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How Is Relapsed Prostate Cancer Treated?

How Is Relapsed Prostate Cancer Treated? 

Prostate cancer is men’s most common form of cancer, not including skin cancer. Initial treatments for prostate cancer include surgery to remove the prostate (radical prostatectomy), radiation (the use of high-energy beams administered externally to kill cancer cells), and brachytherapy (a form of internal radiation). 

These treatments often cure prostate cancer, but nearly one-third of men who undergo initial treatment experience a relapse (also called a recurrence), meaning their cancer has returned. This article discusses relapsed prostate cancer and the standard approaches doctors use to treat it. 

How Do I Know That My Cancer Has Come Back? 

After undergoing initial prostate cancer treatment, your doctor will monitor you closely for signs that your cancer has come back, which can occur if the therapy you received left some malignant cells behind. The most common tool for monitoring men treated for prostate cancer is the prostate-specific antigen (PSA) test, which measures levels of protein associated with prostate cancer in the blood. As you may know, the PSA test is a widely used screening tool for detecting prostate cancer early. But doctors also use the PSA test after a man has been treated to look for signs that some cancer cells remain in his body. You and your doctor will decide on how often your PSA should be tested, but every six months is typical. 

Following initial treatment for prostate cancer, your PSA level should drop. How much and how fast it drops will depend on the form of treatment you receive. For example, after a man undergoes a radical prostatectomy, his PSA level will often drop to zero within weeks. However, in men who undergo radiation, the drop in PSA usually takes longer, up to a few years. Keep in mind that PSA levels fluctuate for various reasons, so if your level rises after treatment, that doesn’t necessarily mean your cancer has returned. 

Doctors often use the phrase “biochemical recurrence” when a man’s PSA rises to a level that suggests cancer may have returned after initial treatment. Different thresholds are used to diagnose the biochemical recurrence of prostate cancer, depending on which initial treatment you received. 

  • If you underwent radical prostatectomy, doctors generally diagnose biochemical recurrence if your PSA rises to 0.2 ng/mL or more. 
  • If your initial treatment was radiation therapy, doctors typically diagnose biochemical recurrence if your testosterone level is average and your PSA level rises to 2.0 ng/mL or above the lowest PSA value you achieved following treatment. 

Other tests your doctor may use to monitor whether your prostate cancer has returned include: 

  • In a digital rectal exam (DRE), your doctor examines the prostate with a gloved and lubricated finger inserted in the rectum. Your doctor will probably suggest performing a DRE at least once a year. 
  • Prostate biopsy with an imaging test. Your doctor may recommend performing a prostate biopsy every one to three years. In a prostate biopsy, fine needles are inserted into the rectum to extract tissue samples from the prostate gland, which are tested for the presence of cancer in a lab. Your doctor may have you undergo a magnetic resonance imaging (MRI) scan of the prostate before performing the biopsy. If any suspicious masses appear on the biopsy, the needles can be aimed to target those areas of the prostate. 

If you experience biochemical recurrence or have other concerning test results, your doctor will discuss additional treatment to get the cancer under control. 

How Does My Doctor Choose A Treatment? 

The treatment your doctor recommends for relapsed prostate cancer will depend on the type of initial treatment you received, whether there’s any evidence that the cancer has spread to other parts of the body, and several other factors, such as: 

  • The tumor’s original Gleason score: In this test, a doctor views cancer cells under a microscope. Normal-looking cells receive a lower Gleason score, but if the tumor has a large portion of abnormal cells, it is suspected of being potentially aggressive and gets a higher score. 
  • PSA doubling time: A doctor will track how fast your PSA is rising. If it doubles in less than six months, the cancer may be more aggressive than if doubling time is higher. 
  • A patient’s age: Older men with relatively short expected lifespans may, in some cases, choose less-aggressive treatment. 

What Are My Treatment Options? 

If you have relapsed prostate cancer, the treatment options your doctor will present to you will depend on the factors described in the previous question, which include the type of initial treatment you received, whether your doctor thinks your cancer has spread, your tumor’s Gleason score, your PSA doubling time, and your age. 

  • Active surveillance: Regardless of what form of initial treatment you received, if your recurring prostate cancer appears to be localized (meaning it hasn’t spread) and is progressing very slowly (as determined by Gleason score and PSA doubling time), and it isn’t causing symptoms, your doctor may give you the option of delaying treatment and undergoing regular monitoring, known as active surveillance (sometimes called watchful waiting). If tests indicate that your relapsed prostate cancer has turned aggressive and could spread, you can initiate one of the following treatments immediately. Studies indicate that active surveillance is a safe option for properly chosen men. 
  • Radiation therapy: If you had radical prostatectomy as your initial treatment for prostate cancer and the disease doesn’t seem to have spread beyond the prostate and nearby tissues, your doctor will most likely recommend radiation therapy to treat a relapse. Your doctor may call this procedure salvage radiation therapy. There are several forms, but in most cases, radiation is administered from outside the body. There are different regimens, but it’s common for patients to require radiation sessions five days a week for several months. 
  • Cryotherapy: If you had radiation as your initial treatment for prostate cancer, you probably are not a candidate for more radiation, which could cause serious side effects. In some cases, doctors will offer cryotherapy, in which probes inserted into the prostate deliver extremely cold gases that freeze and destroy the prostate. 
  • Radical prostatectomy: You may also be offered surgical removal of the prostate if you have a relapse following initial treatment with radiation therapy. Unfortunately, a radical prostatectomy performed after radiation therapy (sometimes called salvage prostatectomy) carries a higher risk for side effects such as urinary incontinence and is technically challenging, which is why some hospitals don’t perform the procedure. 
  • Hormonal therapy: If other treatments haven’t worked or aren’t an option for a patient with relapsed prostate cancer, doctors sometimes use hormonal therapy to slow down cancer progression rapidly. The goal of hormonal therapy is to block the effects of androgens, or male hormones, which feed the growth of prostate tumors. There are various forms of hormonal therapy available.   

Which Treatment Should I Have? 

While there are several treatment choices for relapsed prostate cancer, your options will be dictated in large part by the initial treatment you received and what testing indicates about the nature of your cancer recurrence—whether it appears to be aggressive and may spread, or it seems to be slow growing (often called “indolent”). For example, if you had radiation therapy as initial treatment, that option is likely off the table since an additional course of treatment could be too toxic. Active surveillance probably isn’t the right option if your original tumor had a high Gleason score and your PSA doubling time is six months or less. Ultimately, the choice of what treatment is right for you should be made in consultation and shared decision-making with your doctor. 

What If The Treatment Stops Working? 

If the treatment you receive for relapsed prostate cancer fails and the malignancy progresses, that means your cancer may have begun spreading (or metastasizing) to other parts of the body, such as the lymph nodes and the bones. This condition, known as metastatic prostate cancer, may be treated with hormonal therapy (including orchiectomy or surgical castration), chemotherapy, immunotherapy, or targeted therapies. 

Do I Need Treatment Right Away? 

Whether you need treatment right away depends on what tests indicate about the nature of your relapsed prostate cancer. If it appears indolent (or slow growing), then you may be a candidate for active surveillance, meaning you may be able to safely postpone treatment. However, there are clear evidence studies indicating that tumors with a more aggressive-seeming profile benefit from early treatment. That is, men who undergo additional treatment at the first sign of prostate cancer recurrence have better outcomes than men who delay treatment. 

Can Clinical Trials Help Me? 

When you speak with your doctor about treatment options for relapsed prostate cancer, it’s essential to include a conversation about whether you are a candidate for a clinical trial of an experimental therapy. Massive Bio specializes in finding clinical trials for men with prostate cancer, giving them access to promising drugs and innovative treatments long before they’re made available to the public. If your prostate cancer has relapsed, we’re here to help. If you aren’t sure whether you’re experiencing a cancer recurrence, that’s okay. Additional testing can help you determine your exact diagnosis. 

Sources: American Cancer Society, ASCO Educational Book, Journal of Clinical Oncology  

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