FEATURED JOBS
Comments (1)For the man who underwent a radical prostatectomy and had an undetectable PSA, finding out that your PSA is now detectable and rising can be devastating. The evaluation of most PSA recurrent disease starts out in a similar fashion. The first discussion with the patient is about the point in time that he wants a further evaluation. For a man who had his prostate removed at age 64 and then ten years later at 74 his PSA starts to very slowly increase, I would typically recommend watchful waiting. 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. Obviously at age 74 the likelihood of the patient succumbing to prostate cancer that is slowly advancing is small. However, if you change the ages and the man who had his prostate removed at age 49 gets a PSA recurrence at age 59, you can make a strong argument to institute your metastatic evaluation as soon as his PSA starts to rise.
Typically, I would obtain a whole body nuclear bone scan to see if there are skeletal metastases. If we assume that the prostate cancer was confined to the prostate, there was no penetration of the capsule of the prostate by cancer, the lymph node sampling was negative and the “margins” were negative it is unlikely for the bone scan to turn up positive if his PSA is low and has just started to rise. You might consider and abdominal CT scan or a Prostascint scan but unfortunately both of these tests have significant false positive and false negative rates.
Some in the urological community would recommend empiric radiation therapy to the bed of the prostate. Certainly if there were positive margins at the time of surgery or the “capsule” of the prostate had been penetrated by cancer a strong argument could be made for empiric radiation therapy to the bed of the prostate which has been removed. Some in the community will try to biopsy the area of the bladder neck, but my experience with this has been poor.
If the PSA continues to rise despite irradiating the bed of the prostate, the next step would typically be to start total androgen blockade. Just like breast cancer in women is often estrogen sensitive, prostate cancer in men is similar in that its “food” is testosterone. So by blocking testosterone in the body, you essentially deny prostate cancer its growth food. This is done in two steps. An oral anti-androgen like Casodex is started on a daily basis. This blocks testosterone generated by the adrenal glands which is a small percentage of the body’s total testosterone production. The larger portion is made by the testes. Removal of the testes which is called orchiectomy is a permanent way of denying the body testosterone. For many men, surgical castration is a difficult psychological problem. Most men that I have treated prefer medical castration with a medicine such as Leupron (leuprolide). This is typically given in 3, 4, 6, or 12 month shots or implants. There are multiple medications on the market that do exactly the same thing and personally I consider them interchangeable.
There are significant side effects to these medications. The oral anti-androgens can cause issues with the liver and blood work needs to be followed closely. Leupron will often cause hot flashes. For many men this is mildly bothersome. For some men it can be debilitating. In addition, I have seen men develop nightmares and muscle or joint issues with androgen blockade. Finally, recent studies show that there is a small but real increase in risk of cardiac events in men on these medications. While all of these side effects or complications are uncommon, they certainly are not unheard of. The most common complaint is hot flashes. For the man who has debilitating hot flashes, depo-provera has been shown to ameliorate the symptoms in a large majority of men suffering with the problem.
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.
So the take home message is that PSA recurrence after primary therapy is not a death sentence. And while all medications have significant side effects we have been using androgen blockade for prostate cancer for many decades. It works well and has given a large number of men many productive years despite having “metastatic” disease.
As an aside, the Orioles just finished a sweep of the Red Sox. Has Boston slipped that much, or are the Orioles starting to shake the doldrums of a 4 - 18 start? Finally, kudos to the Wizard of Oz. The Ravens had a great draft. Let’s pick up a veteran cornerback until Webb and Washington are healthy and shoot for the stars. With all the new weapons that Flacco now has to utilize, anything less than a couple of playoff wins would be a severe disappointment. Time to step it up Joe. It’s your third year and you have the weapons you need to get us to the next level. The question is whether or not you are the type of quarterback who just manages a game, or can you be the guy that takes the team on his shoulders and wins the game? I believe you have it in you. Let’s see it this year.
Have a great week. Talk to you soon.
