PSA recurrence is demoralizing whether or not it is after surgical therapy or radiation therapy. Finding out that the primary treatment you chose to attack your prostate cancer did not work is a difficult pill to swallow. In any case the evaluations are similar. The treatment options differ to some degree but not greatly.  Again, the first discussion with the patient is about the point in time that he wants a further evaluation. The older the patient, the less likely he is to succumb to prostate cancer. Therefore, most urologists tend to be less aggressive in their evaluation and treatment options for the patient over 70 as opposed to the patient under 60. As with surgical failure, typically I’d have the patient pick an arbitrary number at which he is no longer comfortable with watchful waiting and if his PSA hits that number we would embark upon the evaluation.

Again, I would obtain a whole body nuclear bone scan to see if there are skeletal metastases. Often we will perform a prostate biopsy to see if there is local recurrence. It becomes somewhat difficult in terms of reading the pathology because of the changes induced by the radiation and very often I will have the pathology sent for a second opinion from Johns Hopkins University Pathology. If it appears that there is active cancer in the pathology specimen and no evidence of distant disease, there is an argument to made for salvage radical prostatectomy. This is a very complicated surgical procedure with a much higher complication rate because of the effect of radiation to the surrounding tissues. In my opinion, it should be left to the surgeons who are very comfortable with salvage procedures because of its difficulties and complications rates.

I have personally performed over 300 seed implants. In all of that time there has only been one man who was a candidate for a salvage radical prostatectomy. It has been my experience that if a patient fails his radiation therapy even if there is local recurrence, invariably there is distant disease as well.

For external beam radiation failures that are local and have no evidence of distant metastases, cryosurgery (or freezing) of the prostate has become a popular treatment. This can also have significant complications and sequelae, but I believe that it is less likely to have the profound complications seen after salvage radical prostatectomy.

If there is evidence of distant disease or no evidence of local recurrence despite a rising PSA, you must assume that there is distant disease. The next step would be to institute androgen deprivation therapy as was discussed last week. Please refer to our last blog for the discussion of these medications and their consequences.

As before, PSA after institution of total androgen blockade is followed closely. Most men will see their PSA nadir to undetectable and stay that way for some time. I personally have followed men who had PSA recurrence after primary therapy start androgen blockade and still have undetectable PSAs over ten years later. The amount of time to PSA nadir and how long the PSA stays undetectable is a good indication of long term effectiveness of the treatment.

So once again,  the take home message is that PSA recurrence after primary radiation therapy is not the worst thing that can happen. Much depends on the metastatic evaluation and the response to therapy as it did when you were treating primary disease. As you must be realizing by now, all prostate cancer is not the same. Treatment must be individualized for each patient whether that is primary therapy or treatment for metastatic disease. Medicine is not cookie cutter, despite what our politicians think. We as physicians need all options in our armamentarium to allow patients the ability to make informed decisions in their care. Let’s make sure that we don’t allow our government to restrict treatment options and the ability of doctors to honestly counsel their patients because we are bowing to the alter of financial efficacy.

Hopefully we will have a surprise for next week’s blog. I am working on an interview with a well known local urologist who has been selected for a prominent position in one of our large community hospitals. More to come.

Have a great week. Talk to you soon.