Even after successful treatment for prostate cancer, there is a possibility that it could come back. When this happens, it is known as recurrent prostate cancer.  

Sometimes cancer cells are left behind, undetected, after the initial treatment. They can remain inactive for months or even years before becoming active again. While this doesn’t happen to everyone, it’s understandable to have concerns about it. Being informed about recurrence will help you understand the importance of follow-up appointments and what signs you can look for to discuss with your oncologist.

A recurrence can occur in the prostate or elsewhere in the body and is classified into the following categories:

  • Biochemical recurrence refers to an increase in PSA levels after prostate cancer treatment. If PSA numbers rise beyond a certain threshold, it may indicate that some cancer cells have survived and are producing PSA. Often, this occurs without any noticeable symptoms.  
  • Local recurrence is when the cancer returns and remains confined to the prostate.
  • Regional recurrence means the cancer has spread outside the prostate and into the pelvic area but has not yet reached other parts of the body. Lymph nodes may or may not be affected. 
  • Distant recurrence

describes cancer that has spread outside the pelvis to other areas, such as the bones and distant lymph nodes.

The approach to treatment of recurrent prostate cancer, and the expected outcome, depend on how aggressive and advanced the cancer is. A study from 2016, done by the European Journal of Cancer, determined that over 83% of patients with returning prostate cancer live five or more years after successful treatment, including a radical prostatectomy (RP).

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Monitoring for Prostate Cancer Recurrence After Treatment Ends

Going to follow-up appointments after treatment is important for monitoring your health and detecting cancer as soon as it returns. During these appointments, your oncologist will perform a physical examination and check your PSA (prostate-specific antigen) levels. You may also need to have imaging tests periodically to ensure there are no tumors present. 

Elevated PSA levels may indicate that the cancer has returned. To determine if this is the case, your oncologist may recommend additional tests, such as imaging scans or bone scans, to identify any recurrent prostate cancer.

An Axumin PET/CT scan may also be used in men whose PSA levels are rising after prostate cancer treatment. This test combines a radioactive tracer called Axumin with imaging from positron emission tomography (PET) and computed tomography (CT) to detect and locate potential prostate cancer recurrences. Unlike traditional imaging methods, which typically detect tumors only when PSA levels range from 10 to 50, Axumin can identify tumors even when PSA levels are between 1 and 10. Detecting recurrent cancer earlier allows for timely biopsies or treatment.

If imaging confirms a cancer recurrence, your oncologist will likely recommend a biopsy to better understand how differentiated the cells are from normal prostate cells.

What to Know About PSA Levels After Initial Treatment

After a prostatectomy, PSA levels should become undetectable within a few months. However, even after the prostate is removed, follow-up testing might still detect small amounts of PSA. This doesn't necessarily mean a new tumor is present; it may simply indicate that some cells in the body continue to produce PSA, though these cells may not be cancerous.

Men who had radiation therapy as part of their treatment plan instead of surgery, on the other hand, will have lower but still detectable PSA levels, as the prostate remains intact and may continue to produce the PSA protein. These levels often decrease more slowly after radiation therapy compared to prostatectomy, with some patients not reaching their lowest levels until two or more years after treatment.

In cases of biochemical recurrence, your oncologist will consider several factors, including your PSA doubling time, which is the time it takes for the PSA level in your blood to double. This helps determine whether treatment is needed and when it should begin. A rapidly increasing PSA level typically indicates a "high-risk biochemical recurrence”, which increases the chance of metastasis (or cancer spreading) and a less favorable prognosis.

Treatment Options for Recurrent Prostate Cancer

Several treatment options are available for recurrent prostate cancer. The recommended treatment plan will depend on factors such as the location and extent of the recurrence, previous treatments, and your overall health.

Localized Recurrent Prostate Cancer

When prostate cancer recurs and is localized to the prostate area, a second attempt to cure it may be possible through salvage therapy. 

Salvage therapy typically involves additional radiation therapy and hormone therapy, which aim to target any remaining cancer cells. Surgical options, such as salvage prostatectomy, may also be considered. For some men, if the only sign of cancer is a biochemical recurrence, active surveillance could be a suitable approach.

Regional Recurrent Prostate Cancer

If prostate cancer has recurred and has spread to areas beyond the prostate, including the bones, hormone therapy is usually the primary treatment. The first line of treatment often involves a luteinizing hormone-releasing hormone (LHRH) agonist drug, which may be combined with a first-generation anti-androgen drug called an LHRH antagonist. Another option is a surgery that removes one or both testicles, known as an orchiectomy.

Distant Recurrent Prostate Cancer

When treating metastatic recurrent prostate cancer, hormone therapy can be an effective approach. However, its effectiveness often reduces over time. Men whose prostate cancer stops responding to hormone therapy are classified into two categories:

  • Castration-resistant prostate cancer (CRPC): This type of cancer continues to grow even with hormone therapies, like orchiectomy or LHRH agonists/antagonists that lower testosterone levels to those typically seen after testicular removal. In some cases, different hormone therapies may still be effective.
  • Hormone-refractory prostate cancer (HRPC): This type of cancer does not respond to any hormone therapy at all.

Fortunately, men with these types of prostate cancer now have more treatment options than ever. Possible treatments include:

  • Newer hormone medications have been added to existing hormone therapies
  • A prostate cancer vaccine
  • Treatments including chemotherapy, targeted therapy, and immunotherapy
  • Radiopharmaceutical drugs that target cancer cells with the PSMA protein, such as Pluvicto™.
  • Ablative treatments that use extreme heat or cold to destroy (ablate) bone tumors

Learn more about the latest treatments for advanced prostate cancer. 

Portland Area Oncologists Specializing in Recurrent Prostate Cancer

Compass Oncology has a team of prostate cancer specialists available to help you understand prostate cancer that has returned, what to expect regarding treatment options, side effects, and overall care. With a multidisciplinary approach, we coordinate expert and compassionate care for patients in the Portland and Vancouver metro area.

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