So, our next question is from a helpline caller and they're wondering if your PSA
is rising and they know it's a recurrence, is there a certain place in time where we need to
go for treatment and this is indicated just by the PSA rising or do they need to see a
biochemical recurrence? Does there need to be metastatic activity? What does that look like?
Well, if I understand the question correctly, the—how urgent is it to get after the cancer
if it's relapsing, and the answer comes down to whether or not someone is hoping to cure it. The,
as I mentioned, there is a possibility of salvage cure for men that are relapsing
and, of course, in those situations the earlier the better, but there are men that have maybe
been through this rigmarole a couple times; maybe they tried to salvage cure and it didn't work and
went on hormone therapy, now the PSA is rising. Intermittent therapy studies
given with hormone treatment suggest that allowing the PSA to float up to five or ten
is not dangerous, that men can take a holiday from treatment, allow the PSA to rise up,
and then resume hormone treatment. So, if the goal is a cure: the earlier the better. If the goal is
quality of life, say in an elderly man who's on intermittent therapy, it's not as critical.
Another question we got from helpline is there a number—like a cutoff—of the number of spots for
metastatic spots like lesions on the body where spot radiation won't work anymore?
Well, arbitrarily the experts have suggested that maybe five spots is the maximum to treat. The
problem is, the more the spots two things occur: one is that if you see five, there's probably
greater numbers that you don't see, and then
the other problem is that when you radiate spots in the bone you sacrifice a small
amount of the immune system because the bone marrow is where the immune system forms.
So selective treatment of small areas is perfectly safe, but you start treating more and more areas
then you have the potential for weakening the immune system. So they say a maximum of
five spots but certainly, it's much more ideal if it's one, two, or three rather than five.
Now, going back to the radiation topic, if a person has had radiation and they suspect
it's possible like a radiation bump in the PSA how often and when should they be checking this PSA?
Yeah, before we had these PSMA PET scans and the Axumin PET scans we had to just tough it out
because we didn't have any way to cross-check whether some cancer was showing up somewhere
and the policy was to check the PSA every month and then look for a pattern of smooth steady
unremitting rise which is characteristic of a cancer recurrence versus a zigzag inflammatory
pattern which is characteristic of a PSA bounce, and by having more data points
you're able to make a distinction between these two possibilities earlier and then, of course,
if it is a cancer recurrence get started on treatment, but now we can really clear the
fog by just doing one of these scans and finding is there any cancer that has come back. The only
exception to that is that the men that undergo radiation to their prostate gland it's been shown
that it takes about two years for the cancer to completely disappear from the prostate,
and this has been demonstrated in men that have had biopsies—random
biopsies—stuck into the prostate one or two years afterward and they can see residual cancer, but
if you wait three years and re-biopsy, the cancer is gone. So it takes a while for the cancer to die
and if a person undergoes a PSMA PET scan in the first year or two after treatment
it's possible to show some viable cancer in the prostate even though
that cancer is destined to die because of the radiation that was given previously.
Do most doctors know that? So would some doctor come in and go well there's still cancer there,
we need to do it again, we need to re-radiate. I mean what situation would that cause?
Well, there's possibilities for all kinds of confusion partly why we do these videos. I've seen
doctors treat men who had rising PSAs from inflammatory bumps and the doctors assume
unfortunately that it's cancer and put them on hormone treatment when no cancer was present.
So there's a a real need to be educated about this evolving world of technology that we have.
So, the next question I have is, is there a general prognosis for men
with relapse confined to the pelvic lymph nodes?
Well, those are the ones that were more hopeful for cure. I have had men that have had
isolated bone metastasis—which we generally consider to be a worse prognosis—maintain
durable remissions and get cured. So, it's not impossible, but it's the people that have relapses
in the lymph nodes—which is the most common site of relapse—that have the highest hopes of getting
salvage radiation, salvage hormone treatment, maybe even a short course of chemotherapy,
and successfully eradicating all the disease. The chances for being cured, much better if it's just
one spot perhaps as high as 50/50 for a second chance at a cure and then dropping down maybe
into the 15 to 20 percent range if there's multiple lymph nodes in the pelvic area.
How often should the PSA be checked after treatment when it comes to surgery and radiation?
So the usual policy is—once treatment is completed—to check the PSA every three months
for two years and then for the subsequent three years out to five years (years three,
four, and five) to check the PSA every six months and then after that annually. That's
sort of a general schema; people have to remember that checking the PSA when
the testosterone is still low is different than after testosterone has recovered and
when men have had hormone therapy they should have their testosterone checked every three months so
that the date of when testosterone recovers is recorded and then you know at that point
the clock really starts ticking as to the possibility for cancer coming back.
Thank you so much for watching. If you would like more information,
you can visit our website pcri.org. Also,
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