you recommend radiation or is hormonal therapy just as effective as radiation?
A: Both are effective. The advantage of radiation is that it is potentially curative if the remaining cancer cells are confined to the radiation fields.
In patients whose PSA remains elevated after surgery, there is a greater chance that the cancer has spread to other sites, and then hormonal therapy is needed.
13. Q: I have a rising PSA after having a radical prostatecomy 16 months ago. I have decided to have salvage radiation. I am getting mixed opinions regarding having a short
course of hormone therapy before the radiation. Do you recommend hormone + radiation therapy for a rising PSA after surgery?
A: Some evidence suggests that when radiation is used as the main treatment for "high risk" tumors (locally advanced or high Gleason grade), combining hormonal therapy with
radiation is beneficial, although there is no proof of this benefit for salvage radiation. However, I frequently recommend it in patients with high Gleason grades (7 or higher).
14. Q: How can prostate cancer recur if it was totally contained within the prostate gland?
A: It cannot recur if it is truly totally contained and the prostate gland is completely removed. However, despite the cancer appearing to be totally contained based upon
the pathology report, some "rogue cancer cells" can escape.
Therefore, there is always a risk for recurrence, no matter how favorable the pathology report, which is why all patients are advised to have follow-up visits. If everything looks
clean on the pathology report, a 5-30% chance of recurrence is still possible, depending upon the Gleason grade and tumor volume.
15. Q: What are the statistics on the recurrence of prostate cancer after a radical prostatectomy?
A: Patients should have their PSA monitored every 6 months for 15 years. The chances for a recurrence decline the longer PSA levels are undetectable.
Overall, about 10% to 30% of patients (depending on the findings in the prostatectomy specimen) who have had a radical prostatectomy have a recurrence in their lifetime. Of these recurrences, about 50% occur during the first three years, about 30% occur from years three to five, and 19% after year five.
16. Q: Do you recommend any tests or procedures other than a PSA for follow up after a radical prostatectomy?
A: I recommend a PSA test every 6 months and a digital rectal examination once a year. If the PSA is in the undetectable range and the digital rectal examination reveals no lumps or bumps that seem suspicious for recurrent prostate cancer, no further testing is indicated.
Although the vast majority of patients with recurrence of their cancer have a rising PSA, a few have a high-grade cancer that might not produce much PSA but might be detected on a digital rectal examination.
17. Q: My pathology report after a radical prostatectomy stated: “Focally involved right posterior, inferior third prostate.” What does focal involvement mean and what does that report mean?
A: “Focal” in this context usually means microscopic amounts of cancer, usually about the size of a pencil dot. The report means that the pathologist found a small region of prostate cancer in the right lobe of the prostate toward the back and lowest regions of the gland. This low-volume of cancer would be a very favorable finding.
18. Q: How long after a prostatectomy is the follow up PSA test a factor in recommending additional treatment?
A: Patients need follow up PSA tests for the rest of their lives.
The PSA should be less than 0.1 after complete removal of the prostate, and if it rises, it is usually evidence of a recurrence.
In some instances the rate of rise is important. If it just begins to rise many years after surgery and rises very slowly, immediate further treatment might not be necessary.
However, if it rises persistently, treatment should be initiated before the PSA rises too much (before the PSA gets higher than 0.5 if the follow-up treatment is to be salvage radiation therapy).
19. Q: My final pathology report after surgery states “perineural invasion present.” What does this finding mean?
A: Perineural invasion is always present in the final prostatectomy specimen, if the pathologist looks carefully.
Basically, the prostate cancer cells are attracted to nerve fibers inside the prostate gland that regulate the amount of prostate fluid secreted.
On the other hand, if perineural invasion is seen on a prostate needle biopsy specimen, it is associated with a higher risk that the cancer has spread at least microscopically outside the prostate capsule, but this is not always the case.
In the final prostatectomy specimen, it has little predictive significance.
20. Q: How can salvage radiation be effective if there's no specific target for the radiation?
A: In patients with tumor recurrence after radical prostatectomy, about 70% of those cases have recurrence that is microscopic and is located in the tissues immediately outside where the prostate was before it was removed.
Thus, treating the tissues surrounding the prostate with radiotherapy has a high likelihood of killing the remaining prostate cancer cells.
21. Q: When post prostatectomy treatment is recommended, when should it be salvage radiation only and when, if ever, should it be hormonal therapy plus radiation?
A: Hormonal therapy plus radiotherapy is recommended when the primary tumor in the prostate had a Gleason grade of 8, 9, or 10.
22. Q: I know you don’t approve of using Avodart when a man has his prostate gland. If I took it after a prostatectomy, could it disguise or slow down a diagnosis of recurrence?
A: Yes, and because there is evidence that men who take Avodart are more likely to have Gleason grade 8-10, it is at least theoretically possible that it might make a tumor recurrence more aggressive, although presently there is no direct evidence that this effect occurs.
23. Q: Please respond to the recent FDA approval of PCA3, the gene labeled as the prostate cancer gene. Reports say it will complement the PSA test and predict which biopsies are needed and which would not be needed. How do you see PCA3 working and what is the testing procedure for it?
A: The PCA3 test is now approved by the FDA for use in men who have already had at least one negative prostate biopsy and are trying to decide whether to have a repeat biopsy. It is now available to the public.
Testing is done by the doctor first performing a finger rectal exam, massaging the prostate to express some prostate cells into the urethra. Then, the patient urinates into a small container.
The urine sample containing the prostate cells is then tested for expression of the PCA3 RNA, which is a gene that is over-expressed in prostate cancer cells.
If the levels are high, it indicates a higher probability for prostate cancer and thus a repeat biopsy is recommended.
In my opinion, the jury is still somewhat out on the value of this test relative to the PSA test or the new Phi test.
24: Q: What would be the difference in effect on recurring prostate cancer between surgical castration, hormonal therapy and radiation?
A: Surgical castration removes all male hormones produced by the testicles. Medical hormonal therapy can also inhibit the effects of male hormones produced in the adrenal glands and other body tissues as well.
Radiation therapy works by an entirely different mechanism; it damages the DNA of prostate cancer cells, preventing them from dividing and growing.
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