PSA Recurrence After 10 Years: Risks, Options & Outlook

Many people with prostate cancer have a radical prostatectomy (RP) to treat it. Even after surgery, prostate cancer management isn’t over. One of the biggest concerns is biochemical recurrence (BCR), which is indicated by rising PSA levels. It happens in a substantial number of cases. Some studies show that roughly a third of all people with prostate cancer will experience BCR. Others show that as many as half of all men with prostate cancer will develop BCR within 10 years.

If you’ve had prostate cancer, a rising PSA level can understandably cause concern. However, it’s important to know that a rising PSA level doesn’t necessarily mean the cancer has metastasized or will lead to prostate cancer-related death, especially if it happens many years after treatment. In these situations, overdetection and overtreatment become important factors to consider.

In this article, we’ll look at the complexities of PSA recurrence after 10 years, including the risk factors and treatment options. We’ll also talk about the importance of individualizing your management strategy and the potential for overdetection and overtreatment. Our goal is to provide a comprehensive overview for medical professionals, people with prostate cancer, and their families as they deal with this challenging aspect of cancer care.

Defining and Detecting PSA Recurrence: What Does a Rise in PSA Mean After a Decade?

So, what does it mean if your PSA starts to creep up again after 10 years? Let’s break down how doctors define recurrence and how they monitor it.

What Constitutes Biochemical Recurrence?

Doctors use the term “biochemical recurrence” (BCR) when they detect PSA in your blood after you’ve had surgery (radical prostatectomy) or radiation therapy. The exact definition can vary slightly depending on the guidelines your doctor follows, but generally, it means your PSA has risen above a certain level – often 0.2 ng/mL after surgery, and sometimes higher after radiation.

BCR is important because it’s linked to a higher chance of the cancer spreading (metastasis) and a greater risk of death from prostate cancer (PCSM).

The Role of PSA Testing in Long-Term Follow-Up

PSA testing is still the main way doctors keep an eye on you after surgery. However, how often you get tested needs to be tailored to your specific situation. Doctors have to weigh the benefits of frequent testing against the potential for “scanxiety” – the stress and anxiety that can come with waiting for test results.

If your pathology reports after surgery looked good and you haven’t had any signs of BCR in the first 5 years, some doctors might question whether you need super-frequent PSA checks going forward.

Differentiating True Recurrence from Other Factors

Just because your PSA goes up doesn’t automatically mean the cancer is back; some research explores whether turmeric can affect PSA levels. Sometimes, there are other reasons for PSA fluctuations. For example, a lab error in measuring your PSA, benign prostatic hyperplasia (BPH, an enlarged prostate that’s not cancerous), or other non-cancerous conditions can all cause your PSA to go up. Some may consider Finasteride and expect certain results after 2 years to manage BPH.

That’s why doctors also look at how quickly your PSA is rising, which they call the PSA doubling time (PSADT). A shorter PSADT usually means a higher risk of the cancer spreading, so it’s an important piece of the puzzle.

Risk Factors and Prognostic Indicators for Late PSA Recurrence

Even after 10 years of a good PSA score after prostate cancer treatment, you still need to keep an eye on things. So, what increases your risk of a late PSA recurrence? What can doctors look at to get an idea of how aggressive any recurrence might be?

Gleason Score and Pathological Stage

The Gleason score is still the gold standard when it comes to predicting what might happen after prostate surgery. If you had a higher Gleason score (like 4+3=7 or higher), the chances of the cancer coming back, spreading, or even causing death are significantly higher.

The pathological T-stage (pT-stage), which tells how far the tumor had grown, also matters. A higher pT-stage, especially pT3 (when the tumor had already grown outside the prostate), means a greater risk.

Surgical Margin Status

Did the surgeon get it all? If the pathology report came back saying there were cancer cells right at the edge of the tissue that was removed (positive surgical margins), that’s not ideal. It usually means a higher chance of the cancer coming back.

PSA Doubling Time (PSADT)

Once the PSA starts creeping up again, how fast is it rising? That’s the PSA Doubling Time (PSADT), and it’s a big deal. A short PSADT means the cancer is likely more aggressive and growing faster.

Knowing the PSADT helps doctors figure out how worried they should be and what treatment plan makes the most sense.

Genomic Testing

This is where things get fancy. Tests like Decipher look at the activity of genes inside the tumor cells. They can give a much more detailed picture of how likely the cancer is to spread and how well it might respond to different treatments.

Genomic testing can be super helpful in making decisions about what to do next if the PSA starts rising again, even years after treatment.

The Likelihood of Metastasis and Mortality After Late PSA Recurrence

So, what happens after a late PSA recurrence? What are the chances the cancer will spread, and what are the odds that it will ultimately lead to death?

The Natural History of Prostate Cancer After Late Recurrence

It’s important to remember that many men who experience a rise in PSA levels 5 or even 10 years after treatment may never develop metastatic disease before they die of something else. This is a key point. As men age, they become more susceptible to other health problems. These other conditions can become more pressing than the prostate cancer itself, influencing treatment decisions.

This highlights the importance of considering “competing risks.” What are the other health challenges a man faces? Are they more likely to impact his life expectancy than the prostate cancer?

Statistical Probabilities of Progression

Research suggests that a notable percentage of men with late PSA recurrence will not experience metastasis. One study indicated that at least 15.6% of patients with PSA recurrence after 10 years may never develop metastasis. This is a significant finding, suggesting that for some men, the rise in PSA may not translate into a life-threatening progression of the disease.

Furthermore, research suggests that at least 31.4% of patients older than 70 with PSA recurrence within 10 years may be overdetected. This means that the PSA recurrence might be identified even though it doesn’t pose a significant threat to the patient’s health or lifespan.

Individual Variability and the Need for Personalized Assessment

It’s vital to remember that these statistics represent averages. Every man’s situation is unique, and outcomes can vary considerably. A comprehensive assessment is crucial. This assessment should take into account factors such as:

• Age
• Overall health
• Gleason score (a measure of cancer aggressiveness)
• PSADT (PSA doubling time – how quickly the PSA level is rising)
• The patient’s preferences and values

Ultimately, the decision about how to manage a late PSA recurrence should be a shared one between the patient and his doctor, carefully weighing the potential risks and benefits of treatment in the context of the individual’s overall health and goals.

Treatment Options for PSA Recurrence After 10 Years: Balancing Benefits and Risks

If your PSA levels rise significantly 10 years after prostate cancer treatment, it can be concerning. A PSA recurrence (also called biochemical recurrence or BCR) means that cancer cells may still be present in your body, even after initial treatment. Fortunately, there are several treatment options available. The best approach for you will depend on several factors, including your overall health, the extent of the recurrence, and your personal preferences. It’s important to discuss the potential benefits and risks of each option with your doctor to make an informed decision.

Salvage Radiation Therapy (sEBRT)

Salvage EBRT is a common treatment, especially when the PSA level is still relatively low. Typically, the earlier you start sEBRT, the better the outcome. However, like all treatments, sEBRT can cause side effects, such as bowel problems and urinary symptoms.

Androgen Deprivation Therapy (ADT)

ADT is often used alongside sEBRT or as a standalone treatment if the cancer has spread beyond the prostate area; medications like Orgovyx may shrink prostate size based on clinical trial results. ADT works by lowering the levels of male hormones (androgens) in your body, which can slow down the growth of prostate cancer cells.

ADT can be given continuously or intermittently (iADT). Intermittent ADT may help reduce the side effects that can come with long-term hormone suppression. Unfortunately, ADT can still cause side effects like hot flashes, fatigue, loss of libido, osteoporosis, heart disease, and even diabetes.

Second-Generation Antiandrogens

Newer medications, like enzalutamide, have shown promise in improving outcomes for high-risk BCR. The EMBARK trial, for instance, showed that enzalutamide plus leuprolide improved metastasis-free survival for patients with high-risk BCR and negative conventional imaging.

Other Salvage Therapies

In certain cases, other local treatments might be considered, like salvage RP (repeating the prostatectomy surgery), cryotherapy (freezing the tissue), HIFU (high-intensity focused ultrasound), SBRT (stereotactic body radiation therapy, a highly focused radiation), and brachytherapy (internal radiation). These therapies all have different side effect profiles and varying rates of success in keeping the cancer from recurring.

Active Surveillance

For some patients, especially older individuals with low-risk BCR, active surveillance might be a reasonable option. This involves closely monitoring PSA levels and other factors, and only starting treatment if there’s evidence that the disease is progressing. It’s a way to avoid or delay the side effects of treatment while still keeping a close eye on the cancer.

The dangers of overdetection and overtreatment

It’s important to understand the concepts of overdetection and overtreatment when talking about PSA recurrence. Overdetection happens when doctors find prostate cancer that’s not really a threat, cancer that would never have caused problems if it had been left alone. Overtreatment is when doctors treat a cancer that doesn’t need it, potentially causing harm without any real benefit.

The key is finding the right balance: catching aggressive cancers early while avoiding unnecessary treatment for those that are harmless. The risk of overdetection depends on things like your age and the specific characteristics of the disease.

We need better ways to figure out who truly needs further treatment (salvage therapy) after initial treatment fails. This is an area of ongoing research aimed at refining our approach to PSA recurrence and prostate cancer management.

Lifestyle Interventions and What’s Next

We’re learning that things like diet and exercise can impact BCR after prostate cancer treatment. For example, some early research suggests a low-carb diet might influence how BCR progresses, but it’s too early to say for sure.

The real key to improving outcomes is better prediction. We need to identify biomarkers that can tell us how a patient’s disease will progress and how they’ll respond to different treatments. This will allow doctors to personalize therapy, rather than relying on a one-size-fits-all approach.

Clinical trials are crucial for figuring out the best way to treat BCR and for giving patients access to the newest therapies. Research is constantly evolving, so staying informed is important.

Frequently Asked Questions

Final Thoughts

A rising PSA after 10 years following prostate surgery can be concerning, but it’s important to remember that every case is different. It’s a complex situation that requires a personalized approach.

Just because your PSA is rising doesn’t automatically mean the cancer has spread or that you need immediate treatment. In fact, sometimes treatment can do more harm than good.

Doctors use a variety of factors to assess your risk, including your Gleason score, how quickly your PSA is rising (PSADT), and genomic testing. This information helps them determine the best course of action.

Especially for older men with low-risk cancer, it’s crucial to avoid overreacting. Sometimes, doing nothing is the best option.

The most important thing is to have an open and honest conversation with your doctor about your goals and preferences. Together, you can develop a management plan that’s right for you.

Researchers are continually working to improve risk assessment tools and develop more effective and less harmful therapies for biochemical recurrence (BCR). As we learn more, we can make better decisions about how to manage this condition.