The Controversial Issue of Treating Recurrent Prostate Cancer:
Part 1: An Initial Discussion
by Jules Reichel
I am the Secretary of the URF Board and a patient of Dr. Catalona. He performed my radical prostatectomy in September 1997. I’ve written in Quest for over 5 years. I study, write, counsel, and lecture, but I am not a doctor.
It’s highly encouraging that recurrence of prostate cancer after surgery continues to decline and is at a fairly low level if one looks at the data from our best urologists/surgeons.
There are, of course, many alternative initial therapies, but the data that I have seen is never better than using surgery (RP) as the first step, so I’ll limit myself to that approach.
Nevertheless, recurrence does occur and there does not seem to be an official view in the medical community as to how best to treat recurrence.
I won’t be able to resolve the issue that the doctors continue to study, but I will try to explore the issue and offer some suggestions.
This article will concern an exploration of the topic, and the next article will
get into more detail on treatment options, and my own tentative suggestions.
Where We Have Been In Prior Articles
Recurrence is a peculiar term and the literature is filled with dispute over how one sets a threshold PSA value so that exceeding this value is a proper sign of recurrence. Nevertheless, a PSA threshold after a radical prostatectomy of about 0.2ng/ml is in common use.
Previously, I discussed the use of radiation therapy after recurrence. There are two ideas: one called adjuvant therapy and one called salvage therapy. Adjuvant therapy applies radiation therapy based on the pathology report after surgery, while salvage therapy waits for some rise in PSA after surgery to indicate that the time is right to use radiation.
I told you of Dr. Bolla’s (2005) excellent results using adjuvant radiation therapy. I wrote: All of Bolla’s patients had one or more poor clinical features suggesting high rates of recurrence, including high PSA level before surgery, extracapsular extension, positive surgical margins, and seminal vesicle invasion. Nevertheless 74% of the men did not recur in 5 years.
I was encouraged.
But subsequently I noticed that while support for adjuvant therapy remains, most of the medical views expressed great concern that the majority of men would be unnecessarily treated. The link between pathology results and use of radiation was too unclear.
For example, Dr. Slawin of Baylor reported that up to 50% of patients with a positive surgical margin after RP will never experience a clinical recurrence. In addition, it is argued that one should be able to find a PSA value which guides doctors to reliably use salvage therapy with equal outcomes and lower risk to the patients.
Fortunately, the same Dr. Stephenson whose work with salvage therapy I cited
previously, has now updated his results and offers us his salvage therapy answer.
As you will see next time, his results are moderately encouraging. But others
have offered interesting ideas as well that I’ll discuss next time.
The Catalona 20-year Data
If Dr. Catalona had not determined the rules for screening, and when best to conduct surgery, there would be no question to discuss since almost everyone would recur. In 2005, he published his 20-year outcomes from his surgery, and his 10-year patient follow-up for those who used salvage radiation therapy for PSA recurrence following radical prostatectomy (RP).
Over a 20-year period, Dr. Catalona performed 3,478 RPs on prostate cancer patients. Of these, 631 (18%) had evidence of cancer progression after surgery. Of those who progressed, salvage radiation therapy (median dose 63Gy) was given to 307 patients.
For those who recurred, the median time from RP to PSA-recurrence was 23 months. There were 162 (73%) responders to radiation therapy. A response is defined as PSA less than 0.3 ng/ml after therapy.
A Gleason score of 8-10 was more common in non-responders. The median PSA at the start of radiation was higher in non-responders. The presence of seminal vesicle invasion or lymph node involvement implied a much worse outcome following radiation.
Men with a PSA less than 1.3 ng/ml at the start of radiation therapy had a significantly better outcome.
The study showed that while initial response to salvage radiation therapy to the bed of the prostate after recurrence was good (73%), a durable response out to 10 years was only maintained in 25% of patients. However, men who had an initial response to the radiation had a 35% rate of non-progression at 10 years.
Analysis of the Catalona Data
Dr. Catalona’s 18% recurrence rate over 20 years is impressive and compares to many citations by other doctors of as much as 40% or even more. In addition, the 18% value is a very pessimistic estimate since many screening techniques have been in use since 1985 when the data set began. Earlier detection would yield better results.
I don’t know what his recurrence rates would be for current patients who were being frequently monitored, but it could be half as much.
When there was PSA recurrence, and patients went to radiation oncologists for salvage radiation therapy, the results are discouraging. Only 25% or 35% of the men had durable 10-year outcomes. More ideas seem to be needed.
The guiding principle for evaluating therapies is clear: firstly, there must
be a response to the treatment, and secondly, the response must be durable. An
endless number of articles claim that some therapy had a response. Patients should
not be deceived. Providing a response is necessary, but it does not define a
Recurrence is Not Always Life Threatening
Soon after I began studying prostate cancer, I noticed that when doctors discussed recurrence, they always pointed to the “Pound data” (1999).
Dr. Pound was at Johns Hopkins when he wrote this article, and they have a long history of suggesting that when it’s possible, recurrence not be treated immediately. They, therefore, have a lot of data on what is called the natural history of the disease: what happens if there is no immediate treatment by the doctors.
Dr. Pound looked at the “median” values and concluded that after recurrence there was 8 years until metastasis, and 5 more years until death. At the time of metastasis, they would often use hormonal therapies (ADT).
To find the median, one lines up all cases from the worst to the best and picks the middle case. But median values can be very deceptive. This commonly cited result seems to imply that once recurrence happens, we are on a sure path of life-ending events over an approximately 13- year period. However, that’s not at all true. There are bad cases and easy cases, and the median case only tells us about some fictional man whose case is neither bad nor easy.
Dr. Freedland (2005), using the same base of patients who had limited initial medical intervention, produced his table showing the risk of dying from prostate cancer after recurrence. The table uses three factors:
1.The PSA doubling time (how long it takes the PSA to double after recurrence). His cutoff point for bad and good cases was 3 months -shorter is worse, and greater than 15 months is much better.
2.A Gleason Score of 8 or higher (lower is better).
3.Time from RP to recurrence of 3 years (lower is worse).
It is interesting that patient age was also tried as a factor, but it turned out that young and old faced the same risks.
In general, it was found that men who indicated high risk on all three factors had a 1% chance of living 10 years, while men who indicated low risk in all three factors had a 2% chance of dying in 10 years.
So the correct answer is not that recurrence is fatal. It’s not. The correct answer is that recurrence implies some added risk. The patient must be carefully followed and proper treatment must be chosen.
What is Proper Treatment?
That is the question for next time. But in general, we are looking at:
2.Using hormonal therapy;
3.Radiation with or without hormonal therapy; or
4.Using chemotherapies with or without other therapies.
These options involve complex choices, especially since the name of a therapy is often less important than the name of the doctor. However, we will try to begin our journey to becoming more educated patients.
A Note About My Health
I want to thank the many people who have written to me with encouraging comments, and I want to calm the fears of some who incorrectly believe that there is a connection between prostate cancer and bladder cancer. There is no known connection.
Of course, patients should not ignore seeing blood in the urine or evident changes in their urinary function, but other than that, they should not be overly concerned.
Personally, I'm still a work in progress but my prognosis is much better.
You can always write to me as you have in the past (Jules105@aol.com). I am not bedridden or in pain. And you can read my 18 prior articles on the URF website: www.drcatalona.com
With warm regards, Jules