What’s Next After Prostate Cancer Recurrence

Prostate cancer recurrence occurs when not all prostate cancer cells were completely killed or removed during initial treatment, or because some of these cells were already beyond the prostate before initial treatment. With time and nourishment readily available, this residual cancer is able to thrive and grow undetected.

About 40% of men who are initially treated for localized prostate cancer, or cancer that has not spread beyond the prostate, will have recurrent prostate cancer later in their lives.  Because the probability of prostate cancer recurrence is so high, it may be more appropriate to view prostate cancer as a chronic life-long disease, rather than a one-time illness curable with a one-time treatment.  In truth, it is a disease that needs to be monitored and cared for throughout a man’s life.

Are You At Risk for Prostate Cancer Recurrence?

Understanding recurrent prostate cancer allows you to work with your doctor in monitoring your health after initial cancer treatment, and if you later need to decide how to handle prostate cancer recurrence.  Follow-up visits, regular PSA testing and other care is essential for men who have undergone prostate cancer treatment.  After treatment ends, it is especially important to be alert to the changes in your body and to report any unusual symptoms to your doctor.

5 Important Questions to Ask Your Doctor About Possible Recurrence:

1. Am I a high risk candidate for prostate cancer recurrence?
2. How shall I be monitored for possible recurrence of prostate cancer?
3. What can I do to decrease my chance of prostate cancer recurrence?
4. What are the recurrent prostate cancer symptoms I should watch out for?
5. Where can I find more information about prostate cancer recurrence?

The Progression of Recurrent Prostate Cancer 

Recurrent prostate cancer and its spread typically follow particular pathways. Prostate cancer recurrence after surgery can occur when microscopic bits of cancer may have been left behind in the bed of the prostate, or the tissue where the prostate had lay.  Recurrent prostate cancer can also occur after radiation treatment, if a portion of the prostate did not receive enough radiation to kill all the cancer cells. At any point, prostate cancer cells may spread beyond the prostate to the seminal vesicles, bladder or adjacent lymph nodes, which is called local spread.  Recurrent prostate cancer may also spread to more distant parts of the body, which is referred to as metastasis.  Bones, especially in the spine, are common areas for prostate cancer metastases, but late in its course the cancer can also metastasize to the kidneys or anywhere else in the body.

Detecting Prostate Cancer Recurrence

Recurrence of prostate cancer after radical prostatectomy or after radiation occurs because either cancer cells in the prostate area survived treatment or because they spread in other places in the body but were not detected. These prostate cancer cells will produce prostate-specific antigen (PSA) that can be detected in a PSA blood test, which will signal recurrent prostate cancer may be present.

Types of Prostate Cancer Recurrence

The recurrent prostate cancer treatment that is most appropriate depends upon where in the body the recurrent prostate cancer occurs and if it responds to hormone therapy.  The type of prostate cancer recurrence is classified in part by its location:

• Local recurrence: Recurrent prostate cancer that appears to be confined only in the prostate or the prostate bed (if it is prostate cancer recurrence after prostatectomy).  However, doctors will be unable to say with certainty that cancer has not spread beyond local recurrence,
• PSA-only recurrence (also called “biological recurrence”): Based on a rise in the PSA level, there is prostate cancer recurrence, but imaging studies show no evidence of prostate cancer.  The PSA is likely coming from microscopic areas around the body that are too small to be seen on imaging tests.
• Metastatic disease: Recurrent prostate cancer has spread to more distant tissues or organs in the body (prostate cancer most often spreads to bone, lymph nodes, and the lungs), metastatic cancer can be detected by imaging studies.

The Main Stages of Prostate Cancer Recurrence and Spread

There are 3 main stages in the spread and recurrence of prostate cancer:

1. Recurrence as measured by PSA – A rise in PSA after surgical or radiation treatment indicates recurrence of cancer. This prostate cancer recurrence is known as biochemical failure. Once cancer has recurred, as indicated by a rise in the PSA, its progression is highly variable. If no treatment is given, the PSA will continue to rise relatively rapidly in approximately 50% of all men, slowly in about 33% of men and very slowly in the remainder.
2. Progression from PSA rise to metastasis – The single best predictor for the continuing progression of recurrent prostate cancer is the PSA doubling time, which is the time it takes for a man’s PSA level to double after initial treatment. For example, doctors will look at how long it takes for PSA levels to go from 2.1 to 4.2 or 4.3 to 8.6. For men treated  with either surgery or radiation, the shorter the doubling time, the worse the recurrent prostate cancer prognosis. If it takes 12 months or more for a PSA level double, most likely the recurrent prostate cancer still localized and near the prostate bed.
3. Progression from metastasis to death – The interval between the development of recurrent prostate cancer metastases and death averages 3 to 5 years in various studies.  One study suggested that the shorter the interval between surgery and the cancer metastases, the shorter the time to death.  Of the men who developed metastases within 3 years of surgery, 87% had died within 5 years after their surgery.

Recurrent Prostate Cancer Treatment

For men who develop metastatic cancer and who have not been on hormonal therapy, the “gold standard” is hormonal therapy.  In other words, there is a general belief among experts that hormonal therapy has the best outcome for the recurrence of prostate cancer in these particular situations.

In all other situations, however, there is not necessarily a standard treatment, and there are many treatment options for any stage of recurrent prostate cancer. Clinical trials have not established one recurrent prostate cancer treatment as superior over others, and different doctors may recommend different treatments.

If the initial prostate cancer treatment was hormone therapy, doctors will typically follow a progression of therapies:

Hormone Therapy – Progression of Recurrent Prostate Cancer Treatment

Although the most common recurrent prostate cancer treatment is hormone therapy, men with prostate cancer recurrence often receive varied types of treatment over a period of years. As with your initial cancer treatment, the recurrent prostate cancer treatment you and your doctor choose will depend on several factors, such as your overall health, treatment side effects, and cost.  It is important for you to understand the options and to have a clear understanding of the side effects and how the recurrent prostate cancer treatment may affect your quality of life.

Many more recurrent prostate cancer treatment options are available to men with prostate cancer recurrence of any stage than a decade ago, and new prostate cancer treatments are currently being evaluated in clinical trials.  The field of treatment for recurrent prostate cancer is advancing quickly.  If your physician is not aware of the range of recurrent prostate cancer treatment options for your stage of prostate cancer, ask to be referred to a specialist who is knowledgeable about newer developments in treating prostate cancer recurrence.