If you or a loved one has finished prostate cancer treatment, you may have questions about monitoring and recurrence. Board-certified medical oncologist Dr. Jacob Berchuck at Winship Cancer Institute of Emory University (previously with Dana-Farber Cancer Institute) shares his insights on recurrence for localized prostate cancer and the importance of monitoring after treatment in this Q&A transcribed from our recent conversation. You can watch our full “Ask the Expert” discussion for a deeper dive into the navigation tools for prostate cancer diagnosis and treatment below.
The following questions and responses have been lightly edited for grammatical purposes.
1) For a stage II prostate cancer patient who has completed radiation therapy, what are the chances of prostate cancer recurring?
I really like this question and I am going to both answer it and not answer it. I’ll start with not answering it. The deferring piece is that it really depends, so that’s a segue to a really important discussion around how important it is to tailor our treatment and counseling to the individual person in front of us because there is a huge range even within stage II prostate cancer. To put it into context, stage II prostate cancer is localized. It’s when the cancer is caught early and is confined to the prostate. It hasn’t spread anywhere else in the body, so the standard options are either radiation or surgery. Both of those are standard and very reasonable options and with both treatments, the cure rates are quite high. Most men are going to be cured.
The reason that I defer is because there’s a lot of nuance. What I tell men that I’m seeing in the clinic is that I don’t treat prostate cancer the same way. I treat the individual and I’m looking at several factors. I’m looking at the PSA level; I’m looking at the Gleason score, which is a measure that we use to say how aggressive the cancer looks under the microscope. I’m looking at how much cancer there is, usually diagnosed on a biopsy. How many of those biopsies contain cancer? If so, how much and what’s the extent of where the cancer is? Is it just one little area, or is it spread throughout the prostate? I would tailor my answer to the individual in front of me, which raises a really important point. We tailor our treatment and counseling about the likelihood of the cancer coming back to the individual, but, generally speaking, it’s more likely than not that it’s not going to come back in stage II.
Again, acknowledging there’s going to be a window depending on the individual, but generally for a stage II, 70-80% of those men, if not higher, will be cured, and the cancer will never come back. I would defer to the provider on individual-specific disease characteristics to give a more accurate estimation of that.
2) What lifestyle changes could a person make to potentially reduce the risk of prostate cancer recurring?
This is a great question because it’s a common one I get in the clinic from my patients. There’s a lot of uncertainty when men are first diagnosed. What we really focus on are what the treatments are going to be and what the impacts are on my life. Once we get that figured out, the natural questions are “What can I do to help reduce the risk of this going back or maximize my quality of life and quantity of life moving forward?”
I have good news and bad news. The bad news is, there’s not a lot we can point to that people can do in their lives to reduce the risk of prostate cancer coming back. I’d say the biggest thing you can do is adhere to and go through with what your oncologist, radiation oncologist, or urologist is recommending as the best treatment for your personal case. There aren’t dietary modifications that we’ve clearly seen associated with reducing the risk of prostate cancer.
The flip side of that is that there is a lot we can do to maximize our health in longevity, independent of prostate cancer. For the vast majority of men diagnosed with prostate cancer, they’re going to be cured and they’re not going to die of prostate cancer. What I tell guys is this is a wake-up call. This most likely will be a health scare. You’ll get through prostate cancer and have a long life ahead of you and we want to make sure we’re doing everything else to maximize your health and longevity. I focus on the common-sense things. If you smoke cigarettes, stop smoking. If you drink alcohol, do it in moderation. If you don’t exercise, start exercising. If you exercise, do a little bit more. Be mindful of your diet. Do the things that we know are associated with good health because odds are, for most men with prostate cancer, they’re going to do well from that standpoint. The way they can maximize their health and longevity is by focusing on all those other things.
I will say one last thing: there’s a lot that we don’t know. Who am I to say, as a prostate cancer expert in the absence of data, what is or isn’t helpful to reduce that risk? So what I tell guys is if they’re interested in trying a new diet or a supplement, as long as it’s safe, I am very supportive of that. I know the limitations of what I do and don’t know, so as long as it’s safe and they feel empowered to make a lifestyle change that they feel good about, I’m supportive of it.
3) How often should people with prostate cancer be monitored after treatment? What changes would prompt further investigation?
This is an important question that’s worth being specific about because it is different for radiation and surgery. For both, what’s common for the first several years after treatment and what I recommend is a PSA every three months. That’s the standard accepted interval for monitoring post-treatment.
The important difference is the PSA threshold or the PSA number. After surgery, the prostate’s gone, so the PSA should go to zero or undetectable levels. Not only should there be no more prostate cancer, there should be no more prostate cells, period. That’s the only thing that makes PSA. After surgery, the PSA should go to zero or undetectable levels with monitoring every three months. Any PSA rise or any detectable PSA is a little bit concerning to me. Sometimes we’ll see the PSA come up a little bit and then stabilize, but in most cases where we start to see the PSA come up, it will continue to rise. In my practice, I think any PSA rising after surgery is a red flag or, at a minimum, a yellow flag that we want to monitor really closely. The guidelines used to call a prostate cancer recurrence is 0.2. In my clinic, a PSA of 0.1 or 0.2 is rising. That’s sort of where I would consider a recurrence and think about starting treatment, but per the guidelines, after surgery, 0.2 is the PSA level we call concerning for recurrence.
After radiation, the cancer should be dead, but the prostate’s still there. As the prostate wakes up after radiation, the normal prostate makes a little bit of PSA. The normal range for PSA in a man without prostate cancer is 0 to 4. We allow the PSA to drift up a little bit, and it usually does. It’s normal after radiation for the PSA to come up a little bit, and usually in my experience, it comes up to the 0.1, 0.2, 0.3 range and it’ll bounce around. It’ll bounce around reflecting a normal recovered prostate. The threshold for calling recurrence after radiation is a PSA of 2.0. So it’s 0.2 after surgery and 2.0 after radiation. You can see there’s a big difference there.
I think people can remember those numbers or just know that their physicians will be monitoring for these thresholds. The most important thing is that you stick with monitoring every three months for at least the first few years. Most men with localized prostate cancer who get good treatment are going to be cured. For men, who for no reason other than bad luck, aren’t [cured], it’s important to catch that early. In a lot of cases, we have a second shot at cure or can initiate the correct treatment early.
Watch our full discussion with Dr. Berchuck in the Outcomes4Me app.
