Lesson 3: Prostate Cancer Treatment Options
Successful Treatment or Remission
If you have had surgery, your doctor will first check the pathology report. This tells the Urologist whether there was any evidence of cancer left behind (e.g., at the surgical margin, or in the lymph nodes). If the pathology report is OK, your doctor will then look at the PSA blood test. If the surgery was successful, the PSA should be undetectable. This level varies from lab to lab but for many labs the lowest level that can be detected is 0.02 ng/ml (the "normal" range of 0-4 ng/ml has no meaning for you now). Sometimes your Urologist will watch a low but non-rising PSA.
If your PSA level is detectable, especially if it is rising, this tells your doctor that there are active prostate cells in your body. Most often, this is because of prostate cancer. Your doctor may perform x-ray tests (chest x-ray, CT scan and/or bone scan) or perform a biopsy of the prostate bed to see where the prostate cancer is active. Very often, these groups of cells are too small to see by these tests: you need a clump of about 10 billion cells (1 cubic cm) to detect them. You may be referred to a Radiation Oncologist for consideration of salvage radiation treatments, hormone therapy, or your doctor may wish to just watch. If you are going to be referred to a Radiation Specialist, the best evidence suggests that patients with lower PSA’s do better. Patients who’ve had surgery and who have a PSA level greater than 2 ng/ml have a very small chance of radiation alone curing the remaining cancer.
If you have had radiation, the definition of "success" is different for you than for those who have had surgery. Because you still have a prostate, your PSA will almost always be detectable (unless you are also on hormones). Your doctor will watch for the lowest level your PSA reaches (the nadir), which can take several years. While you are not "radioactive" after external radiation, the damage that the radiation did to your prostate cancer cells stays with you. Sometimes prostate cancer cells are in a rest phase and don’t know that they’ve been damaged by radiation. When they "wake up" or prepare to divide, then they realize that they are damaged and then die. If you have had seed Brachytherapy, the seeds will actually continue to give low doses of radiation to the prostate for over a year after the implant.
After the PSA reaches its lowest level, it will often fluctuate around that point. This is what you want – as long as it continues to do this, you will likely never have to worry about your cancer coming back.
If, however, the PSA continues to rise, this indicates that the prostate cancer is active and growing in your body somewhere. Your doctor will likely perform some x-ray tests and/or a biopsy of your prostate to determine where this active cancer is. Often, the cancers are too small to be detected.
If the cancer regrows in your prostate and there is no evidence of cancer elsewhere in your body, then your doctor may refer you for local treatments. This is an uncommon situation now that higher doses of radiation are being used. Treatment options for this situation includes radical prostatectomy, cryotherapy (freezing treatment), microwave therapy or seed Brachytherapy (if you haven’t had it previously). Because of the effects of the initial radiation, radical prostatectomy will be more difficult for the surgeon, and comes with a higher rate of complications, but is not impossible. However, most men are too old to have surgery by the time their cancer recurs.
The most common treatment if the cancer comes back after radiation is hormone therapy. While it is not curative, hormones can effectively put the cancer to sleep (into remission) for a number of years and allow men to live a full life. In addition, new medications and chemotherapies are constantly being tested so that while a cure is not available at this time, it may be a few years down the road.
