|
Any man with prostate cancer, regardless of stage or treatment, should include in his action plan a contingency plan for recurrence. The first step in this action plan is to be aware of how to detect a recurrence and how to deal with it.
Your cancer may be recurring if:
- Your physician feels a lump on digital rectal examination after primary treatment
- Rising or persistently elevated PSA
- Repeat biopsy is positive
- Positive bone scan
- Positive ultrasound or MRI
- Positive prostatic acid phosphatase
- Bone pain
- Increasing fatigue, gradual weight loss, and loss of appetite
- Increased severity of existing symptoms
Persistently elevated or rising PSA is often the first evidence that cancer has not been fully eliminated or is recurring. It may precede any clinical symptoms by 18 months or more. The definition of abnormal PSA after treatment depends on the form of treatment and the nadir reached during treatment (nadir refers to the lowest level reached after treatment).
A promising new imaging technique, Prostascint ™, may indicate the site of recurrence in a patient with persistently elevated or rising PSA with no other signs of recurrence. This test is based on immunoscintigraphy with antibodies directed against prostate specific membrane antigen.
Secondary Treatment of Cancer After Recurrence
If the first-line therapy has failed, there are still many options, and some men experience lengthy survival even in this situation. Many of the secondary therapies are sub-optimal due to side effects, whereas others are useful for palliation but are not curative.
Secondary Treatments:
- Hormone therapy
- Chemotherapy
- Salvage therapy
- Experimental therapy
- Expectant mangement
Hormonal therapy: The mechanism of action and benefit of hormonal therapy is similar whether it is used as a primary or secondary therapy. Of considerable debate is the timing of hormonal therapy. Some doctors prefer to institute hormonal therapy as soon as recurrence is identified, and therapy is then continued indefinitely. Others wait until bone pain or other symptoms occur, and provide therapy only until there is resolution of symptoms. Still other argue that if relapse occurs during use of hormonal therapy, the treatment should be stopped because the cancer cells are becoming unresponsive.
Chemotherapy: These drugs may provide symptomatic relief, but are not curative. These are described in the section Alternate Therapies.
Salvage therapy: Salvage therapy refers to the use of first-line therapy after cancer recurs. For example, radical prostatectomy can be performed after failure of radiation therapy, but the patient should be in good health and motivated to receive this treatment. The side effects are considerably greater, probably due to the scarring effect on tissue from the radiation therapy, the increased possibility of higher stage cancer, and the increased difficulty of the procedure.
Salvage cryosurgery: After first-line radiation therapy can also be effective, but carries a heightened risk of incontinence and impotence then its use as a first-line treatment.
Salvage radiation: Radiation therapy is often employed in patient with positive surgical margins or extraprostatic extension identified at radical prostatectomy. In such cases, the dose may be less than when it is used as a first-line therapy. Up to 45% of men treated with salvage radiation after prostatectomy were free of cancer at 5 years.
Salvage hormonal therapy: The utility of androgen deprivation therapy at the time of radiation therapy is under active investigation.
Experimental treatments: These are dealt with in the section on Alternate Treatments.
Expectant management (Symptomatic treatment): In men with recurrent or metastatic prostate cancer, cure is less likely, and the focus of treatment is on avoiding unwelcome symptoms such as bone pain. In such cases, the focus is quality of life.
|