Recommended further reading

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Maintaining your well being - information on depression and anxiety for men with prostate cancer and their partners.
Click here to download
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Nutrition, exercise and prostate cancer
A guide for men affected by or at risk of prostate cancer.
Click here to download - Nutrition, excercise and prostate cancer
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Click here to download - Report to the Nation on Prostate Cancer a guide for men and their families
A detailed 108p American book on prostate cancer diagnosis, and treatment options.

Can doctors tell me the likelihood
 of cancer recurring?
 
If the initial treatment is radical prostatectomy (surgery to remove the prostate and surrounding tissues), a specialist doctor (a pathologist) carefully examines the prostate gland which has been removed during the operation. This gives more information about the risk of return (or recurrence) of the cancer. Should the cancer be confined to the prostate gland then the outlook is better than if it has spread outside the "capsule" of the prostate or into the attached seminal vesicles, small sacks that are removed with the prostate

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How is cancer recurrence detected? 

The best indicator of whether cancer growth continues in your body (ie. the cancer has recurred) is the PSA (prostate specific antigen) blood test. PSA is a protein produced by both normal prostate and prostate cancer cells. It is found in the blood in higher amounts than normal when cancer is present. It is a very good indicator of whether living cancer cells remain following either radical surgery to remove the prostate or radiotherapy to kill the prostate cancer cells. However the meaning of the test result differs depending on which of these treatments you have had.

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Monitoring after surgery 

Since PSA is produced by both normal and cancer cells in the prostate, if all prostate cells have been removed at the operation, then the level of PSA ought to fall to almost zero, or less than 0.1 ng/ml. The time taken for the PSA to drop to this level after surgery depends on how high it was before the operation; however, in most cases, it should be undetectable at 3 months after surgery.

Most surgeons recommend measuring the PSA once every 3 - 4 months after surgery for the first 2 years and then 4 - 6 monthly for 2 - 5 years. After this, the risk of the cancer returning is small. Annual testing is then recommended. Your doctor may suggest a different testing program, however. It very much depends on the nature of your cancer.

What happens if the PSA starts to rise again?

If the PSA remains high or starts to rise after the initial treatment, then there must be prostate cells producing it. This is almost always the first sign of a return of the cancer. If the PSA becomes detectable then the doctor may repeat the test to confirm the rise - usually 3 months later. The next decision depends on where the likely site(s) of the cancer recurrence is.

One possibility is that the cancer cells remain only in the pelvic region (in the area close to where the prostate was). The pathology of the removed prostate, for example, may show that the cancer extends to the cut edge (positive surgical margin), and so some cells may remain. A bone scan, CT scan or MRI investigation can help to determine if the cancer has spread to other parts of the body. If cancer is identified in the pelvic area and not elsewhere in the body, then radiotherapy can be used to treat it. In this case, the chance of curing the cancer is uncertain, but is unlikely to be greater than 1 in 2.

If the PSA continues to rise, the most common treatment is hormone therapy, ie. removal of the male hormone activity, since the majority of prostate cancer cells need male hormone to divide. Exactly when hormone therapy should be started is a matter of some debate. Many urologists suggest starting hormonal therapy before the PSA climbs above 15ng/ml. This decision depends on the rate at which the PSA is rising and the acceptability of the side effects of this treatment to the patient.

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Monitoring after radiotherapy to the prostate 

After radiotherapy (external beam and/or brachytherapy which aims to cure the cancer), the PSA ought to drop to low levels and remain low. The time taken for this fall is quite different to that following surgery, since the prostate gland still remains inside the body and PSA is produced by both normal and cancer cells. The lowest PSA reading (called the nadir) may not occur for up to 12-18 months following radiotherapy. Ideally the PSA ought to fall to below 1.0 ng/ml.

Up to one third of men who have had brachytherapy will show a temporary rise in PSA during the first 18 months, after which the PSA will resume falling. This is referred to as “PSA bounce”. The cause of PSA bounce is not well understood. It can cause concern about cancer for both patient and doctor, but patience, with continued 3 monthly PSA testing is usually he best strategy.

The frequency of measuring the PSA after radiotherapy is somewhat controversial, however, most specialists would recommend once every 3 - 6 months for the first 2 years, 6 monthly for 2 - 5 years and annually thereafter.

What happens if the PSA starts to rise again?

Should the PSA rise and continue to rise, then, as with surgery, this normally indicates a return of the cancer. However, on rare occasions, the rise may be due to growth of benign prostate cells, inflammation or infection within the prostate and other treatments may be appropriate. The way the PSA changes is the important factor and a steady continued increase is likely to prompt the doctor to suggest further treatment (often hormone treatment). Tests to try to identify where the prostate cancer cells are, in the body, may not be helpful until the PSA is over 20ng/ml., because they are not sensitive to small amounts of cancer.

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Monitoring when no additional treatment is given 

Sometimes a patient, with his doctor, may choose not to have additional treatment when the PSA rises. This may be because the cancer does not pose a current threat and/or is slow-growing. This is called medical observation and is different from “active surveillance” or “watchful waiting”, an option for some patients prior to any prostate cancer treatment. In this case, the doctor may suggest a PSA test every 3 - 6 months. If the PSA level rises sharply or symptoms of the disease develop which affect quality of life, the doctor may suggest more active treatment. PSA doubling time is often used now, to learn how rapidly a cancer is growing and so how much of a threat it is.

We are not sure yet whether starting hormone therapy early or late changes the overall control of the prostate cancer. Quality of life is a factor in these choices.

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Avoiding needless worries 

After your treatment (surgical, radiotherapy or observation only) you will still go on having the common aches and pains (such as headaches and back aches) that are a normal part of living and growing older! However, men tell us that, after a diagnosis of cancer, they are more likely to think of these common symptoms as a sign of the cancer returning or spreading, when this is not the case.

In addition, sometimes after surgery to remove an organ, something feels different, because your organs internally have a different arrangement with each other. This is not harmful in any way but may be interpreted as due to the cancer.

Recovery from surgery or radiotherapy will also involve symptoms which may be new to you, but part of the healing process. Again, you may wonder if these new feelings are a sign of cancer returning. If you are concerned about any of these, you may be worrying unnecessarily. Talk to your doctor or specialist when in doubt. These are sources of worry you can easily do without! Talking to other men who have had your type of treatment may also be helpful. See contact details under “For more information” at the end of this information sheet. Routine monitoring is normal after treatment of prostate cancer.

Because the PSA level is the best reassurance that the cancer is not growing, it is easy to become very focused on that regular test result, and let it invade one’s day to day living. This kind of focus can distract a person from their normal enjoyment in life, and is not necessary once you have established a program of regular monitoring with your doctor. After initial treatment and recovery, there is no reason why you should not return to your normal activities and enjoy an active life.

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Maintaining quality of life 

Aches and pains will occur - but may be just due to growing older!
In Mr PHIP no. 3, we mention the importance of taking time, talking with your partner, family, your GP and repeat consultations with your urologist so that you feel confident in the steps you are taking with your health advisers. It is also important to keep active doing things that you enjoy. Some men feel down after treatment for prostate cancer, but it usually gets better over a few months. If it persists and is troubling, you should discuss it with your GP or specialist.
It may be helpful to have short term and long term goals, and step by step work towards them. Relaxation and meditation can be a valuable way of releasing tension and anxiety and give your body its best chance to recover. Dietary advice can also be important. Partners of men with prostate cancer also need support. Resources for both men and their partners are listed at the end of this sheet under ‘For more information’.

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What the future holds 

If the PSA begins to rise then there is typically a long delay (usually several years) before you feel any symptoms from the disease. Specialists usually offer hormonal treatment well before you develop any symptoms and hormonal therapy itself can control the cancer, wherever it may be in your body, typically for many years. Prostate cancer is not contagious and is not known to affect your partner or close contacts. Living with the knowledge that currently medical science does not have a cure for this stage of cancer is a difficult course, but the slow-growing nature of prostate cancer works in your favour. For many men, the years of life ahead are meaningful and enriching.

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Wesley Urology Clinic
Suite 42, Level 4 Wesley Medical Centre
40 Chasely St, Auchenflower, 4066
p: (07) 3720 6920
f: (07) 3720 6921

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Copyright © 2011- Geoff Coughlin