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AFTER PROSTATE CANCER What if it comes back?

By Virginia ‘Ginya’ Carnahan, APR, CPRC
Dattoli Cancer Center & Brachytherapy Research Institute

AFTER PROSTATE CANCER What if it comes back?For any man who has been treated for prostate cancer, there is a nagging little voice in the back of his mind asking these questions:  How do I know they got it all?  What do I do if it comes back?

These are pretty weighty questions.  After all, prostate cancer can kill you.  In fact, in the U.S. one man out of 39 dies from prostate cancer.  It is the third leading cause of cancer death in men, behind #1 lung cancer and #2 colorectal cancer.

However, the 5-year survival rate for most men with local or regional prostate cancer is almost 100%. Ninety-eight percent (98%) are alive after 10 years, and 96% live for at least 15 years. For men diagnosed with prostate cancer that has spread to other parts of the body, the 5-year survival rate is 29%.
Prostate Cancer: Statistics | Cancer.Net

But you want to be one of those who live a good long life following your treatment.  Whether you have chosen surgery, or radiation, or some other type of treatment, unfortunately there are failures.   Prostate cancer is sneaky.  It sneaks up on you with very few symptoms in the beginning, and it can sneak up on you the same way following what you thought would be definitive treatment.

So what is a man supposed to do?  The key is that simple blood test that started you on this journey.  The PSA (prostate specific antigen – a protein that is specific to the prostate gland) was identified at the Roswell Park Cancer Institute in the 1970s.  T. Ming Chu, PhD, DSc lead a team of 20 researchers looking for this key to helping diagnose prostate cancer.  Up until that time, only about 4% of prostate cancers were treatable/curable when diagnosed.

Dr. Chu and his team first published their finding in 1979.  By the mid-80s, this simple blood test was heralded as the key to finding prostate cancer early enough to treat it with intent to cure.

The PSA test alone, however, will not diagnose prostate cancer, but it can raise a red flag that something is amiss within the gland.  After thousands of tests, a standard “normal” chart of PSA levels was established, but this arbitrary number remains a subject of debate.

We know that some men can have an aggressive prostate cancer that does not excrete additional PSA, and some men can run an abnormal “elevated” PSA but not have any evidence of cancer.  Prostate cancer is kind of like a finger print:  each one is different.

So, as much as the recently treated man would like to think that his journey with prostate cancer is over after he completes treatment, it is not.  He will need to continue to have a PSA blood test on a regular basis for the rest of his life.

In the beginning, a PSA test should be taken every 90 days.  Depending on the aggressiveness of his cancer and the follow-up PSA levels will determine how often the tests should be run.  The goal is for the PSA to go down to nearly undetectable and to stay there.  0.002 is a very good PSA for someone after treatment.  Even if the PSA is 0.02, and stays there, that is good.  But if it is 0.2, 0.6, 0.8, or up over 1.0 – or rises two times following surgery – the patient should be evaluated for recurrence or persistence of disease.

If the PSA starts to rise, or never really goes low (reaches a “nadir”) following treatment, this could mean that cancer was left behind.  Cancer cells could remain in the prostate bed, or could have escaped into the surrounding tissue, especially the lymph nodes in the pelvis and abdomen.  This would be called recurrent or persistent prostate cancer.

Like any experience with any cancer, the sooner this is discovered, the better.  There are a number of advanced diagnostic tools that can be used to determine if cancer remains and where it is located.  Cancer that is in the prostate bed and surrounding tissue is called “local recurrence.”  Prostate cancer that has been found to have traveled out into the body, usually through the lymph nodes, – to the bones, other organs, brain, lungs, etc. – is called “distant recurrence” or metastatic prostate cancer disease.

Treatment for recurrent prostate cancer is based on considering what type of treatment was already used.  If the man had surgery, he might need radiation now.  If the man had radiation, he could have a different type of radiation the second time around.  The addition of hormone drugs can assist in shrinking tumors.

The Twenty-First Century, in my mind, has become the era of the alphabetic drugs.  Just in the realm of prostate cancer, we have seen these new drugs come to market for treating prostate cancer:  Provenge®, Zytiga®, Jevtana®, Xofigo®, Xtandi®, Firmagon®, Yervoy®, Opdivo®, Prolia®, Xgeva® and Lynparza®.  Don’t you wonder where they come up with these names?

Bottom line (no pun intended) is that if you’ve been down the prostate cancer path, you owe it to yourself to be vigilant with your follow-ups  The PSA could end up to be your best friend.

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