September 23, 2012 By Deborah Mitchell
If you have prostate cancer and you have your prostate removed (radical prostatectomy), can your cancer return? If it does return, are there treatment options available? These are questions men ask when they are faced with making a decision about prostate cancer treatment. Unfortunately, the answer to the first question is “yes” while an affirmative to the second question is (fortunately) a positive sign. If you are faced with making a treatment decision about prostate cancer that involves prostatectomy, it’s a good idea to learn all you can about the procedure and other cancer treatments so you can be prepared to tackle a possible return of your cancer.
Chances Prostate Cancer Will Recur
Overall, a man who has undergone prostatectomy for localized prostate cancer has a 10 to 30 percent chance of experiencing prostate cancer recurrence during his lifetime. Among these cases of recurrence, about half happen during the first three years after prostatectomy, another 30 percent occur from years 3 to 5 post-prostatectomy, and about 19 percent happen after year 5. Some experts say the figure of recurrence is even higher.
Prostatectomy as a treatment option for prostate cancer is usually chosen by men who have localized prostate cancer; that is, it has not spread beyond the prostate gland. Therefore, the hope is that removal of the prostate will also rid the body of prostate cancer cells. A prostatectomy can be performed as either a traditional open surgery, a laparoscopic procedure, or as a robot-assisted approach (computer-enhanced robotic prostatectomy). Most men who are candidates for traditional open prostatectomy can have a laparoscopic or robotic prostatectomy.
While recovery times and the risk of postoperative symptoms and complications differ depending on which type of prostatectomy you choose, the burning question after surgery is whether the cancer will come back. You may wonder how prostate cancer can recur if the diseased prostate has been removed. Although a man may have prostate cancer that appears to be entirely localized (limited to the prostate), it is possible for some prostate cancer cells to migrate outside the prostate and beyond the surgical area, which includes not only the prostate but the tissue surrounding it that is removed during surgery.
There is no way to know for certain if prostate cancer cells have migrated outside the surgical area, and so it is these cells that may trigger a cancer recurrence. That’s why men who undergo prostatectomy are told to have a PSA test regularly, typically every six months for at least 10 to 15 years. In addition, many men choose to have radiation therapy following prostatectomy to kill any cancer cells that may have migrated.
For men who have a prostatectomy and whose prostate cancer is limited to the prostate and whose tissue surrounding their prostate and lymph nodes are free of migrating prostate cancer cells, survival is similar to that of a man who never had the disease at all. However, then there are men who have rogue cancer cells, and they face the possibility of needing to treat recurring prostate cancer.
Treatment Options for Prostate Cancer Recurrence
The two treatment options for prostate cancer that has recurred after prostatectomy are radiation and hormone therapy. Some physicians recommend radiation therapy alone, while others suggest a combination of radiation and hormone therapy. In many cases, physicians suggest starting radiation therapy for prostate cancer when the PSA level rises above 0.2 ng/mL and remains there for two consecutive readings. Hormone therapy often is not started unless the PSA level rises above 0.4 ng/mL, however, each case is unique and so you need to consult with your healthcare provider.
Studies of Prostate Cancer Recurrence
At the University of California, San Francisco, investigators reported that 15 percent of 1,439 men who underwent prostatectomy experienced recurrence. Prostate cancer recurrence was defined as:
- a PSA (prostate-specific antigen) level of 0.2 ng/mL or greater on two consecutive tests, or
- the patient needed a second cancer treatment at least six months after surgery
Another study extended that 15 percent figure to 40 percent, noting that this was the number of men who will experience prostate cancer recurrence within 5 years.
If you want to improve your chances of survival after prostatectomy, a course of radiation therapy may be in order, as already mentioned. The potential benefit of radiation therapy after prostate removal was explored in a study published in the Journal of the American Medical Association.
The researchers evaluated 635 men who had a prostatectomy between 1982 and 2004 and then followed up through 2007 and who had a recurrence of prostate cancer and received no treatment (397 men), radiation treatment (160 men), or radiation plus hormone therapy (78 men).
At a median of six years after prostate cancer recurrence and nine years post prostatectomy, a total of 116 men (18%) had died of prostate cancer. They included the following:
- 89 men who were not treated after cancer recurrence
- 18 men who underwent radiation treatment only
- 9 men who received both radiation and hormone therapy
Overall, the researchers found that giving radiation therapy after prostatectomy and the recurrence of prostate cancer was associated with a nearly 60 percent reduced risk of death and threefold increase in prostate cancer-specific survival when compared with men who did not undergo any treatment at cancer recurrence. Radiation was also associated with a significant increase in overall survival. Notably, the addition of hormone therapy to radiation therapy did not improve survival.
Also notable in this study are the following findings:
- The increase in prostate cancer-specific survival associated with radiation therapy was seen only in men who had a PSA doubling time of less than six months. Among the 166 men who met this description, radiation as well as radiation plus hormone therapy were associated with a greater than 75 percent reduced risk of prostate-cancer specific death.
- Men who started radiation therapy more than two years after their cancer recurred did not experience a significant increase in prostate cancer-specific survival.
- Men whose PSA levels never reached zero after they had radiation therapy post prostatectomy did not experience a significant increase in prostate cancer-specific survival.
When Radiation and Hormone Therapy Fail
For some men, radiation and hormone therapy do not put the brakes on prostate cancer that recurs after prostatectomy, and the disease continues to spread. In such cases, one treatment option may include chemotherapy with docetaxel (Taxotere), which may extend survival and effectively treat cancer pain. Another option is the immunotherapy sipuleucel-T (Provenge), which for now is limited to men with metastatic prostate cancer who have no symptoms or whose cancer pain does not require use of narcotics and who have not responded to hormone therapy.
Two other choices for men who have not responded to traditional hormone therapy are abiraterone (Zytiga), a form of hormone therapy that has been approved by the Food and Drug Administration (FDA) for advanced cancer that has resisted previous hormone therapy; and enzalutamide (Xtandi), which is approved for men whose prostate cancer has spread and not responded to both hormone therapy and chemotherapy (docetaxel).
For the majority of men who undergo prostatectomy for localized prostate cancer, the disease does not recur. However, for those men who do experience prostate cancer recurrence, there are treatment options, and patients should discuss the risks and benefits of all the alternatives with their healthcare providers and loved ones before making a decision.