Recurrent cancer
- Advanced Cancer
- Recurrent cancer
- Anatomy
- Structure
- Function
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Recurrent cancer
Recurrent cancer
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.
On this page:
Discover our animated video!
Symptoms, risk and screening
Are you over 50 years old, or have you been having urinary problems for some time now? This video is for you! Several diseases can affect your prostate, and it’s important to detect them early. Let’s take a closer look.
Anatomy
What is the prostate
The prostate is a gland:
- Located between the bladder and the penis, just in front of the rectum;
- Formed of 2 lobes which surround the urethra, a canal that runs through the center of the prostate, from the bladder to the penis, letting urine and sperm flow out of the body;
- The size of a walnut, which grows larger in size in your forties;
- That has a soft, spongy texture to the touch like a small, ripe plum.
The prostate is made of:
- Gland cells that secrete liquids for ejaculation;
- Muscle cells that participate in the evacuation of your sperm during ejaculation;
- Fiber cells that maintain the structure of the gland.
Around the prostate, we find:
- The seminal vesicles, glands that produce sperm and that are located on either side of the prostate;
- The vas deferens, the tube that carries sperm from the testicle to the seminal vesicles;
- The nerve bundles that control your bladder and erectile function and that are located on either side of your prostate.
Structure
Three main zones of the prostate
Peripheral zone
- The peripheral zone is the largest area of the prostate. It can easily be felt by the doctor during a digital rectal exam (DRE).
- Most prostate cancers start in the peripheral zone.
Transition zone
- This is the area located in the middle of the prostate, between the peripheral and central areas. It surrounds your urethra that runs through the prostate.
- With age, the transitional area increases in size until it becomes the largest portion of your prostate. This is called benign prostatic hyperplasia (BPH) or enlarged prostate.
Central zone
- It is the part of the prostate that is farthest from the rectum. This is why prostate tumors located in this area can not be felt by the doctor during a digital rectal examination.
- If the doctor is in doubt, the following information will help decide if additional investigation is necessary:
- Your PSA level
- Your age and family history
- Your ethnic origin
Fonction
In short
Your fertility and natural fertilization
- It produces … a prostatic fluid rich in enzymes, proteins and minerals that nourishes and protects your spermatozoa.
- It makes … a protein (APS) that is used to liquefy your sperm to facilitate the mobility of your spermatozoa.
- It allows … ejaculation by contracting.
- It promotes … fertility through its enzymes facilitating the penetration of sperm through the cervix.
- It is not related to the mechanism of erection. Therefore, the origin of erectile dysfunction lies elsewhere.
Additional details
Exocrine Function
The prostate is made up of thousands of tiny fluid-producing glands. Specifically, the prostate is an exocrine gland. Exocrine glands are so-called because they secrete through ducts to the outside of the body (or into a cavity that communicates with the outside). Sweat glands are another example of an exocrine gland.
The fluid that the prostate gland produces forms part of semen, the fluid that carries sperm during orgasm. This fluid, produced in the prostate, is stored with sperm in the seminal vesicles. When the male climaxes, muscular contractions cause the prostate to secrete this fluid into the urethra, where it is expelled from the body through the penis.
Urine Flow
The prostate wraps itself around the urethra as it passes from the bladder to the penis. Prostatic changes can affect urine flow. Increasing the size of the prostate or muscle tone may impede the flow of urine due to the close anatomical relationship between the urethra and the prostate.
Prostate Specific Antigen (PSA)
The prostate also produces a protein called prostate-specific antigen (PSA). PSA is released with the ejaculatory fluid and can also be traced in the bloodstream. The testing of PSA levels in the blood is used to detect prostate cancer. The level of PSA in the blood is usually measured in nanograms of PSA per milliliter of blood (ng/mL).
A raised PSA level
Usually, a PSA rate of less than 4 nanograms per milliliter of blood is normal, but age should also be taken into consideration as PSA levels gradually increase with age. A rise in PSA concentration may indicate the presence of:
- An enlarged prostate (benign prostatic hyperplasia)
- An inflammation or infection of the prostate (prostatitis)
- A prostate cancer
Your doctor will have you undergo other tests to determine the exact cause of the increase in your PSA.
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You have questions or concerns? Don’t hesitate. Contact us at 1-855-899-2873 to discuss with one of our nurses specialized in uro-oncology. They are there to listen, support and answer your questions, and those of your family or your loved ones. It’s simple and free, like all of our other services.
Also take the time to visit each of our pages on this website, as well as our YouTube channel, in order to get familiar with the disease, our expert lectures, our section on available resources, the support that is offered to you, our events and ways to get involved to advance the cause..
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Sources and references
- Prostate Cancer – Understand the disease and its treatments; Fred Saad, MD, FRCSC and Michael McCormack, MD, FRCSC, 4th et 5th editions
- Canadian Cancer Society
- Prostate Cancer Foundation-PCF.org
- National Cancer Institute-USA
- American Cancer Society
- Memorial Sloan Kettering Cancer Center
- Prostate Cancer UK
Last medical and editorial review: September 2023
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