The first question asked by men diagnosed with prostate cancer after completed treatment (prostatectomy or radiotherapy) with the growth of the DOG: “How to live?” Fear is understandable: biochemical progress (relapse) implies that the cancer, despite radiation therapy, or cancer cells in the prostate bed after surgery, or neoplastic process has entered the stage of metastatic spread to other organs or bone.
The likelihood of full recovery decreases with confidence and hope, which is a significant stressful situation for the patient. This contributes to a common misconception that if prostate cancer has returned, the outcome is always extremely unfavorable.
This is not true, although in some cases, the prognosis is indeed serious.
Prostate cancer is a disease that can manifest itself in various forms, so each relapse requires an individual approach.
The factors that determine the likelihood of recurrence of prostate cancer
For determining the life of the forecast are the following aspects:
- risk: the stage at which the tumor is diagnosed+ the total number of points on the scale Gleason+ PSA level (prostate specific antigen);
- the time range after the treatment;
- as rapidly increasing PSA levels.
Experts believe that biochemical recurrence means exacerbation of a chronic disease (in this case, cancer) that require correction treatment to solve new problems.
Consider predictors of biochemical recurrence:
- low risk: indicator for a Gleason score of less than or equal to 6, PSA less than or equal to 10 ng/ml, stage of cancer Т1с or Т2а. The probability of biochemical progress for 5 years 33%.
- medium risk: based on a Gleason score of 7 (3+4) and/or PSA greater than 10 ng/ml but less than 20 ng/ml and/ or stage of prostate cancer Т2в; the probability of relapse within 5 years – 50%.
- high risk: the sum of scores for a Gleason score 7 (4+3) or 8 or more and /or PSA greater than 20 ng/ml and/or tumor stage T2s and more.
How to define biochemical recurrence
That is why the PSA level after performing a prostatectomy (removal of the cancer) drops to undetectable values, but not reduced to zero after radiation therapy, even if it was successful.
In the treatment of hormonal preparations (after completing the course), the level of testosterone rises as the PSA levels.
Biochemical recurrence may be suspected on the basis of the following:
- Radical prostatectomy. 0.2 ng/ml in two consecutive results of the blood test for PSA (some experts use a higher threshold of 0.4 ng/ml or slightly higher).
- Radiation therapy (external radiation or brachytherapy). Three consecutive rising PSA levels compared to the original. Many oncologists use a working definition that biochemical progress cannot be excluded, if the PSA level above 1-2 ng/ml in 12 to 18 months after initial therapy.
It is believed that ideally, PSA levels for prostate cancer after treatment should be less than 0.5 ng/ml, which in practice is rare, usually registers a number from 0.6 to 1.4 ng/ml.
After neoadjuvant hormonal or radiotherapy, the PSA threshold that would suggest a relapse are unknown.
Hormone therapy suppresses testosterone production, as soon as she stops, the level of testosterone increases that conducts to growth of DOG. The level of tumor marker may increase until, until stabiliziruemost hormones.
Experts know this fact: some men after radiation exposure (remote or contact) recorded a sharp increase in the level of prostate specific antigen that is not necessarily evidence of relapse.
The rise of PSA after initial treatment is a common problem. Studies indicate that biochemical recurrence affects between 15-30% of men who initially was considered completely curable with localized prostate cancer.
Thus, the results of a study published in the journal of the American Medical Association, in the study of 1997 patients after radical prostatectomy for 5 years showed that 15% had biochemical recurrence.
Men after radiation therapy are faced with this problem more frequently, in 19-26% of cases. The observation was carried out for 12 years.
It should be noted that approximately 50% of patients received neoadjuvant hormone therapy, or a combination of brachytherapy and external radiation exposure, which increased the effectiveness of treatment.
High-dose radiation therapy is more effective compared to conventional radiation therapy because of biochemical progress for 5 years is 19.6% against 38.6 per cent.
The journal of the American medical Association dated 27 July 2005 shows interesting data that assess the relationship of the rate of growth of PSA for prostate cancer and chances of survival:
- At lower risk and the rate of growth of PSA less than or equal to 2 ng/ml over 12 months, the probability of survival for 7 years after radiation therapy or after radical prostatectomy is 100%. If the PSA rises more than 2 ng/ml was 81%.
- At high risk and increase PSA level less than or equal to 2 ng/ml 12 months after treatment 96% and with the growth of PSA more than 2 ng/ml – 76%.
- If the level of prostate specific antigen doubling in 6 months, and even more so for 3 months, there is a high probability of proliferation of prostate cancer that requires systemic treatment.
The length of time during which the level of the tumor marker is increased by 2 times, can be used for predictions of the progress of cancer, not only with biochemical manifestations, but also with the clinic (the appearance of symptoms and confirmation of the distribution by using instrumental methods of diagnosis). It is established that:
- a doubling of PSA in 6 months – probability of cancer spread – 62%;
- during 6-11 months – 54%;
- within 1 year-9years 11 months – 38%;
- 10 years or more – 13%.
What if rising PSA after surgery
Initially, oncourology need to determine which cancer to treat: localized or metastatic.
Consider what may be possible.
Option # 1
The DOG never after surgery is not reduced to zero or its level began to grow rapidly. The situation is complicated for treatment and prognosis.
Most likely, the cancer cells continue to grow in the bed of the prostate or cancer spread outside the gland.
The treatment is carried out immediately, possible radiation, hormone therapy, their combination, or experimental therapy.
Option # 2
PSA falls to undetectable numbers for several months after radical prostatectomy, and then slowly begins to grow. This biochemical relapse. If the PSA level increases during the first year after surgery, there is a likelihood of metastasis.
Commonly used treatment option is hormone therapy (continuous or intermittent).
Option # 3
The DOG begins to grow to a year or more after surgery. Most likely, the tumor is localized, but completely eliminate its spread is impossible.
Methods of treatment depend on the doubling time of PSA.
Perhaps the use of radiation or hormonal therapy.
Option # 4
After surgery, PSA increases after a year or more, but the doubling time is slow (12 months or more). It is likely that prostate cancer is localized and not aggressive. In this situation, shows the dynamic observation with control of the level 1 PSA every 3 months, TRUS and digital rectal.
Victoria Mishina, urologist, medical columnist