Advice for the Recurrent Patient

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For Those Patients Experiencing a Recurrence

Virtually all patients who have been treated for prostate cancer live with the possibility that their cancer will reappear at some point in the future. There is some risk of relapse or recurrence over time regardless of the type of treatment or the stage of the cancer when the disease was first diagnosed. Since there is no perfect treatment, there will always be some cases of recurrence, but the good news is that all treatments for prostate cancer, including salvage therapies for treating recurrence, have greatly improved in recent years.

If you are facing recurrence, you should know that you are not alone. The fact is that recurrence after radical surgery is very common regardless of whether the technique is robotic or by hand. A recent multicenter study citing research by Memorial Sloan Kettering Cancer Center estimates that 25,000 patients annually experience treatment failure (biochemical recurrence) after radical surgery, with 50% to 95% of high-risk patients developing recurrence after radical surgery (Spratt DE, et al, Am Soc Clin Oncol Educ Book, 2018 May 23;(38):355-362). In addition, more than 10,000 patients will experience treatment failure each year after primary, single source radiotherapy. Statistics are not available for other forms of treatment (such as Proton Beam Therapy, HIFU, Cryosurgery, Cyberknife®, etc.), but they no doubt contribute to a large number of recurrence cases.

Many men are of the mindset that if they go through with a major operation like radical prostatectomy and have their cancers removed, they may have to suffer the consequences of erectile dysfunction and/or incontinence, but at the end of the day they assume their prostate gland and cancer will be gone. However, the truth is that neither the cancer nor the gland may have been entirely removed. Even the most contemporary studies demonstrate that the majority of patients undergoing radical surgery will ultimately be faced with a recurrence. Surgery patients more often than not find themselves asking their urologist, “How could my cancer have come back? Why is my PSA rising? I don’t even have a prostate anymore!”

We have known and advocated for two decades that surgery is not a reasonable solution for prostate cancer because of the propensity of the disease to appear close to the gland margins and to grow aggressive microscopic fingers outside the gland, which cannot be removed with the surgical scalpel regardless of the technique employed.

Fortunately, for most patients who have to face the disease again, there are still courses of treatment available regardless of which treatment they underwent in the past. At our center, we have had success over the years with DART (Dynamic Adaptive Radiotherapy) and brachytherapy (radioactive seed implantation) utilized as salvage therapies for recurrence. Depending on a man’s age and the stage of his disease, recurrence of prostate cancer for some patients may not be life threatening and he may not require further treatment. Keep in mind that it is never patients who fail, but rather treatments that sometimes fail to completely eradicate the disease. Treatment failure means that a particular type of initial therapy has not been successful in fully eliminating the cancer or controlling the progression of the disease.

Before deciding on any second course of treatment, you should fully investigate the likelihood of eradicating the cancer and the risk of side effects that may alter your quality of life. These are the most important considerations in deciding on salvage therapy. Given your age and overall health, you will want to find a balance between effectiveness and side effects—a balance with which you are comfortable, that you can live with both before and after treatment. Knowing what to expect each step of the way is one of the keys to fighting this disease.

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