A cancer that returns after radical prostatectomy, radiotherapy, or brachytherapy—whether or not these treatments were combined with hormone therapy—is considered an advanced cancer, whether the recurrence is local or metastatic.

Local recurrence – Your cancer may reappear in the same place where it was before your initial treatment. By local recurrence, we mean that cancer cells have remained in the anatomical location where the prostate was.

With metastases – Your cancer may manifest in another part of your body. In this case, it is called metastatic recurrence.

Recurrences can occur at any time

However, after treatment, the risk of recurrence decreases over the years. Although we often hear about the ‘magic number’ of five years, this is not guaranteed. Therefore, long-term follow-up is conducted.

In general, the doctor detects a recurrence when your PSA level starts to rise again. The rate at which your PSA level rises (doubling time), your grade, and stage of the tumor that was removed (or treated with radiotherapy) help your doctor determine whether it is a local or metastatic recurrence. The higher these parameters, the more likely it is to be a metastatic recurrence.

In the case of a recurrent prostate cancer, various treatment options or combinations of treatments can be used: radiotherapy, hormone therapy, surgery, chemotherapy, new generation hormone therapy, research protocols, etc. Your doctor is best placed to propose a treatment plan that suits you.

New imaging test

PSMA PET is a brand-new type of nuclear imaging test that uses the principle of radiotracers. This method helps to find where cancer cells may have spread outside the prostate. It is particularly recommended in certain cases of recurrence after surgery or radiotherapy when the PSA level is high.

Currently, the use of PSMA PET is limited to specific cases, but it is expected to expand to more situations in the future.

Recurrence after radical surgery

Usually, your PSA level warns the doctor very early on about what is happening, often many months or years before there are enough metastases to be detected during a physical or radiological examination.

Radiotherapy with or without hormone therapy – In some cases where a localized recurrence is suspected, complete cure can still be hoped for (it is not too late to prescribe radiotherapy, with or without hormone therapy, and achieve a cure).

When to treat?

• If your recurrence seems localized and slow, and does not concern the doctor too much, he may choose not to intervene. This would be the case if, for example, your PSA level starts to rise five years after the operation. At this rate, it is likely that metastases will not appear for another 10 or 15 years.
• If you are elderly or have a reduced life expectancy, it may be better not to intervene or to delay treatment rather than prescribe hormone therapy that will affect your quality of life.
• If you are younger and therefore have a long life expectancy, the doctor’s approach will often be more aggressive. Radiotherapy, with or without hormone therapy, will then be used.
• If it is decided not to undergo radiotherapy, one may choose to wait for a significant increase in PSA levels before starting hormone therapy. There will still be time to intervene if the progression becomes worrying.

Since each case is unique, it is important that you make your decision in consultation with your doctor, weighing the pros and cons of each option.

Recurrence after radiotherapy

Salvage brachytherapy after initial prostate radiotherapy is an emerging technique that adds to the therapeutic arsenal in cases of localized recurrence. This option should be discussed with your radiation oncologist before making a decision.

Hormone therapy – Hormone therapy is often considered the standard treatment in the event of recurrence following radiotherapy. In the absence of metastases, intermittent hormone therapy is a valid option. In this case too, treatment can be withheld for some time if the recurrence is slow.

Surgery – In rare cases, it sometimes happens that the doctor turns to radical prostatectomy to remove the prostate. It is often referred to as salvage surgery. However, this requires the doctor to be convinced that the recurrence is limited to the prostate. Candidates for this procedure must meet specific selection criteria. They must also understand the side effects of this procedure (they may be more significant than with radical prostatectomy as the first treatment) in order to make an informed decision.

Note

Focal therapy – Other options such as cryotherapy and HIFU are currently being studied. It should be noted that these are not standard treatments. They are used when it is believed that the recurrence is still limited to the prostate. However, for now, neither of these techniques can be considered a viable alternative to standard prostate cancer treatments. And since their long-term effectiveness is not known, few health centers offer them in Canada.