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• Highlights
• Introduction
• Prognosis
• Risk Factors
• Symptoms
• Conditions with Similar Symptoms
• Screening and Diagnosis
• Tests to Determine Severity of Cancer
• Staging and Grading
• Treatment Options by Staging and Grading
• Treatment for Localized Prostate Cancer
• Surgery
• Radiation Treatments
• Options if Treatments Fail
• Other Treatments
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Prostate cancer

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of prostate cancer.

Options if Treatments Fail

Indications of Persistent Cancer after Initial Treatment

Rising PSA Levels. If prostate cancer has been eliminated, PSA levels should drop to 0.5 ng/mL or less after treatment. A sudden rise or persistently elevated PSA levels after treatment are often indications that prostate cancer persists:

• If PSA levels are above 2.0 ng/mL, then cancer is most likely still present.
• If PSA levels are between 0.5 and 2.0 ng/mL, the situation is less clear. One study indicated that measuring free PSA may help determine the status of the cancer in such patients. An average free PSA of 27% indicated that cancer had been eliminated, while an average of 15% meant that cancer was still present.

Note: It is common for PSA levels to temporarily rise following radiation seed implantation without signaling cancer recurrence.

General Prognosis with Recurrence or Failure

Rising PSA levels do not necessarily mean that the cancer has spread or even that the cancer will recur during a man's lifetime. An actual cure is still possible if the cancer is localized within the prostate. In one study, 64% of patients with rising PSA levels after surgery still had cancer confined to the prostate. Indications of a poorer outlook in this study included:

• Cancer penetration of the prostate capsule
• Positive surgical margins (microscopic evidence of cancer cells at the very edge of the resected specimen)
• Invasion of nearby vessels or lymph nodes

Still, among the men in the study, after 7 years only 3% of patients had died of prostate cancer. After 15 years, only 19% had evidence of recurrence. Other markers for persistent cancer are under investigation. For example blood tests that show low levels of acid phosphatase (ACP) before treatments may predict a higher chance for recurrence-free survival.

Treatment Options for Recurring or Persistent Prostate Cancer After Local Treatment

Treatment for recurring cancer is not always clear-cut. If the cancer recurs locally, cure may still be possible:

• Surgery and androgen-suppression therapy may be considered for patients who were first treated with radiation
• For patients who were initially treated with surgery, radiation or androgen-suppression therapy are both options

If the disease has already spread or if the doctor suspects that it may have spread, the patient is typically given androgen-suppression therapy. Chemotherapy drugs in combination with hormonal drugs are being investigated for patients who fail surgery or radiation.

A 2005 study in the Journal of the American Medical Association suggested three factors that may help doctors and patients decide if additional treatment is needed if cancer recurs after surgery:

• How quickly PSA levels double after surgery (shorter time equals higher risk)
• How quickly the cancer recurred after surgery (shorter time equals higher risk)
• Gleason score (higher score suggests more aggressive tumors and greater risk)

Patients at high risk are more likely to die from the recurrent cancer and should be considered for additional treatments. Patients at low risk face a lower likelihood of death from prostate cancer and probably do not require more treatment. The study found that for patients at low risk, the time to death after cancer recurrence was very long, generally lasting more than 16 years

Androgen-Suppression Therapy. Treatments that block or suppress androgens (male hormones) are often the appropriate response to rising PSA levels after treatment failure. There has been some debate over whether to start this therapy as soon as PSA levels rise or wait until symptoms develop. Some studies indicate there is no increased survival from early treatment, and patients have a better quality of life if therapy is started only after symptoms have occurred. A major analysis in 2002, however, reported that early intervention prolonged survival over a 10-year period.

Salvage Prostatectomy. Salvage prostatectomy is sometimes performed after unsuccessful radiation treatment if the cancer is still local. The odds of the procedure's success are only 10 - 64%. Many experts recommend against salvage prostatectomy in most cases of radiation failure. Severe complication rates for salvage prostatectomy are very high: 10 times that of men who have not had radiation. For example, incontinence after salvage prostatectomy is often untreatable with medications, collagen implants, or other standard treatment measures.

Salvage Cryosurgery. Salvage cryosurgery may be effective in certain patients who fail external beam radiotherapy. The best candidates are those with Stage II cancer or less and PSA levels below 10 ng/mL.

Adjuvant and Salvage Radiation. Radiation is proving to help patients who still show detectable levels of PSA after surgery (generally 2 ng/mL or less). It may even be useful years after surgery if PSA levels rise. Depending on timing, radiation after treatment failure is referred to as either:

• Adjuvant radiation is radiation therapy performed within 6 months of surgery. One area of controversy is whether to use adjuvant radiation after surgery on patients whose PSA levels are very low or undetectable but who have other test results that indicate the cancer is likely to spread. Patients with adverse findings and low PSA have to weigh the potential complications of radiation therapy against the odds of recurrence without it, which are about 20 - 30%. A small 2006 study found that adjuvant radiation worked much better than salvage radiation for men with advanced (stage III or IV) local prostate cancer.
• Salvage radiation is radiation therapy more than 6 months after surgery. A 2004 study suggested that salvage radiation could be more beneficial than previously thought, even for men with aggressive prostate cancer. Researchers studied 501 men who had undergone radical prostatectomy (surgical removal of the prostate gland) and subsequently received radiation treatment for recurrent cancer (as indicated by rising PSA levels). Men with lower Gleason scores and lower PSA levels benefited the most from salvage radiation. However, even men with higher-grade cancers were able to delay metastatic cancer progression as long as they received radiation at an early stage while their PSA levels were relatively low (less than 2.0 ng/mL).

• Review Date: 7/9/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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