(These subjects are frequent topics in QUEST. In addition to the Q&As below, please use the website search engine for additional coverage. Also, please see QUEST, Fall 2004, New Results for Postoperative Radiotherapy and QUEST, AND Spring 2003, Postoperative Treatment After a Radical Prostatectomy.)

1. Q: Where is the cancer when the PSA rises after a radical prostatectomy?
A: It is not possible to say for certain where the recurrent cancer is located, but there is about a 70% chance that it is in the “bed of the prostate” (where the prostate used to be). Accordingly, radiotherapy has a good chance of controlling it.

2. Q: After a prostatectomy, how can a man have a PSA level without a prostate gland? What is producing the PSA protein material that is in the blood stream if there is no prostate gland?
A: After the prostate gland has been completely removed, any PSA in the blood is produced by prostate cancer cells that have left the prostate gland and spread to other areas of the body. However, sometimes the PSA can appear to be elevated because of a laboratory error.

All elevated PSA levels after surgery should be re-checked to rule out a laboratory error. For practical purposes, it is very difficult to detect PSA when levels are less than 0.2 ng/ml. Therefore, we consider any PSA value less than 0.2 as being negligible. A value of 0.2 or 0.1ng/ml would be considered essentially zero. PSA above 0.2 or above is an indication of cancer recurrence, and treatments for recurrence should begin before the PSA reaches 1.0ng/ml.

3. Q: What kind of follow-up do you recommend after a radical prostatectomy?
A: With any cancer, not only prostate cancer, there’s always a possibility that the cancer can come back and that’s why patients need to have follow up visits. I recommend a PSA test every six months for 15 years after the operation.

That said, in the category of men who have a prostate cancer removed that is very small and totally contained within the prostate and all the margins are clear and it has not spread to any lymph nodes, the life expectancy is virtually equal to that of the normal population who have never had prostate cancer.

4. Q: How useful is a PSA test once a patient is diagnosed with cancer and in therapy?
A: PSA is an excellent marker for use during and after cancer therapy. Ninety-nine percent of the time, PSA lets a patient know how the cancer is responding to the treatment.

5. Q: What should I do when my PSA level begins to rise after a radical prostatectomy?
A: The two treatment options are postoperative radiotherapy, which should begin before the PSA rises above 1.0ng/ml, and intermittent or continuous hormonal therapy, which can be initiated immediately or delayed until the PSA rises to 4.0.

6. Q: What is follow-up (postoperative) radiotherapy and why would it be needed after a RRP?
A: Sometimes, it is strongly advised when the pathology report shows positive (cancerous) surgical margins or extension of the tumor beyond the prostate gland. p>Also, it is sometimes advised when the PSA begins to rise after surgery. p>There are two types of follow-up radiotherapy:

1. Adjuvant radiotherapy is given as a precautionary measure in patients who have adverse features in their pathology report. This radiotherapy is usually given 3 to 4 months after the operation when urinary continence has returned. It may be delayed further if continence has not yet returned.
2. Salvage radiotherapy is for a rising PSA, which means a recurrence of the cancer. This radiotherapy should be given before the PSA level rises about 1ng/ml.

7. Q: Is there any way of predicting if follow-up treatment will work once a PSA has started rising after initial prostate cancer treatment?
A: Not really, but the prospects are better if the PSA begins to rise after a long interval from radical prostatectomy and if the rise is gradual.

8. Q: Why check PSA values after a radical prostatectomy if a man has no prostate?
A: Some rogue cancer cells might escape from the prostate and not be noticed by the pathologist. Any PSA that they produce will be absorbed into the bloodstream and elevate the PSA level. (See www.drcatalona.com and search on postoperative PSA.)

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