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Rising Psa After Radiation And Hormone Therapy

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During Treatment For Advanced Prostate Cancer

PSA After Radiation | Ask a Prostate Expert, Mark Scholz, MD

When treatments such as hormone therapy, chemotherapy, or immunotherapy are used for more advanced prostate cancer, the PSA level can help show how well the treatment is working or when it might be time to try a different treatment.

Treatments should lower the PSA level , although in some cases they may just help keep it from rising further, or even just slow the rise. Of course, other factors, such as whether youre having symptoms from your cancer and whether imaging tests show it is growing, are also important when deciding if it might be time to change treatments.

If the cancer has spread outside the prostate, the actual PSA level is often not as important as whether it changes, and how quickly it changes. The PSA level itself does not predict whether or not a man will have symptoms or how long he will live. Many men have very high PSA levels and feel just fine. Other men with low PSA levels can have symptoms.

Other Key Findings In The Study

Patients who had lower PSA scores:

  • Experienced an eight-year disease-free survival rate of 75 percent, compared with only 18 percent for those with the highest PSA scores.
  • Had a 97 percent distant metastasis-free survival rate, compared with 73 percent for those with the highest PSA scores.

However, the study also indicated that, when a PSA is falling, there is no specific number that predicts future survivability.

While there is no magic number for the PSA that guarantees that prostate cancer has been cured in an individual patient, in general, the lower the PSA number, the better chances that the cancer will not return or spread, said Michael E. Ray, M.D., Ph.D., lead author of the study and a radiation oncologist at the University of Michigan Medical Center.

Treating Prostate Cancer That Doesnt Go Away Or Comes Back After Treatment

If your prostate-specific antigen blood level or another test shows that your prostate cancer has not been cured or has come back after the initial treatment, further treatment can often still be helpful. Follow-up treatment will depend on where the cancer is thought to be and what treatment you’ve already had. Imaging tests such as CT, MRI, or bone scans may be done to get a better idea about where the cancer is.

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How Are Hormone Therapies For Prostate Cancer Administered

LHRH agonists, the most commonly used drug class for hormone therapy, are given in the form of regular shots: once a month, once every three months, once every four or six months, or once per year. These long-acting drugs are injected under the skin and release the drug slowly over time. LHRH antagonists include degarelix and relugolix, an oral form.

Rise In Psa After Radiation And Hormone Treatment

Postoperative Radiation for Prostate Cancer

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Cancer That Clearly Has Spread

If the cancer has spread outside the prostate, it will most likely go to nearby lymph nodes first, and then to bones. Much less often the cancer will spread to the liver or other organs.

When prostate cancer has spread to other parts of the body , hormone therapy is probably the most effective treatment. But it isnt likely to cure the cancer, and at some point it might stop working. Usually the first treatment is a luteinizing hormone-releasing hormone agonist, LHRH antagonist, or orchiectomy, sometimes along with an anti-androgen drug or abiraterone. Another option might be to get chemotherapy along with the hormone therapy. Other treatments aimed at bone metastases might be used as well.

What If My Psa Rises While Im On Hormone Therapy

When the PSA is rising or cancer is spreading despite a low level of testosterone, prostate cancer is called castration-resistant, or hormone-refractory. Despite this name, some hormonal therapies may still work. But prostate cancer in this setting may progress and become more aggressive and resistant, and you should be prepared to discuss additional treatment strategies with your doctor. This is the time when a medical oncologist, if not already involved in your care, gets involved. These doctors specialize in medical, systemic treatments for prostate cancer, which is useful at this time given that your disease is typically metastatic, meaning that it is not confined to only one location. Cancer cells in this situation have typically spread through the blood stream or lymphatics to other places in the body, and localized treatments are rarely helpful except in circumstances where where you are having symptoms, such as problems with urination.

Fortunately, more and more treatments for metastatic castration-resistant prostate cancer have become available in recent years, including certain newer androgen directed therapies, taxane chemotherapy, immunotherapy, PARP inhibitors, and, in 2022, lutetium-PSMA radionuclide therapy. Additional tests are required for some of these treatments to see if your particular type of prostate cancer is likely to respond. See Chapter 5 in PCFs Prostate Cancer Patient Guide for more details.

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Are There Different Types Of Hormone Therapy For Prostate Cancer

Yes. There are several different ways to block the secretion of testosterone, including the surgical removal of the testes, drugs known as LHRH agonists, and drugs called LHRH antagonists. These are considered standard hormone therapy. Another class of medications that can be used in combination with standard hormone therapy is called antiandrogens.

In the past decade, newer medicines called androgen directed therapies have been approved for certain states of advanced prostate cancer.

Side Effects Of Treatment

PSA Recurrence: When Should You Treat? | Ask a Prostate Expert, Mark Scholz, MD

Treatments for prostate cancer can cause side effects, which might carry on after your treatment has finished. Some side effects can even start several months or years after treatment finishes.

Side effects will affect each man differently you may not get all the possible side effects from your treatment.

Read more about:

Managing side effects

Side effects can affect your day-to-day life, but there are treatments for them, as well as things you can do to manage them yourself. Its important to speak to your doctor, nurse or GP about them.

If youre having problems with a side effect, you might have a meeting with your doctor or nurse to work out what support you need. They may refer you to someone who can give you more advice and support.

Read more about managing the side effects of prostate cancer treatment.

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Hormone Therapy In Treating Patients With Rising Psa Levels Following Radiation Therapy For Prostate Cancer

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
First Posted : January 27, 2003Last Update Posted : June 23, 2021

RATIONALE: Androgens can stimulate the growth of prostate cancer cells. Hormone therapy may fight prostate cancer by reducing the production of androgens. It is not yet known which androgen suppression regimen is more effective for prostate cancer.

PURPOSE: This randomized phase III trial is studying two hormone therapy regimens and comparing them to see how well they work in treating patients with rising PSA levels following radiation therapy for prostate cancer.

Condition or disease

Phase
Prostate Cancer Drug: bicalutamideDrug: buserelinDrug: cyproterone acetateDrug: flutamideDrug: goserelinDrug: leuprolide acetateDrug: nilutamide Phase 3

OBJECTIVES:

OUTLINE: This is a randomized, multicenter study. Patients are stratified according to prior radical prostatectomy , time since completion of prior radical radiotherapy , baseline prostate-specific antigen value , and prior hormonal therapy . Patients are randomized to one of two treatment arms.

Patients are followed annually for survival.

Table : Predictors Of Biochemical Recurrence At Time Of Diagnosis

Although a number of clinical factors contribute to your risk of relapse after treatment, the parameters below provide a simpler assessment of your chances of biochemical recurrence, based on your clinical profile at the time of diagnosis. For more sophisticated estimates, based on specific risk factors, see Figures 1 through 3.

Low risk Gleason score less than or equal to 6and Cancer stage T2c or more

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Results Side Effects And What’s Next

According to their results, the more intensive treatments led to better outcomes. Just over 70% of men in group 1 were still avoiding disease progression after five years, compared with 80.3% of men in group 2 and 87.4% of men in group 3. More specifically, 145 of the men in group 1 developed further PSA elevations during the follow-up period, compared with 104 men in group 2 and 83 men in group 3. Similar trends were observed with respect to how many men developed metastases, or cancer that becomes resistant to hormonal therapy after it begins to spread.

The more intensive treatments also had more short-term side effects, especially diarrhea. But differences in side effects between the three groups disappeared after three months.

The authors emphasized that longer follow-up is still needed to confirm whether adding ADT and pelvic node radiation to PBRT actually lengthens survival. Moreover, the study did not evaluate a newer therapeutic strategy for biochemical relapse, where doctors use novel imaging methods to find exceedingly small metastases throughout the body that they treat directly with radiation.

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

How Does Hormone Therapy Work Against Prostate Cancer

Postoperative Radiation for Prostate Cancer

Early in their development, prostate cancers need androgens to grow. Hormone therapies, which are treatments that decrease androgen levels or block androgen action, can inhibit the growth of such prostate cancers, which are therefore called castration sensitive, androgen dependent, or androgen sensitive.

Most prostate cancers eventually stop responding to hormone therapy and become castration resistant. That is, they continue to grow even when androgen levels in the body are extremely low or undetectable. In the past, these tumors were also called hormone resistant, androgen independent, or hormone refractory however, these terms are rarely used now because the tumors are not truly independent of androgens for their growth. In fact, some newer hormone therapies have become available that can be used to treat tumors that have become castration resistant.

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Frequent Urination Burning With Urination And Difficulty Urinating

These are the most common complaints. Occasionally the urinary stream will weaken. Generally these symptoms are managed with medications to help the bladder function better or eliminate burning. Rarely, your doctor may order a urine test. Symptoms will resolve after the end of treatment. Contact your doctor if you see blood in your urine or if you are unable to urinate.

Salvage Androgen Ablation Therapy

Hormonal manipulation is likely to be the therapy most commonly administered to patients with recurrent prostate cancer and yet it has been the least well studied to date. A total of 54% of urologists and radiation oncologists in one study recommended androgen ablation or observation with delayed androgen ablation for patients with recurrent prostate cancer.22 Certainly, androgen ablation is not a curative intervention, and therefore the optimal timing of its application is uncertain. The cancer-specific survival after androgen ablation administered upon identification of local-only recurrence in one series of 72 patients was 70 and 84 months.23 Although this relatively short survival may be a reflection of the advanced stage of disease of these patients or the intrinsic response rate of prostate cancer to hormonal therapy, the more morbid attempts at salvage therapy, such as radical prostatectomy, cryoablation, and brachytherapy, should demonstrate improved survival beyond that of androgen ablation in order to be reasonably administered to patients with recurrent prostate cancer.

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Salvage Radiotherapy And Androgen Deprivation Therapy

GETUG-AFU 16 was the first randomized trial comparing SRT vs. SRT and short ADT as salvage treatment for biochemical recurrent prostate cancer after radical prostatectomy and was presented in abstract form at the American Association of Clinical Oncology 2015 Annual Meeting. The trial randomized 743 patients most of them having high intermediate risk features . The 5-year PFS was 62.1% vs. 79.6% for SRT and SRT + ADT, respectively . The 5-year OS was 94.8% for RT vs. 96.2% for SRT + ADT . Cause of death was progressive disease in 2.1% of the patients on SRT arm vs. 0.8% in the SRT + ADT arm. Acute toxicities occurred more frequently in SRT + ADT arm . This trial will require longer follow-up to see if the benefits observed in progression-free survival translate into the same OS benefit .

Common Thoughts And Feelings

PSA & Hormone Therapy for Prostate Cancer | Ask A Prostate Expert, Mark Scholz, MD

You may feel all sorts of things after you finish treatment. Some men are relieved and feel ready to put the cancer behind them and get back to normal life. But others find it difficult to move on. Adjusting to life after cancer can take time.

For some men, the emotional impact of what they have been through only hits them after they have finished treatment. You might feel angry for example, angry at what you have been through, or about the side effects of treatment. Or you might feel sad or worried about the future.

Follow-up appointments can also cause different emotions. You might find it reassuring to see the doctor or nurse, or you may find it stressful, particularly in the few days before your appointments.

Worries about your cancer coming back

You may worry about your cancer coming back. This is natural, and will often improve with time. There are things you can do to help manage your concerns, such as finding ways to reduce stress. Breathing exercises and listening to music can help you relax and manage stress. Some people find that it helps to share what theyre thinking with somebody else, like a friend. If you are still struggling, you can get help for stress or anxiety on the NHS you can refer yourself directly to a psychological therapies service or ask your GP.

If youre worried about your PSA level or have any new symptoms, speak to your doctor or nurse. If your cancer does come back, you’ll be offered further treatment.

Feeling isolated

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What Causes The Bounce

Scientists are still trying to pin down exactly what the bounce is all about. In an August, 2019 blog about a PSA bounce after brachytherapy, I cited a 2016 paper which theorized that a strong anti-tumor immune response coupled with the therapeutic effect of radiation on the tumor is responsible for the PSA bounce. According to that theory, radiation initially delivers a setback to immune system cells already present at the tumor. However, radiation causes corruptions in the DNA of PCa cells, so they cannot reproduce and begin to die off. As they start dying in numbers, months after the treatment has ended, their biochemical fragments are released into the bloodstream, catalyzing the immune system to recognize and tackle the invader. This inflammatory response may be the source of the PSA bounce, serving to reinforce the lethal activity of the radiation. Thus, the bounce is a good sign.

If this is correct, it might help explain why younger patients are more likely to have a bounce, since their immune systems are more robust. It would also account for better radiation success with low-risk PCa cell lines, which seem to be less radiation-resistant than aggressive cell lines.

What Does Psa Velocity Mean

PSA velocity or PSA doubling time, both of which measure the rate at which your PSA rises, can be a very significant factor in determining is the aggressiveness of your cancer. Men with a shorter PSA doubling time or a more rapid PSA velocity after initial therapy tend to have more aggressive disease, and are therefore more likely to need more aggressive therapies. Likewise, men who have recurrence soon after surgery have a higher risk of aggressive disease.

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What Is Intermittent Adt

Researchers have investigated whether a technique called intermittent androgen deprivation can delay the development of hormone resistance. With intermittent androgen deprivation, hormone therapy is given in cycles with breaks between drug administrations, rather than continuously. An additional potential benefit of this approach is that the temporary break from the side effects of hormone therapy may improve a mans quality of life.

Randomized clinical trials have shown similar overall survival with continuous ADT or intermittent ADT among men with metastatic or recurrent prostate cancer, with a reduction in some side effects for intermittent ADT .

Do I Need Additional Treatment After Prostate Surgery

Postoperative Radiation for Prostate Cancer

After surgery, one of the most important questions to ask is whether you may benefit from additional therapy, such as adjuvant radiation . The decision to use radiation to lower your risk of recurrence and dying from prostate cancer after surgery is based on whether the cancer has spread to your seminal vesicles, whether there were positive margins, and whether the cancer spread beyond the prostate capsule. In addition, it is important to allow time to recover your urinary function before considering radiation therapy after surgery, as radiation to this region increases the risk of urinary strictures, leakage, and high urination frequency.Many, but not all men, often can safely avoid adjuvant radiation therapy, and closely monitor their PSA to determine if they will need early salvage radiation therapy .

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