Is there any human being who would greet a cancer diagnosis with good cheer? I suspect not, because it’s not good news. It automatically triggers the most basic of all fears: am I going to die? Even the most optimistic or logical person can’t keep that question from popping up, at least momentarily.

If the diagnosis is prostate cancer (PCa), knowing the facts can ease a patient’s mind. Fact: today, more low-risk cases than ever before are picked up as a result of prostate specific antigen (PSA) screening. Fact: Only a small proportion of men with low-risk PCa progress to clinical symptoms, metastases, or death. Fact: clinical trials have not shown a benefit for immediate radical treatments, so focal therapies and active surveillance are excellent PCa management strategies. Correct information can be consoling.

However, there are other emotions that may accompany the PCa journey from the moment of diagnosis to living with the consequences of one’s treatment decision. As the PCa support organization Us Too notes, “A cancer diagnosis of any type triggers a wide range of initial reactions and emotions. While in some instances, it can be relief, a more typical response may include sadness, loss, fear, guilt, stigmatization, embarrassment, anger or disappointment.” These are all normal responses.

Facing the prospect of lifelong monitoring

For many PCa patients, it is particularly depressing and anxiety-provoking to realize that once they have been treated, they are still not home free. For the rest of their lives, the shadow of possible recurrence becomes a haunting fact of their future. With the passing of time the risk lessens, but even after a radical prostatectomy (RP) when PSA is supposed to remain undetectable, a large scale German study from 2017 reports sobering data for 2,480 post-RP patients who had undetectable PSA for 10 years following their surgery: 249 of them, or roughly 10%, subsequently had rising PSA even as far out as 20 years.^[i] This is not something you want to hear when you thought you were cured.

How does monitoring occur? The standard method is the PSA blood test. The type of treatment determines when the first post-treatment blood draw will occur, and what the doctor expects the PSA level to be. For example:

• RP – 6 to 12 weeks is usual, since a small amount of PSA may still be in the bloodstream for several weeks. At the first blood draw, PSA should be undetectable (less than 0.1 ng/mL).
• Beam radiation – After radiation, there may still be prostate tissue because the radiation beam is narrowly focused on the tumor, so there may be detectable but low PSA.
• Focal therapy – Focal ablation will lower PSA but because healthy prostate tissue is preserved PSA will be detectable but expected to remain stable.

Following the first post-treatment blood draw, the doctor will recommend a PSA protocol for the patient to follow. The recommendation may take into account the pre-treatment clinical factors and risk level, but the important thing is for the patient to adhere to the schedule set by the doctor. In most cases, it will be an annual blood draw after the first year.

How we can help

A rising (or suspiciously high) PSA following PCa treatment is likely to rekindle the patient’s earliest fears and worries at the time of initial diagnosis. No matter what the treatment was, it is easy to immediately jump to the conclusion that the cancer is back! In fact, most doctors will quickly advise that a patient who had radiation, ablation, or is on Active Surveillance undergo an invasive needle biopsy. However, this course of action may be premature because the PSA test itself is not specific enough.

This is where multiparametric MRI (mpMRI) comes into play. The American Society of Clinical Oncology (ASCO) calls the use of mpMRI along with PSA monitoring “added value.” A growing number of studies confirm that mpMRI, coupled with PSA, can detect the presence of even a small amount of significant PCa with incredible accuracy. If the imaging is negative, the patient may be able to wait and have a repeat PSA test in several months. At our Center, we offer the technology and the experience to rule out the presence of recurrence in the prostate and neighboring structures.

What if the mpMRI detects a suspicious lesion? In that case, we provide an alternative to the conventional TRUS biopsy, a 12-14 needle procedure with what we consider an unacceptable error rate (underdetection of significant PCa, overdetection of insignificant PCa). Instead, our in-bore targeted biopsy targets the suspicious area using a minimum number of needles. The resulting tissue samples have the highest probability of an accurate diagnosis.

Thanks to the pictorial information from the scan, along with the biopsy, the most advantageous treatment for any recurrence can be planned.

Monitoring need not be a depressing future. A final word: Today’s medical advances mean that many more men are able to live longer, healthier lives with greater vitality. This may mean that monitoring will continue into advanced age, but perhaps less often than annually depending on other factors. In any case, mpMRI is a noninvasive safety measure if some day after PCa treatment, PSA “speaks up.”

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Liesenfeld L, Kron M, Gschwend JE, Herkommer K. Prognostic Factors for Biochemical Recurrence More than 10 Years after Radical Prostatectomy. J Urol. 2017 Jan;197(1):143-148.