How to handle a relapse after treatment for prostate cancer - Part One

Marc B. Garnick, M.D., discusses what biochemical recurrence means and what your options are

“Am I going to die?”

This is the first question a patient usually asks me when a follow-up blood test reveals that his prostate-specific antigen (PSA) level has risen after he has already undergone treatment for prostate cancer (usually a radical prostatectomy or radiation therapy).

The fear is understandable: When PSA levels rise to a certain threshold after prostate cancer treatment, the patient has suffered what is known technically as a biochemical recurrence, sometimes also referred to as a biochemical relapse or stage D1.5 disease.

Whatever term is used, it means that prostate cancer remains within the prostate after radiation therapy, that it survived outside the excised area after radical prostatectomy, or that it has reappeared in metastatic form in other tissues and organs.

In most cases the cancer remains at a microscopic level, and many years will pass before any physical evidence of it is detectable on a clinical exam or any abnormalities are seen on a bone scan or CT scan.  That’s usually of small comfort to the patient whose PSA has risen. It’s emotionally traumatic to go through treatment for prostate cancer, thinking it is cured, and then learn that it might have come back.

For many men, it’s as if they’re dealing with another diagnosis of cancer, except this time it’s much worse because there is less likelihood of getting cured.

A man’s confidence and sense of safety may be shattered, especially because the popular misconception is that when prostate cancer recurs, it is deadly.  Which brings me back to my patient’s question: “Am I going to die?”  The simple answer is yes, eventually — we all do — but you may not die from prostate cancer. Of course, with prostate cancer, nothing is simple.

This may be one disease, but it can appear in multiple forms, so every diagnosis or recurrence requires individualized assessment and intervention. To start thinking about the salient issues, see “Four key questions.”

Four key questions

If your PSA rises after prostate cancer treatment, answering four key questions will help you and your doctor determine next steps:

   •   What were your risk characteristics, such as Gleason score, PSA, and cancer stage, at the time of diagnosis? (See Table 1.)

   •   What type of treatment did you have? That will help determine your next treatment options.

   •   How long has it been since you underwent initial therapy for prostate cancer? This helps indicate how aggressive follow-up treatment needs to be.

   •   How fast is your PSA rising, as determined from several evaluations?

In practical terms, biochemical recurrence means that you are now dealing with a chronic disease, like diabetes, so that your clinical monitoring will have to increase and you may need to choose or adjust treatment to meet new challenges.

 

Unfortunately, we don’t yet have sufficient research to provide clear guidance about when a second therapy (referred to as salvage therapy) should be considered after biochemical recurrence, and which type of salvage therapy is most effective in particular circumstances. (Salvage therapy is a terrible term, but I use it in this article because it is the standard name for follow-up therapy.)

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Table 1: Predictors of biochemical recurrence at time of diagnosis Although a number of clinical factors contribute to your risk of relapse after treatment, the parameters below provide a simpler assessment of your chances of biochemical recurrence, based on your clinical profile at the time of diagnosis. For more sophisticated estimates, based on specific risk factors, see Figures 1 through 3 ____________________________________________________________________________________________________________

Low risk (33% chance of biochemical recurrence within five years)

Gleason score less than or equal to 6 and PSA less than or equal to 10 ng/ml and Cancer stage T1c or T2a.

</></></> Intermediate risk
(50% chance of biochemical recurrence
within five years)
 
Gleason score of 7 (if 3+4)

and/or PSA greater than 10 but no greater
than 20 ng/ml

and/or Cancer stage T2b.
</></></> High risk
(85% chance of biochemical recurrence within
five years)
Gleason score of 7 (if 4+3), or 8 or more

and/or PSA greater than 20 ng/ml

and/or Cancer stage T2c or more
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For those who have already suffered a biochemical recurrence after being treated for prostate cancer — or dread each follow-up blood test because it might signal such a recurrence — the next article in this series explains what a rising PSA after treatment really means and what your treatment options are.