In interviews I did for the Prostate Cancer Foundation website, Weill Cornell Medicine urologist Jim C. Hu, MD, MPH (whose expert opinion was also featured in ours book)discusses what a rising or persistent PSA means after treatment for localized prostate cancer and what to do next. Remember the first lesson from Part 1: Don’t Panic!
If the PSA does not go down after prostatectomy, this is called “PSA persistence,” and there are three things that could be causing it, says Jim Hu.
There may be some normal prostate tissue left. “This was more common when we first started doing robotic prostatectomies,” instead of open surgery, “but it still happens.”
There may be some prostate cancer that has left the prostate but is still in the local area and can be treated with ‘salvage’ radiotherapy. Even if you had a PSMA-PET scan and/or a bone scan or CT scan before treatment, this is a possibility, particularly if you had a high-volume (Grade Group 3, or Gleason 4+3=7) or higher grade adverse-risk cancer cancer (Grade Group 4 or 5, or Gleason 4+4=8 or higher). It could be that this cancer was too small to show on imaging and now it has gotten bigger. “This can happen even if the lymph node dissection during surgery did not show cancer,” says Hu. “There could be one area or several areas that produce enough PSA to be above 0.2 ng/ml.”
Depending on the imaging results – PSMA-PET, bone scan and/or CT scan – salvage radiation could cover only the prostate bed or the entire pelvis. Or, it could just target very specific areas because:
Oligometastasis may be present. Here again, it is possible that some micrometastases – too small for even PSMA-PET to see – escaped the prostate before surgery and have now grown large enough to be seen. If there are only a few single points, this is called oligometastasis. It’s not a complete metastasis, and the most important thing to know: “You can still go for treatment,” Hu says, “with targeted stereotactic radiation therapy to those areas and lymph node salvage.” There is a chance that further micrometastases will be revealed after this treatment, says Hu. But University of Maryland radiation oncologist Phuoc Tran, MD, Ph.D., who has pioneered research and treatment in prostate cancer oligometastases, says these new spots can also be “scooped out” — even with possibility of treatment. He likens this approach to “hitting a mole.”
What about androgen deprivation therapy (ADT) with radiation? “There’s still shared decision-making,” Hu notes, where you and your doctor discuss the risks and benefits of a short-term course of ADT along with radiation therapy. However, he advises patients to seriously consider it. “The new guidelines say you should add ADT to salvage radiation if someone has high-risk features, such as positive surgical margins, seminal vesicle cancer, or group 4 or 5 cancer.” and that, in Hu’s opinion, is the smartest thing to do. “There’s not a definitive, randomized trial that says you absolutely have to have it — but if you want to have the best chance of a cure, I think you should do ADT along with radiation. If I have prostate cancer and the primary treatment doesn’t work, I don’t want to miss the window of healing again. i want to to maximize my chance of healing with radiotherapy and temporary ADT’.
Next: Understanding PSA after Radiation Therapy
In addition to book, I have written about this story and many more about prostate cancer on the Prostate Cancer Foundation website, pcf.org. The stories I have written are in the “Understanding Prostate Cancer” and “For Patients” categories. As Patrick Walsh and I have said for years in ours books, Knowledge is power: Saving your life can start with going to the doctor and knowing the right questions to ask. I hope all men put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s and if you are of African descent or have a family history of cancer and/or prostate cancer, you should be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask.
© Janet Farrar Worthington
