Biochemical Recurrence and Prostate Cancer – what you MUST know
A 57- year old prostate cancer patient comes to my office for his post-operative wellness care. His first PSA 3-months after prostate surgery is un-detectable. His pathology report revealed he had positive margins, Gleason 7, no lymph nodes involved.
I explain to him that part of the program is for him to optimize his lifestyle so that he does not get a recurrence of prostate cancer.
He looks at me strangely. I ask him – what’s wrong? He responds, “ I thought I don’t have to ever worry about prostate cancer again since it has been taken out. I expect my PSA to be zero forever, no? What do you mean by recurrence?”
The confusion
Men who opt for aggressive treatment of prostate cancer (Radical prostatectomy, Radiation Therapy, etc), unfortunately believe they are “home-free” after treatment.
If this is true, why do treated men return to their physician every 3 to 6 months for a PSA test?
After an initial treatment of prostate cancer men must be even more encouraged to live an aggressive anti-cancer lifestyle (also known as a CaPLESS lifestyle).
Two reasons for this:
1. Close to 40% of men experience biochemical recurrence (PSA recurrence) after initial treatment. (Freedland et al. 2007)
2. Men treated initially with Radiation Therapy (RT) have a higher chance of getting secondary bladder cancer or rectal cancer (Nieder et al. 2008)
Secondary cancers after initial cancer treatment should not be a surprise after this New York Times article highlighted this very important point.
What does biochemical recurrence (BCR) / PSA recurrence mean?
PSA recurrence is defined by a PSA of 0.2ng/ml to 0.4ng/ml after removal of the cancerous prostate depending on the research you read.
PSA recurrence after Radiation therapy (RT) is more difficult to determine as PSA initially increase’s (known as PSA bounce) after treatment and does not reach its lowest level for up to 18 months. There is no consensus on the definition of treatment failure but most agree that the lowest PSA value after RT plus 2 is the cut-off.
For men who undergoes RT as primary treatment for prostate cancer the most common treatment after PSA recurrence is cryotherapy (freezing the prostate) Cryotherapy in this patient population can induce close to 100% impotence but not worsen urinary incontinence.
Does PSA recurrence mean this is the beginning of the end?
Not necessarily. Average time from PSA recurrence to prostate cancer death is 16 years (Freeland et al. 2007). Most men with PSA recurrence, however, die of other causes than from prostate cancer, i.e. heart disease.
Also it is possible that a detectable PSA may reflect presence of benign, non-cancerous prostatic tissue left after prostate removal which may still produce PSA (Djavan et al., 2005).
These statistics do not include men on an aggressive CaPLESS lifestyle after initial treatment of course.
Men with a high rapid PSA doubling time (PSADT) are at the highest risk of progression.
Once there’s PSA increase after prostate removal, your physician may decide to consider radiation therapy (RT) at any point after the PSA increase. Studies suggest RT may be a good idea in men with a PSA of ≤ 2.0ng/ml after prostate removal.
When does hormone therapy come into play?
The term hormonal therapy (also known as Androgen Deprivation Therapy (ADT)) is used to refer to treatments meant to eliminate testosterone production (surgical or pharmacological castration), prevent the binding of testosterone to cellular receptors (steroidal or nonsteroidal antiandrogens)or a combination.
The negative impact on quality of life in men on ADT can be significant, including hot flashes, bone loss, increased fracture risk, sexual dysfunction, loss of libido, memory loss, increased fat deposition, loss of muscle mass and other metabolic changes (increases in cholesterol and insulin resistance) that may increase risk for heart disease.
Men on ADT are encouraged to include weight resistant exercises in their regimen and to supplement with Advanced ADT support to support bone, heart and brain health.
Lastly, not everybody with BCR (PSA recurrence) needs treatment
A man with a detectable and low PSA level of 0.05ng/ml after RP may have a persistently detectable PSA without significant change for a long time. Such a patient is unlikely to progress and suffer prostate cancer related death.
Doggy Bag Message:
· BCR is more common than people think.
· Men seem to be, intentionally or un-intentionally naïve about the possibility of BCR
· Not all men with BCR die from it. Most die from other causes. About a third of men with BCR do die from prostate cancer.
· A CaPLESS lifestyle no only help men improve their prostate cancer BCR prognosis, but also decrease their chances of succumbing to heart disease along with being in better physical shape than before their diagnosis.
To learn more about the CaPLESS method and retreat; GO HERE
The next CaPLESS retreat is on May 18th and 19th in NYC and we still have a few more available openings.
We only have the capacity to host a maximum of 20 people for our CaPLESS retreat.
Time is running out!
Make sure to contact us immediately if interested.
Reference:
Nieder AM, Porter MP, Soloway MS. Radiation therapy for prostate cancer increases subsequent risk of bladder and rectal cancer: a population based cohort study. J Urol. 2008 Nov;180(5):2005-9;
Djavan B., Milani S., Fong Y. K. (2005). Benign positive margins after radical prostatectomy means a poor prognosis – pro. Urology 65, 218–220.
Freedland S. J., Humphreys E. B., Mangold L. A., Eisenberger M., Dorey F. J., Walsh P. C., Partin A. W. (2005). Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. JAMA 294, 433–439.