How can a PSA go up if the prostate has been removed for prostate cancer?

As a surgeon I have to often times dissuade patients from choosing surgery. You think I’m kidding don’t you? Surgeons do it all the time. Radiation therapists also tell some patients that radiation may not be the best option for them. That I know is even harder to believe….just kidding. (It’s a surgeon-radiation therapist thing.)

Many patients and their family think that if you take the prostate out you are cured. When I speak of needing to follow the PSA every three months after a radical prostatectomy, I am often asked why that is necessary. PSA is variable in the diagnosis of prostate cancer, but very reliable in terms of determining if the cancer has returned after treatment.

A PSA should go to negligible, usually something like .02 and stay there. If a PSA rises then that might indicate recurrence.

How does this happen?

• For surgery it happens because there was microscopic disease outside the prostate before the prostate was removed. Imagine one cell just outside the prostate that slowly grows after the surgery and then begins to produce increasing amounts of PSA. The rising PSA is usually “local” i.e. somewhere very near the bed of where the prostate is removed. The increase usually occurs with in the first year but sometimes later. The Partin tables can predict on a percentage basis one’s likelihood of having a rising PSA after surgery based on the exam, PSA, and the specifics of the path report.
• For radiation or any of the other “non surgical removal” type procedures, a rising PSA after treatment is because of the reason above and or that the treatment did not kill all of the disease in the prostate. It may have stunned it, damaged it, but with time “came back” and then begins to produce PSA.

In my mind, surgery assures you that all the cancer in the gland will be gone and out. The other forms of treatment cannot make that claim. All the treatments respond the same if cancer is outside the gland before the treatment. As I was young and had many years at risk for recurrence, this concept was very important to me in making my decision. Had I been in poor health, older, this particular concept would not have been as important.  This why the decision is tricky and must be based on “stats” specific to you. See my “Who are you factors.” Most importantly, knowing that surgery doesn’t assure cure, should factor heavily in your “Decision.”