What PSA recurrence mean? And what you should do about it.
63 year old patient, one year after prostate cancer surgery, see’s me at the clinic for his recent diagnosis of recurrence PSA. 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 I had it taken out. I expect my PSA to be zero forever, no? I’m confused” – he says.
The confusion with PSA recurrence
Men who opt for aggressive treatment of prostate cancer (i.e. Radical prostatectomy, Radiation Therapy, etc), unfortunately believe they are “home-free” after treatment. If this were to be true, why are patients required to return to their urologist every 3 to 6 months for a PSA test after surgery or radiation?
Men after prostatectomy or radiation even more so need to make lifestyle changes to reduce their risk of prostate cancer recurrence.
Here are two reason’s why:
1. Up 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) and PSA recurrence mean?
PSA recurrence is defined by a PSA of 0.2ng/ml to 0.4ng/ml after removal of the cancerous prostate.
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 for me?
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.
Importantly, PSA increase after prostatectomy may be due to benign, non-cancerous prostate tissue left behind after surgery (Djavan et al., 2005).
These statistics do not include men on an aggressive CaPLESS Wellness lifestyle after initial treatment of course. None of these studies monitored lifestyle changes or integrative modalities in their statistics which clinically shows PSA stabilization plus optimal overall health benefits in prostate cancer patients.
Here’s a doozy however: Men with a high rapid PSA doubling time (PSADT) after treatment are at the highest risk of disease progression. This is typically when the harder drugs and chemotherapy come into play.
Radiation after prostatectomy
Once there’s PSA increase after prostatectomy, 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. Every physician has a different point when the “pull the trigger” and suggest RT after surgery (also known as salvage radiation.)
When does hormone therapy come into play?
The term hormonal therapy (also known as Androgen Deprivation Therapy (ADT)) refers to treatments meant to eliminate testosterone production by surgical removal of the testicles or chemically castrate the patient with drugs such as Lupron.
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, 3 times a week and to consume a group of that can help 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 because as Djavan et al. showed, there can be benign prostate tissue left behind.
Bottom line: Every prostate cancer recurrence situation is different and the treatment approach should be individualized.
The Doggy Bag Message:
· Biochemical recurrence (PSA increase) after prostate treatment is more common than people think.
· Men tend to be, intentionally or un-intentionally naïve about the possibility of biochemical recurrence.
· Not all men with rising PSA after prostate cancer die from this disease. Most die from other causes. About a third of men with cancer recurrence of the prostate do die from prostate cancer.
· A **CaPLESS lifestyle not only helps men reduce the chances of prostate cancer recurrence, but also decrease their chances of succumbing to heart disease along with improved physical shape than before their prostate cancer diagnosis.
** Details of the CaPLESS Wellness method and the CaPLESS lifestyle will be out in my book on June 2014. Subscribers to DrGeo.com will learn details about this program before the release of my book. So stay tuned. For more information on the CaPLESS retreat please go to the NYU CaPLESS Wellness Retreat website. We hold this event once a year in New York City – the Big “Organic” Apple.
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.