Rising PSA Post-prostatectomy

Li Liu, MD
Last Modified: November 1, 2001

Dear OncoLink "Ask the Experts,"
My father is 65 and had a radical prostatectomy 2 years ago. His PSA is now up to 0.5. All of my research indicates he still has cancer and should undergo radiation. His urologist advised him to come back in 6 months. I am worried that this is too long to wait and he should seek further treatment now. What do you think?
S

Li Liu, MD, OncoLink Editorial Assistant, responds:

Dear S,
Thank you for your interest and question.

Serum prostate specific antigen (PSA) is produced by prostate cancer cells as well as normal prostate cells. After radical prostatectomy, PSA should be undetectable (<0.2 ng/mL as defined by most of the laboratories). When PSA becomes detectable after radical prostatectomy and there is no evidence of disease spreading, it is called biochemical failure. This means that there is NO clinical proof that the cancer has come back on rectal exam or radiographic studies, but since it is detectable, there may be prostate cancer present at the microscopic level. The usual workup for this group of patients consists of a careful physical examination, including rectal examination, transrectal ultrasound (TRUS), and, occasionally, needle biopsy via TRUS. Chest x-ray, CT or MRI scans of the pelvis and abdomen, and bone scan are reasonable procedures to detect lymph node involvement and/or distant spreading of cancer.

Treatment options include continued interval checks of the PSA and rectal exam without other medical interventions, radiation therapy, and/or hormone therapy. Radiation therapy can be used to the area where the prostate used to be, if it was deemed that he was at risk to have had a local recurrence. Some retrospective studies demonstrated that radiation therapy improves local control of tumor in patients with a rising PSA after radical prostatectomy (International Journal of Radiation Oncology Biology Physics 1997 Sep 1;39(2):327-33). Longer follow-up of patients being treated in this category is necessary to further evaluate this option.

Hormonal therapy is also an option to be given alone or concurrently with radiation therapy. These hormones give an anti-testosterone effect to essentially cut off the hormone which stimulates prostate cancer (testosterone or male androgens) (Urology 1996 Mar;47(3):382-6). Radiation therapy with or without hormonal therapy is currently under investigation.

Without knowing the detailed history of your father's disease, it is impossible to make any clinical recommendations. He should discuss the case with his urologists, perhaps obtaining consultations from radiation oncologists and medical oncologists.