Your PSA Is Rising After Prostate Cancer Treatment. What Happens Next?

• By David Y.T. Chen, MD, FACS, Professor, Fox Chase Department of Urology, and member physician of the Fox Chase-Temple Health Urologic Institute

  A rising PSA after prostate cancer treatment can be frightening. Many patients understand that as a result of treatment, they should expect the PSA drops to low levels, and so when it is detectable or rising, they worry their prostate cancer has recurred and might have spread. Importantly, that result is not always true.

  A PSA increasing after treatment deserves a careful review. By itself, the PSA does not automatically indicate where the cancer is or what to do. The possible next steps greatly depend on the original prostate cancer details such as Gleason score and stage, on the type of treatment that was first applied, on the PSA trend, and the approach can include updated testing such as body scans and should take into account the man’s current age and overall health.

  What Does a Rising PSA Mean?

  PSA stands for prostate-specific antigen. After any standard treatment (surgery or radiation) the PSA should fall to a very low level—and after prostatectomy it is expected to be essentially at a zero level, often referred to as “undetectable”. If it later rises, doctors may consider this the first sign of possible return, possibly describe this situation as “biochemical recurrence”. In many cases, a change in the PSA can show by a blood test a possible return of prostate cancer, and typically this happens before a scan may find it.

  In contrast, after radiation therapy, as the prostate remains in the body, a low value of PSA is normal and expected. The level may fall slowly or fluctuate within a range, it commonly shows some minor movement up or down. Doctors look for a clear pattern, and don’t need to act based on a single higher PSA test result.

  We also look at how fast the PSA rises over time. This is commonly described using the parameter of “PSA doubling time”, which is the period it shows a double in value (for example, it might be about 6 months to increase from 0.2 ng/mL to 0.4 ng/mL). A fast rise, a shorter period of PSA doubling time, can indicate a more active degree of prostate cancer.

  Additionally, the timing of when the PSA might increase matters too. A rise soon after treatment may mean something different from a PSA rise that develops many years later following initial treatment.

  Imaging Can Help Find Where the Cancer Is

  New imaging can help us look for prostate cancer that has returned. Traditional exams relied on CT scan and bone scan to investigate for possible recurrence. A PSMA PET scan is now commonly applied and recognized to be more sensitive imaging; it may find small areas that are potentially missed on a CT scan or bone scan.

  A scan does not answer every question. A scan may be negative and unable to visualize tiny sites or amounts of prostate cancer. There are also cases o  a positive finding that may be equivocal, and it may be confirmed in comparison to other types of scans and sometimes warrants a specific targeted tissue biopsy to guide treatment.

  Options After Prostate Surgery

  When PSA rises after surgery and the cancer seems limited to the prostate area, salvage radiation is a common next step. There can be a high success of post-surgery radiation therapy, and some patients also need hormone therapy applied in combination with radiation therapy.

  Learn more about salvage radiation after prostatectomy at Fox Chase.

  Options After Radiation Therapy

  Cancer that returns after an initial treatment with radiation therapy can be more complex. Many patients can still have a local treatment, and more careful considerations are needed. First, the team must confirm the presence of cancer and check if it has spread.

  Options may include robotic salvage prostatectomy, salvage cryoablation, focal treatment, or repeat radiation therapy, often with high-dose rate brachytherapy. There is a wider choice of options for salvage treatment after radiation therapy, and these treatments need careful review because risks of functional side effects may be higher with a salvage treatment after initial radiation therapy.

  Fox Chase has unique expertise in the specialized options such as robotic salvage prostatectomy and prostate salvage cryoablation, available for selected patients.

  If scans show cancer is present outside of the prostate, whether in lymph nodes, bones, or other organs, there is a need for a broader treatment that can address the entire body. Options may include hormone therapy, targeted drugs, chemotherapy, radioligand therapy, radiation, or a clinical trial. The goal may be long-term control, fewer symptoms, or both.

  Review the broader range of prostate cancer treatment options and clinical trials at Fox Chase.

  Do Not Wait for the PSA to Become Very High

  A rising PSA does not always need treatment right away. But it should not be ignored—possible intervention when PSA is lower often results in better outcomes. An early review gives the team time to confirm the trend, gather records, order scans, and discuss the full range of options.

  A prostate cancer recurrence may benefit from the input from urologic oncologists, radiation oncologists, medical oncologists, and dedicated radiologists and pathologists.  A team-based second opinion can be very helpful. The key questions are: Where is the cancer? How is it acting? Which option offers the best balance of cancer control and quality of life?

  If your PSA is rising after prostate cancer treatment, request a second opinion at Fox Chase or call 888-FOX-CHASE (888-369-2427).