I discovered this blog, so if you do have a relapse, there's some very useful stuff here...
Four key questions
If your PSA rises after prostate cancer treatment, answering four key questions will help you and your doctor determine next steps:
Table 1: Predictors of biochemical recurrence at time of diagnosis
Although a number of clinical factors contribute to your risk of relapse after treatment, the parameters below provide a simpler assessment of your chances of biochemical recurrence, based on your clinical profile at the time of diagnosis. For more sophisticated estimates, based on specific risk factors, see Figures 1 through 3.
|Low risk (33% chance of biochemical recurrence within five years)||Gleason score less than or equal to 6|
andPSA less than or equal to 10 ng/ml
andCancer stage T1c or T2a
|Intermediate risk (50% chance of biochemical recurrence within five years)||Gleason score of 7 (if 3+4)|
and/orPSA greater than 10 but no greater than 20 ng/ml
and/orCancer stage T2b
|High risk (85% chance of biochemical recurrence within five years)||Gleason score of 7 (if 4+3), or 8 or more|
and/orPSA greater than 20 ng/ml
and/orCancer stage T2c or more
Defining biochemical recurrence
Table 2: Guidelines for determining biochemical recurrence
|Initial therapy||PSA threshold||Comments|
|Radical prostatectomy||0.2 ng/ml on at least two successive tests||Some physicians continue to use a higher threshold of 0.4 ng/ml or greater|
|Radiation therapy (external beam or brachytherapy)||Three successive elevations in PSA compared to nadir (low point), regardless of actual reading, according to the American Society for Therapeutic Radiology and Oncology||Many oncologists use a working definition that biochemical recurrence has occurred if PSA levels are greater than 1–2 ng/ml 12 to 18 months following initial treatment.|
Ideally, post-treatment PSA levels should be less than 0.5 ng/ml, but this is rare; levels of 0.6–1.4 ng/ml may occur.
|Neoadjuvant hormone therapy and radiation therapy||Unknown|
A common challenge
Biochemical recurrence after surgery
Pound CR, Partin AW, Eisenberger MA, et al. Natural History of Progression after PSA Elevation Following Radical Prostatectomy. Journal of the American Medical Association 1999;281:1591–7. PMID: 10235151.
Roehl KA, Han M, Ramos CG, et al. Cancer Progression and Survival Rates Following Anatomical Radical Retropubic Prostatectomy in 3,478 Consecutive Patients: Long-Term Results. Journal of Urology 2004;172:910–14. PMID: 15310996.
Biochemical recurrence after radiation therapy
Potters L, Morgenstern C, Calugara E, et al. 12-Year Outcomes Following Permanent Prostate Brachytherapy in Patients with Clinically Localized Prostate Cancer. Journal of Urology2005;173:1562–6. PMID: 15821486.
Zietman AL, DeSilvio ML, Slater JD, et al. Comparison of Conventional-Dose vs High-Dose Conformal Radiation Therapy in Clinically Localized Adenocarcinoma of the Prostate: A Randomized Controlled Trial. Journal of the American Medical Association 2005;294:1233–9. PMID: 16160131.
Assessing your personal risk
Table 3: PSA velocity before diagnosis and estimated chances of survival
An analysis of PSA velocity in the year preceding diagnosis reveals that it can predict the likelihood of survival seven years after external beam radiation therapy. (Similar findings have been reported for an analysis of men who underwent radical prostatectomy.)
|Overall risk profile (based on PSA, Gleason score, cancer stage)||When PSA velocity is less than or equal to 2 ng/ml per year||When PSA velocity is greater than 2 ng/ml per year|
|Source: Journal of the American Medical Association, July 27, 2005.|
Table 4: PSA doubling time and outcome five years after biochemical recurrence
A study involving 2,809 men who were treated with surgery and subsequently experienced biochemical recurrence (defined as a PSA of 0.4 ng/ml or more) found a clear relationship between PSA doubling time and eventual clinical outcomes.
|PSA doubling time||Percentage of men without prostate cancer*|
|Less than 6 months||38%|
|12 months–9 years, 11 months||62%|
|10 years or more||87%|
|*No clinical indication of local or systemic disease, based on digital rectal examination, transrectal ultrasonography, biopsy, or bone scan.|
Source: Mayo Clinical Proceedings, June 2001.
PSA velocity and prognosis
D’Amico AV, Chen MH, Roehl KA, Catalona WJ. Preoperative PSA Velocity and the Risk of Death from Prostate Cancer After Radical Prostatectomy. New England Journal of Medicine2004;351:125–35. PMID: 15247353.
D’Amico AV, Renshaw AA, Sussman B, Chen MH. Pretreatment PSA Velocity and Risk of Death from Prostate Cancer Following External Beam Radiation Therapy. Journal of the American Medical Association 2005;294:440–7. PMID: 16046650.
Knowing whether and when to act
Options for men who had surgery
Salvage options after radical prostatectomy
For more information: Salvage radiation therapy
Buskirk SJ, Pisansky TM, Schild SE, et al. Salvage Radiotherapy for Isolated Prostate Specific Antigen Increase after Radical Prostatectomy: Evaluation of Prognostic Factors and Creation of Prognostic Scoring System. Journal of Urology 2006;176:985–90. PMID: 16890677.
Sengupta S, Christensen CM, Zincke H, et al. Detectable Prostate Specific Antigen Between 60 and 120 Days Following Radical Prostatectomy for Prostate Cancer: Natural History and Prognostic Significance. Journal of Urology 2006;176:559–63. PMID: 16813889.
Stephenson AJ, Shariat SF, Zelefsky MJ, et al. Salvage Radiotherapy for Recurrent Prostate Cancer after Radical Prostatectomy. Journal of the American Medical Association2004;291:1325–32. PMID: 15026399.
Radiation with hormone therapy
For more information: Erectile-sparing hormone therapy
Boccardo F, Rubagotti A, Barichello M, et al. Bicalutamide Monotherapy Versus Flutamide Plus Goserelin in Prostate Cancer Patients. Journal of Clinical Oncology 1999;17:2027–38. PMID: 10561254.