Prostate Cancer Recurrence

Although prostate cancer is highly treatable through surgery, radiation therapy, and other treatments, there is no guarantee that the cancer won't return. If it does, it is referred to as recurrent prostate cancer.

Recurrence often occurs because the initial treatment did not eliminate all the cancer cells. These remaining cells can stay in the body undetected and may become active later. It's normal to feel concerned about this, but understanding the nature of recurrence can help you be better prepared if your prostate cancer returns.

If recurrence happens, it does not necessarily mean the cancer has spread. It could be contained in the prostate. Your oncologist will inform you about which category your recurrence falls into:

Biochemical recurrence: Occurs when PSA levels rise to a certain threshold after treatment. This indicates that some cancer cells have survived and are producing PSA. Usually, there are no apparent symptoms.
Local recurrence: Refers to cancer that recurred and remains confined to the area of the prostate.
Regional recurrence: Describes cancer that has spread to the pelvic area but has not yet reached other parts of the body.
Distant recurrence: Means the cancer has spread outside the pelvis to other areas, such as the bones and distant lymph nodes.

Just like an initial prostate cancer diagnosis, the outlook for individuals with recurrent prostate cancer depends on how aggressive and advanced the cancer is. However, according to a 2016 study published in the European Journal of Cancer, more than 83% of people with recurrent prostate cancer live at least another five years or more after successful treatment, particularly if they underwent a radical prostatectomy (RP).

Monitoring and Diagnosis After Initial Prostate Cancer Treatment

Follow-up appointments are key to identifying recurrent prostate cancer as early as possible. Your oncologist will likely request a follow-up every six months to a year. During these appointments, a physical examination will be conducted, and your PSA (prostate-specific antigen) levels will be tested. The results of this test help your prostate cancer specialist detect if there is a recurrence of the cancer.

If your PSA levels suggest that the cancer has returned, your oncologist will recommend additional testing. Typically, this includes imaging scans such as X-rays, CT scans, MRIs, and bone scans, which can identify the presence of recurrent prostate cancer.

Another test that can be used is an Axumin PET/CT scan. Axumin is a radioactive tracer attached to an amino acid that prostate cancer cells absorb quickly. It’s given to men who have had prostate cancer and now have a rising PSA. Unlike traditional imaging methods that may only detect tumors when PSA levels reach between 10 and 50, Axumin can identify tumors even when PSA levels are between 1 and 10. Detecting any recurrent cancer earlier means it can be biopsied or treated sooner.

If imaging shows signs of cancer recurrence, the oncologist may also suggest another biopsy to better understand how differentiated the cells have become from normal prostate cells.

Understanding PSA Levels After Initial Treatment

Since PSA is produced only by the prostate, levels should become undetectable within a few months after prostatectomy. However, small amounts of PSA may still be detected in follow-up tests. This does not necessarily indicate the presence of a new tumor; it may simply mean that some cells in the body continue to produce PSA, though these cells are not necessarily cancerous.

Radiation therapy, on the other hand, does not remove the prostate gland. As a result, some normal prostate cells may continue to produce PSA, meaning that your PSA levels will drop after treatment, but not to undetectable levels. Additionally, levels typically decrease more slowly after radiation therapy compared to prostatectomy, with some patients not reaching their lowest levels until two or more years after treatment.

If you are experiencing biochemical recurrence, your doctor will consider several factors, including your PSA doubling time, which is the time it takes for the prostate-specific antigen (PSA) level in your blood to double. This information helps determine whether treatment is necessary and when it should begin. A rapidly rising PSA may indicate a "high-risk biochemical recurrence," suggesting a greater likelihood of developing metastases and a poorer prognosis.

Treatment Options for Recurrent Prostate Cancer

There are various treatment options available for recurrent prostate cancer. The recommended treatment plan will depend on several factors, including the location and extent of the recurrence, previous treatments, and your overall health.

Localized Recurrent Prostate Cancer

If the cancer is suspected to still be localized to the area of the prostate, a second attempt to cure it may be possible. This is referred to as salvage therapy.

Typically, salvage therapy involves additional radiation therapy and hormone therapy aimed at targeting any remaining cancer cells. Surgical options like salvage prostatectomy may also be considered. If the only sign of cancer is a biochemical recurrence, active surveillance could be appropriate for some men.

Regional Recurrent Prostate Cancer

When prostate cancer has spread to other parts of the body, including the bones, hormone therapy is usually the preferred treatment. The first line of treatment often includes a luteinizing hormone-releasing hormone (LHRH) agonist, often combined with a first-generation anti-androgen, an LHRH antagonist, or orchiectomy (a surgical procedure that removes one or both testicles).

Distant Recurrent Prostate Cancer

While hormone therapy is effective for treating recurrent prostate cancer that has spread, its effectiveness often decreases over time. Men whose prostate cancer no longer responds to hormone therapy are categorized in one of two ways:

Castration-resistant prostate cancer (CRPC): This type of cancer continues to grow despite hormone therapies, such as orchiectomy or LHRH agonists/antagonists, which lower testosterone levels to those typically seen after testicular removal. In certain cases, alternative hormone therapies may still be effective.
Hormone-refractory prostate cancer (HRPC): This category includes cancer that does not respond to any form of hormone therapy.

Fortunately, men with these types of prostate cancer now have more treatment options than ever before. Possible treatment options for these men may include:

Newer hormone medications added to the existing hormone therapy
Radiopharmaceutical drugs, especially for cancer cells that express the PSMA protein
A prostate cancer vaccine
Therapies using various medicines, including chemotherapy, targeted therapy, and immunotherapy
Ablative treatments, which use extreme heat or cold to destroy (ablate) bone tumors

Emerging Clinical Research Results for Prostate Cancer

Many ongoing clinical trials are focused on prostate cancer, exploring new therapies and treatment strategies. Several emerging medications have shown promising results in managing castration-resistant and hormone-refractory prostate cancer. One such medication is Pluvicto™, a targeted radiation infusion that is now available for some men diagnosed with advanced prostate cancer.

Learn more about the new cutting-edge therapy for advanced prostate cancer.