Question: Options for failed or failing cryosurgery for prostate cancer.

                                                                                                                                                                                                                                                                                   

First of all the PSA as a judge of the status of prostate cancer after treatment is reliable. There is a PSA bump that is sometimes seen after seed therapy which reverts to normal with time. The period of time when the PSA begins to rise, hovers and then goes back down in these patients is a time of anxiety for both the patient and the doctor.

Another potential side-effect of brachytherapy, indeed all forms of radiation, is called the PSA “bump” phenomenon. The PSA “bump” is a delayed PSA rise occurring after the radiation finishes. Although the exact cause of PSA “bump” is not known with certainty, it is believed to result from irritation of the residual prostate gland by radiation. The “bump” follows a benign clinical course and usually resolves itself within a year. The main danger of the PSA “bump” comes when physicians mistakenly conclude that the rising PSA represents recurrent cancer and decide to start ADT when no cancer is present. From PCRI

Well, I don’t much about cryosurgery so feel free to take what I say with the proverbial grain of salt. I do recall that our old friend Richard Albin “discover of the PSA” is a proponent of the cryo-destruction of cancers. Here’s what I do know by having read about it…I have not learned to perform the procedure:

• It is recommended for the more favorable types of prostate cancer
• It can be repeated if it fails
• It can be done if someone has failed external beam radiation, probably not the best idea if seeds have been done
• It is very operator dependent…probes are inserted and the key is getting all of the prostate “freezed”…certainly one guy may be better at it than the next or if a particular doctor has done 500 vs. one that has done 30.
• It has a high rate of impotence
• It appeals to the guy that can’t have surgery and doesn’t want radiation
• It is usually out-patient or a one night stay
• It has acceptable complication rates
• The reason I chose surgery is that ” I knew that all the cancer in the gland would be removed…I did not know for certain that seeds (or any local procedure such as HIFU, NanoKnife, or Cryosurgery) would kill all the cancer in the gland.

Now if you have had cryosurgery for your prostate cancer and after a few years the PSA begins to rise and on rechecking the PSA over time and the PSA continues to rise…this most probably represents recurrence of your prostate cancer. Maybe an area of the cancer was “stunned” but not killed and it is showing its head. What to do?

• This is where the “who are you” factors come into play
• An older person with some medical issues would do something differently than a  young guy that is healthy
• If either category of patient in whom the PSA rises and they want to be treated for cure…the first thing one would do is to prove that the PSA that is showing up is from only the prostate and not from  metastatic spread.
• This is problematic…a PSA of less than 10 (the very level that one would want to pursue another curative treatment) probably would not show up in the most common staging studies.
• But anyway…you’d do a Prostatic Acid Phosphatase blood level (this is the study we used to do that was fairly sensitive for spread of prostate cancer beyond the prostate
• A bone scan looking for bone mets, a CT scan looking for pelvic lymph nodes and then a Prostascint Scan which has a certain degree of false positive and false negatives…may or may not be covered by insurance.
• I have ordered about five ProstaScint scans. Talking about a hassle. A thousand questions about the patient to help the radiologist look for the cancer, and then all the medical necessity questions from insurance. Marginal helpfulness….
• So…you jump through all the hoops and you ring all the bells and to the very best of your doctor’s ability…your PSA is going up but it is not from anywhere but the prostate..i.e. not metastatic spread.
• I  am very familiar with this situation in the post-radiation patient..but not for cryosurgery, but there are some things that are in common and may be helpful
• A young guy will be more aggressive than an older guy
• The younger guy might find someone to remove the prostate if he will accept all the risks….remember surgeons don’t like operating on “dirty” tissue planes
• The younger guy might repeat the cryosurgery or consult a radiation therapist for any options he might offer
• The younger guy probably would not do hormones of any sort
• The younger guy might consider the nanoKnife or HIFU

Now the older guy…say late 70’s and moderately healthy and anticipated life expectancy of 10 years. Well this is tricky any why medicine is an “art and not a science.” Options:

• He’d have to do all the tests to prove it is no where else
• He could repeat the cryosurgery if his doctor and him agree on the risks, side effects etc
• He could consult a radiation therapist, consider HIFU or nanoKnife (not FDA approved and expensive)
• He could do nothing ( a quality of life first type person) and watch the velocity of the PSA change…I had a patient on time whose PSA rose after a prostatectomy to 2.5 and then stayed there….he passed away of something else….I was a pallbearer in his funeral. He had a soldier there playing taps in full uniform….very moving and an honor.
• Now this is where the urologist and the patient and patient’s family have a long talk and where finesse comes in.
• Hormonal therapy…options casodex like drugs, LHRH shots, or something that is a mild anti hormone like Avodart
• Hormonal therapy corrects the PSA (usually) but doesn’t cure the cancer

How nice would it be for the 77-year-old if you could do some sort of  intermittent hormonal therapy that would keep the PSA at bay and not put him through all the tests and another treatment with a whole “nother” set of problems and complications and as well limit the side effects of hormonal therapy.(Hot flashes, breast enlargement)

What if you gave this patient Avodart and for a year or so it keep the PSA from rising…and then if it did you then went to Casodex for a few years. Now we are in our 80’s and all of the other options previously discussed are still available or some new treatment was available or FDA approved.

So tricky huh? What would I recommend if I were the doctor for the older post cryosurgery patient…..I’d do with him like I always do….I’d take my lead from him…If he’s aggressive and knows what he’s getting into we’d discuss curative things.. If he values his quality of life and is okay monitoring the PSA with a mild anti-hormone…we might go that way. We’d consider a second opinion and together come to a plan that suits all. In this case however I’d say the most important factor is the age of the patient. I’d lean away from another curative treatment unless the patient were adamant about it. Tricky tricky.

 Always remember…. Primum non nocere-First do no harm