Recurrent Prostate Cancer
Addressing Biochemical Recurrence
Biochemical recurrence means that the only evidence of cancer recurring is a laboratory value—a rising PSA. No spots of cancer are seen on scans, either in the prostate area or elsewhere in the body.
If you are experiencing biochemical recurrence, your doctor will consider your PSA doubling time and other factors in determining whether and when to initiate treatment.
Patients with a rapidly rising PSA (doubling time of approximately 9 months or less) can be considered to have “high risk biochemical recurrence.” They are at greater risk for developing metastases and for death from prostate cancer. One treatment option is enzalutamide, an androgen receptor pathway inhibitor. This medicine can be given with or without another medicine, a type of hormone therapy called a GnRH analog. Talk to your doctor about your risk of cancer progression and whether starting treatment would be right for you.
Treatment of Locally Recurrent Prostate Cancer
If PSA starts to rise after surgery or radiation therapy, your doctor may determine that the cancer is local, meaning in or near the prostate. In this case, re-treating the prostate area may provide a second chance at cure. This is called salvage therapy. Whether your initial treatment was radiation therapy or surgery, you can discuss salvage options with your treatment team (see chart). In some cases, hormone therapy will be combined with radiation therapy.
| If your initial treatment was surgery, your salvage treatment can be: | If your initial treatment was radiation therapy, your salvage treatment can be: |
|---|---|
| Radiation therapy with or without hormone therapy | Further radiation with SBRT or brachytherapy with or without hormone therapy OR Cryotherapy OR Prostatectomy |
| Radiation therapy | Uses external beams of high-energy radiation to kill cancer cells. Patients come to the treatment center each weekday for 4-6 weeks. |
| Brachytherapy | Radiation therapy “seeds” or catheters (small tubes) are placed inside the prostate. This is internal, rather than external, radiation therapy. |
| Cryotherapy | Prostate cancer cells are frozen to death via probes inserted into the prostate through the perineum (between the scrotum and anus). |
| Hormone therapy | Medicines that work throughout the body to lower testosterone or block its effects, slowing or stopping prostate cancer growth. |
Timing of Salvage Radiation and Use of Hormone Therapy
The best time to receive salvage radiation therapy following radical prostatectomy is when your PSA first becomes detectable again, ideally when it is 0.2 ng/mL or less, and definitely below 0.5 ng/mL if possible.
Another approach is to give radiation therapy upfront, or “prophylactically,” after surgery, without evidence of cancer recurrence (i.e., without a rise in PSA). This is called adjuvant radiation therapy. However, research shows that waiting to give radiation therapy until the PSA becomes detectable results in similar outcomes for the majority of patients with biochemical recurrence.
Your physician may recommend the use of hormone therapy along with your salvage radiation therapy. There is evidence that use of 2 years of hormone therapy in this setting may delay the development of metastasis. This shared decision will be made in conjunction with your treating physician and will depend on many factors, including your PSA level and imaging findings.
Side Effects
Since this is essentially a cumulative treatment beyond your initial treatment, there is a risk of increased side effects. These include rectal bleeding, incontinence (urinary leakage), strictures and difficulty urinating, diarrhea, and fatigue. Be sure to discuss potential side effects with your doctors before deciding on a course of therapy, but don’t delay; addressing side effects may be better than risking disease spread.
In particular, salvage prostatectomy appears to carry a significant risk of side effects, including urinary incontinence, rectal injury, and erectile dysfunction. This option should only be considered in discussion with a urologic surgeon who has extensive experience with this procedure.
While it is important to know about all of the possible side effects, keep in mind that they can also be managed. Urinary leakage can be managed without surgery (with various types of urine collections systems) or with a surgical procedure such as placement of a sling or artificial urinary sphincter. Options for erectile dysfunction include oral medications, injections, a vacuum pump, or an implant. You may need to see a specialist for help with certain side effects; your urologist may not have formal training in these areas.
In some patients, the PSA may be coming from prostate cancer cells outside the prostate area. Those patients are less likely to benefit from additional local therapy.
Learn More About Metastatic Prostate Cancer
Last Reviewed: 12/2023
