RISING PROSTATE SPECIFIC ANTIGEN (PSA) AFTER SURGICAL REMOVAL OF ATHE PROSTATE (RADICAL PROSTATECTOMY) FOLLOWED BY RADIATION THERAPY FOR PROSTATE CANCER


PSA stands for Prostate Specific Antigen and is a blood test that is used to screen for the presence of prostate cancer and, in those men known to have prostate cancer, PSA becomes a tool to measure the effectiveness of the treatments that have been used.

WHAT IS PSA, AND HOW DO WE MEASURE IT?
An antigen is a medical or biological term for a substance or protein that stimulates the body to make antibodies.

Prostate Specific Antigen is a protein found in the serum that is unique or specific for the prostate, both normal prostate and prostate cancer cells. In the case of prostate cancer, the PSA will reflect the presence of the tumor, wherever the cancer cells are present in the body. No other tissues or body parts can make Prostate Specific Antigen. Therefore, the PSA levels can be measured in an individual's serum and with this information we are able to follow prostate cancer. PSA, itself, is not harmful and a rising PSA in the blood by itself is only a laboratory test or assay of a small amount of this unique protein in your blood. It is the prostate cancer which must be treated, not the PSA.

Almost all prostate cancer cells manufacture PSA and as the prostate cancer grows, more PSA is released into the blood stream and the PSA values rise. Conversely, if the cancer is diminishing the PSA values fall. This fact allows us to track treatment effectiveness using PSA levels.

WHAT IS THE SIGNIFICANCE OF THE PSA IF I HAVE PROSTATE CANCER?
When a man has had a surgical removal of the prostate (radical prostatectomy) followed or preceded by radiation therapy, the entire prostate are is treated and hopefully all of the cancer cells will have been killed or at least made unable to grow further. The PSA level, which is a reflection of the presence of the cancer, should fall as the cancer cells die. Because not all cells are killed immediately and many of the non-cancerous prostate cells will not be killed, some cells will remain that do manufacture PSA. The normal values printed on laboratory sheets that say ‘less than 4.0’ are screening values for men who still have their prostate. After radiation, we would hope that the PSA will fall to very low levels, certainly less than 1.0. But whatever the lowest value achieved, we look for a stable value. If the PSA falls and then starts to rise, this almost always means that cancer cells are growing once again.

Said again, if a man has a rising PSA after radical surgery and then radiation therapy, he has residual or recurrent prostate cancer. The PSA rise does not tell where the cancer is, only that it is somewhere. Prostate cancer may return in the bed of the former prostate (local recurrence-for the most part this means the lower portions of the bladder) or it may return in any body tissue away from the prostate (distant spread or metastases), most commonly in bone or lymph nodes. In most cases the rate of rise of the PSA reflects the growth rate of the residual cancer.

WHEN SHOULD THE FIRST PSA LEVEL BE DRAWN AFTER RADIATION THERAPY FOR FAILED RADICAL PROSTATECTOMY?
While there is no set standard, we measure the PSA values every three months for the first year after radiation completion, every six months the second year, and then yearly for ten years.   

Free PSA, Complex PSA (PSA-ACT), hK2 and other new PSA screening tests have no benefit over the current used PSA tests in patients who already have a diagnosis of prostate cancer. They are helpful only in screeing situations in helping us determine who needs or does not need a biopsy.

WHAT TO DO WHEN THE PSA LEVEL IS FOUND TO BE RISING?
Whenever cancer recurrence is suspected, we often try to determine the whereabouts and extent or stage of the cancer. That is, where is it and how much is there? If we can localize the cancer, we may have a better chance of treating it and following its course. Statistically, the most common place for return of the cancer is in the prostatic bed.

The tests that will be done might include a rectal examination and ultrasound and biopsy of the prostatic bed to look for local recurrence. Other prostate cancers will recur at distant sites, particularly bone, and more particularly, the bones of the pelvis and spine, or the lymph nodes of the pelvis. To complete the evaluation, a bone scan, chest X-ray, CAT scan or MRI scan might be done depending on how recently those tests might have been done.

WHAT TO DO?? - THE THREE SCENARIOS

THE AREA OF RECURRENCE CANNOT BE FOUND?
First, NO MORE RADIATION MAY BE GIVEN TO THE PROSTATIC BED!!. The tissues around the prostatic bed would not tolerate further treatment and severe rectal and bladder problems would be expected. 

This is a dilemma but since surgery of local recurrence is rarely effective and since radiation to the prostatic bed a second time is not feasible, we treat patients as if the disease was at distant sites.

Hormone therapy could be started immediately, or delayed until symptoms of cancer growth are present. Overall survival time may be improved by starting hormone treatments earlier and much evidence exists that treating early will prevent recurrence for a longer period of time. This is particularly true for patients with higher grade cancers (Gleason score 8, 9 or 10). Some series of patients with very early spread of cancer can have very long survivals if treated with hormone therapy early.

Another approach to determine a reasonable start to therapy may be the rate of rise of the PSA. Experience suggests that the faster rising PSAs will cause trouble sooner. A recent study suggested that if the PSA doubles within a year that a high probability for bone spread exists. If the ‘doubling time of PSA’ is more than one year, many patients remained without cancer problems for 6 or 7 years.

If the side effects of hormone deprivation are unacceptable (impotency, no libido, hot flashes), then delay in treatment may improve quality of life without shortening life expectancy too significantly. The PSA rate of rise (or the time it takes the PSA to double in value) and the grade of the cancer should be taken into consideration when making a decision whether or not to start treatment. Many patients elect to delay treatment until actual evidence of spread of the cancer can be found. The most common area of spread is to the bones and bone spread occurs rarely with the PSA below 10.

CANCER IS FOUND IN THE PROSTATIC BED AND NOWHERE ELSE?
First, NO MORE RADIATION MAY BE GIVEN TO THE PROSTATIC BED!!. The tissues around the prostatic bed would not tolerate further treatment and severe rectal and bladder problems would be expected.

If the cancer is found in the prostatic bed suggesting an incomplete response to radiation and if no other evidence of cancer is found, the cancer might still be curable by removing the recurrent mass. This option is rarely suggested or performed because of a very high complication rate due to the prior radiation and surgery and a statistically very small chance of removing all the cancer. In addition, to have any realistic chance of removing all the cancer cells, the bladder and rectum would have to be removed to do this type of salvage procedure. Bladder removal would entail diversion of the urine flow to a stoma (bag on the skin for urine drainage) or some other type of urinary diversion. Rectal removal would require a permanent colostomy (a second bag on the skin for stool drainage)

Hormone therapy could be started immediately, or delayed until symptoms of cancer growth are present. Overall survival time may be improved by starting hormone treatments earlier and much evidence exists that treating early will prevent recurrence for a longer period of time. This is particularly true for patients with higher grade cancers (Gleason score 8, 9 or 10). Some series of patients with very early spread of cancer can have very long survivals if treated with hormone therapy early.

Another approach to determine a reasonable start to therapy may be the rate of rise of the PSA. Experience suggests that the faster rising PSAs will cause trouble sooner. A recent study suggested that if the PSA doubles within a year that a high probability for bone spread exists. If the ‘doubling time of PSA’ is more than one year, many patients remained without cancer problems for 6 or 7 years.

If the side effects of hormone deprivation are unacceptable (impotency, no libido, hot flashes), then delay in treatment may improve quality of life without shortening life expectancy too significantly. The PSA rate of rise (or the time it takes the PSA to double in value) and the grade of the cancer should be taken into consideration when making a decision whether or not to start treatment. Many patients elect to delay treatment until actual evidence of spread of the cancer can be found. The most common area of spread is to the bones and bone spread occurs rarely with the PSA below 10.

Alternatively, the cancer could be left alone. If the PSA rise is slow, suggesting slow growth, particularly in men with advanced age or other medical problems, watchful waiting may be the wiser of choices.

CANCER IS FOUND AT DISTANT SITES OR BOTH DISTANT AND NEARBY?
If the cancer is found elsewhere, even at only one spot, it is very likely that more areas exist that cannot be seen. Surgery in these situations, again, is not curable. Sometimes a specific area will cause symptoms, or in the case of a bone, have the risk of fracture. In these circumstances, we recommend radiation to the specific area. If a weight-bearing bone is not involved and no symptoms are present, the best options are the use of hormone treatments or observation until symptoms or danger are imminent.

Hormone therapy could be started immediately, or delayed until symptoms of cancer growth are present. Overall survival time may be improved by starting hormone treatments earlier and much evidence exists that treating early will prevent recurrence for a longer period of time. This is particularly true for patients with higher grade cancers (Gleason score 8, 9 or 10). Some series of patients with very early spread of cancer can have very long survivals if treated with hormone therapy early.

Another approach to determine a reasonable start to therapy may be the rate of rise of the PSA. Experience suggests that the faster rising PSAs will cause trouble sooner. A recent study suggested that if the PSA doubles within a year that a high probability for bone spread exists. If the ‘doubling time of PSA’ is more than one year, many patients remained without cancer problems for 6 or 7 years.

If the side effects of hormone deprivation are unacceptable (impotency, no libido, hot flashes), then delay in treatment may improve quality of life without shortening life expectancy too significantly. The PSA rate of rise (or the time it takes the PSA to double in value) and the grade of the cancer should be taken into consideration when making a decision whether or not to start treatment. Many patients elect to delay treatment until actual evidence of spread of the cancer can be found. The most common area of spread is to the bones and bone spread occurs rarely with the PSA below 10.

SUMMARY
Some the these issues have not been completely described here, including the various forms and side effects of hormone deprivation therapy. We will be happy to go over this with you in more detail or provide further reading.

Ask questions if you have them.