What does a rising PSA after prostate surgery mean?

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Prostate cancer and PSA levels: When should you worry?

Dr Samadi explains the relation between prostate cancer and PSA levels

PSA (prostate specific antigen) blood tests are familiar routine for men over the age of 40. The test is typically used as a screening tool for prostate cancer, and has helped countless men detect and treat their prostate cancer early. When treated early, the cure rate for prostate cancer is upwards of 95 percent.

The purpose of this article, however, is not to discuss routine PSA screenings and early treatment, but what happens after preliminary treatment and the removal of the prostate. How important is a PSA test after prostate surgery?

The answer is that PSA tests post-surgery are very important.

Obtaining your PSA level after surgery is a major milestone in prostate cancer treatment. The expected result after a prostatectomy is an undetectable PSA or level of zero. In some men, however, a PSA level above zero presents itself and this could mean a number of things, among them a return of their cancer.   

According to the Prostate Cancer Foundation, about 20 to 30 percent of men have PSA recurrences after five years of initial prostate cancer treatment, whether they chose surgical intervention or radiation treatment.

As a patient, the prospect of PSA recurrence can be very worrisome. What many patients do not know is that not all PSA recurrences are the same. Some types of recurrences are much more troublesome than others and treatment approaches can vary tremendously case by case.  

Seemingly simple at a glance, PSA post-prostatectomy is anything but simple. Although PSA should be zero after surgery, some patients are faced with one of two scenarios: PSA recurrence or PSA persistence.

PSA persistence is the detection of a PSA higher than zero within the first three months after prostatectomy. The distinction is that the PSA has not recurred, but rather persisted after surgery. The key difference this small distinction makes is in the prediction of the course the disease will take. A persistent PSA can unfortunately mean the cancer has progressed and metastasized. In many cases the best course of secondary treatment is hormone therapy.  

Unlike PSA persistence, PSA recurrence is characterized by a PSA of zero postoperatively, and a rise in the blood test after an unspecified period of time. Traditionally the value of 0.2 has been used as the benchmark to indicate PSA recurrence.  As previously noted, PSA recurrence can mean many different things in terms of the status of the prostate cancer. These different prognoses are based on several different factors, outlined below:

1)      Gleason Score of Prostate Cancer:  The Gleason score is a measure of how aggressive the prostate cancer cell's are.  The higher the score, the more aggressive the cancer.  Men with higher Gleason scores who experience PSA recurrence are at greater risk for metastasis of prostate cancer than those men with lower Gleason scores.

2)      Time from Surgery: How soon after surgery the PSA reappears is one indicator specialists use to determine the aggressiveness of the cancer. Generally, the longer the time between surgery and PSA recurrence, the less likely it is that the cancer is aggressive and going to spread and the better the survival rates will be.  

3)      PSA Doubling Time:  The term refers to the time it takes for the PSA to double in value. The value measures the rate at which the PSA rises, and can be a very significant indicator in the aggressiveness of the cancer. Men with a shorter PSA doubling time postoperatively are more likely to have more aggressive disease. In these cases a more aggressive secondary treatment plan may be advised.

Depending on these factors, secondary treatment, if needed, can be individualized to best manage the case at hand. Using the PSA in this way can be crucial in mapping out a predicted course of the disease and helping patients manage their disease as best as possible.

Some factor combinations could predict a localized, slow moving cancer – best treated and cured with radiation therapy by targeting the remaining prostate cells.  Other factor combinations could predict aggressive, metastatic disease, in which case hormonal treatment may be the best treatment. Still, in other cases, when evaluating all the aspects of the PSA and the patient, no treatment may be the best treatment.  

Ultimately, not All PSA recurrences are the same. And although experiencing a rise in PSA post-prostatectomy can be frightening, all hope is not lost. Many reoccurrences are still manageable and a cure is possible with the right treatment plan.

An important point to remember is that while radiation is a possible secondary treatment after surgery, the opposite is not true. Surgery is rarely possible after radiation as primary treatment. For this reason, choosing the right initial treatment for prostate cancer is crucial in your long term care.

Speak to your urologist about your specific risk factors if you have a PSA recurrence and map out the right course of treatment for you.