Radical prostatectomy, the surgical removal of the entire prostate gland, is a common and effective treatment for localized prostate cancer. While surgery aims to eliminate cancerous tissue, the possibility of the cancer returning remains a concern for many individuals. Understanding the nature of this potential return and the factors that influence it is important.
What Prostate Cancer Recurrence Means
Prostate cancer recurrence after surgery indicates that cancer cells not fully removed during the initial radical prostatectomy have begun to grow again. This return of cancer can manifest in different ways.
Biochemical recurrence (BCR) is typically the first sign, marked by a detectable rise in prostate-specific antigen (PSA) levels in the blood after they had dropped to very low or undetectable levels post-surgery. This rise in PSA means that some cancer cells have survived and are producing PSA again.
Clinical recurrence, on the other hand, refers to the detection of a tumor through imaging or the appearance of new symptoms. Biochemical recurrence often precedes clinical recurrence, serving as an early warning sign. After radical prostatectomy, biochemical recurrence can occur in approximately 20% to 40% of patients within 10 years. The underlying reason for recurrence is the presence of microscopic cancer cells that were either left behind during the surgery or had already spread beyond the prostate before the operation.
Key Factors Affecting Recurrence Risk
Several factors influence an individual’s specific risk of prostate cancer recurrence following radical prostatectomy. The characteristics of the cancer itself, typically found in the pathology report after surgery, are particularly informative.
One significant indicator is the Gleason score, which assesses the aggressiveness of the cancer cells. A higher Gleason score, such as 8 to 10, correlates with a higher risk of recurrence.
The pathological stage, which describes the extent of the cancer’s spread, also impacts recurrence risk. Cancer that has extended beyond the prostate capsule (extracapsular extension), invaded seminal vesicles, or involved lymph nodes indicates a higher risk of recurrence.
Another important factor is the presence of positive surgical margins, meaning cancer cells are found at the edge of the removed tissue. This finding significantly increases the risk of biochemical recurrence. Pre-surgery PSA levels also provide an indication of the initial disease burden, with higher levels generally linked to a greater chance of recurrence.
Monitoring for Recurrence After Surgery
Monitoring for prostate cancer recurrence after radical prostatectomy primarily relies on regular prostate-specific antigen (PSA) blood tests. Following surgery, the PSA level is expected to become very low or undetectable within a few weeks. A common follow-up schedule involves PSA testing every three to six months for the first few years, followed by annual tests thereafter.
Biochemical recurrence is generally defined as a PSA level of 0.2 ng/mL or greater, confirmed by a subsequent rising value. A rising PSA level warrants further investigation, but it does not automatically confirm widespread clinical recurrence. Imaging tests, such as multiparametric MRI (mpMRI) or PET scans, are typically not performed unless PSA levels are significantly rising or symptoms develop, as they are less sensitive for detecting very low PSA levels. For higher PSA levels, mpMRI can help localize recurrence in the prostate bed, while PSMA PET/CT scans are useful for detecting distant metastases.
Next Steps After Recurrence
When prostate cancer recurrence is confirmed after surgery, treatment decisions are tailored to the individual, considering their overall health, the extent of the recurrence, and prior treatments. One common approach is salvage radiation therapy, which delivers radiation to the area where the prostate was removed, known as the prostate bed. This therapy aims to eliminate any remaining cancer cells and can be a potentially curative option.
Hormone therapy, also known as androgen deprivation therapy (ADT), may also be used. This treatment works by lowering testosterone levels, which can slow the growth of prostate cancer cells. It can be given alone or in combination with radiation therapy. Active surveillance may be an option in select cases, involving close monitoring without immediate intervention. Additionally, participation in clinical trials offers access to new and experimental treatments for recurrent prostate cancer. These decisions are best made in discussion with a multidisciplinary medical team.