This question comes up often and is an unfortunate situation. I thought of it myself as a possibility when I went through all I went through having my prostate removed. Think about it… the surgery, the catheter, the leaking, the sexual uncertainties and then the PSA begins to rise. The hell?
- Normal prostate tissue can be left at the time of a prostatectomy, particularly at the apex of the prostate where it goes into the urethra just before the external sphincter and if there is a median lobe that grows into the bladder. In this case the PSA may not revert to zero but it will go up very slowly. “A slow increase in PSA velocity.” In this case I would not recommend any treatment and I’d advise very close monitoring the PSA to evaluate the rate of change before subjecting the patient to radiation.
- If there is indeed residual prostate cancer then the PSA will not go to zero and will begin to rise at a faster rate. In this case I would recommend post prostatectomy radiation.
- There is a small chance of radiation causing other cancers…I have seen post radiation bladder cancer on many occasions.
- If the PSA is rising slowly, the option of a weak anti androgen to hold off on radiation is an option and I have often used Avodart or Proscar to see if it lowered the PSA and allowed a patient to think on or wait until the effect was gone before pursuing radiation.
- Radiation oncologists like to begin radiation as soon as it is felt that the PSA is real and related to prostate cancer. The number used as a nadir for this is a PSA of .5. The zero value of a PSA after a prostate has been removed should be by the ultra sensitive method of PSA would be about .02. So .5 would represent a small number in and of itself but related to the negligible expected post prostatectomy PSA, it represents a big change upward.
- I tell my post prostatectomy patients to begin to consider a radiation consult at .5.
- It has not been proven that if you start XRT at .5 vs 1 that there is that much difference. In general the sooner you start XRT and the smaller the volume of disease the better.
- It has not been proven that XRT for a rising PSA after prostatectomy definitively changes longterm survival. To me however it is a reasonable thing to do and it would be what I would do it if it were me.
The way I view the treatment of prostate cancer, for the cancer that all would feel is clinically significant, is that years from now if the cancer were to come back…”Did I do all I could do to eradicate my cancer?” If you view it this way, one would pursue XRT for a rising PSA after prostatectomy. All of the options should be discussed to include:
- doing nothing and just watching PSA’s over time
- a weak anti androgen like Avodart
- a strong anti androgen like Casodex
- a LHRH agonist
As I have said in my book, a lot of what people do depends on who they are, their perceptions, desire for quality of life issues, and the wishes and concerns of the family members who love them.