Prostatectomy is a treatment that works very well for prostate cancer. For many men, it successfully controls or cures the disease.
However, no treatment can guarantee that prostate cancer will never come back. Because of this, regular follow-up is an important part of your care.
PSA Testing After Surgery
After surgery, you will have regular prostate-specific antigen (PSA) blood tests. These are done to monitor for signs that the cancer has returned. The PSA test is a very good way to check if the cancer has returned after treatment.
A typical follow-up schedule for PSA testing is:
- Every 3 months during the first year
- Every 6 months during years 2 and 3
- Once a year after that
Your healthcare provider may recommend a different schedule based on your situation.
What Happens to PSA Levels After Surgery?
Because the prostate gland has been removed, your PSA level should fall to an undetectable level after surgery.Different labs use different methods to measure PSA, so the exact number reported may vary. Your healthcare provider will explain what your results mean.
What Does a Rising PSA Level Mean?
A rising PSA level after prostate cancer treatment is called biochemical recurrence.After surgery to remove the prostate, biochemical recurrence is a PSA level of 0.2 ng/mL or higher. This is confirmed by a second PSA test.
A biochemical recurrence does not mean the cancer can be seen on a scan or that treatment is needed right away. It is often the earliest sign that the cancer may be active again.
Some men have a rising PSA but no evidence of cancer on a physical exam or imaging tests. This is called a biochemical-only recurrence.Other men have clinical recurrence. This means the cancer can be detected with a physical exam or imaging test.
A single elevated PSA result does not always mean the cancer has returned. For this reason, your healthcare provider will usually repeat the test before confirming a recurrence.
What Happens If My Cancer Comes Back?
If your PSA begins to rise after surgery, your healthcare provider will determine if and when you need more treatment.In many men, imaging tests are not needed when the PSA first begins to rise because they are unlikely to show where the cancer is located.
Instead, your healthcare team will consider factors such as:
- Your PSA level and how quickly it is rising
- The results of your surgery, including the tumor grade, stage, and if cancer cells were found at the edge of the removed tissue (positive surgical margins)
- Your age and overall health
What Is Salvage Radiation Therapy?
Salvage treatment means treatment done for cancer recurrence. For men whose PSA rises after surgery, the standard treatment is salvage radiation therapy.Radiation is usually directed at the prostate bed. This is the area where the prostate gland was located before surgery. In some men, the nearby pelvic lymph nodes are also treated.
Many studies have shown that salvage radiation therapy offers the best chance of long-term cancer control after recurrence following surgery.
Why Is Early Treatment Important?
Research has shown that salvage radiation therapy is most effective when it is started early, while PSA levels are still low.Many experts advise starting treatment when the PSA is around 0.2 to 0.4 ng/mL, rather than waiting for it to rise more. Starting treatment earlier may improve the chance of long-term cancer control.
Will I Also Need Hormone Therapy?
Some men benefit from having androgen deprivation therapy (ADT), also called hormone therapy, along with salvage radiation therapy.
If ADT is recommended depends on:
- Your PSA level when you start treatment
- How aggressive the original cancer was
- The results of your surgery
- Your age and overall health
For men having early salvage radiation therapy, the benefits of hormone therapy are still being studied. Your healthcare provider can help you decide if it is right for your situation.
Will I Need Another Imaging Test?
Treatment with salvage radiation therapy often begins without another imaging test. In some cases, a PSMA PET scan may be used to identify small areas of cancer that can be treated with highly focused radiation, such as stereotactic body radiation therapy (SBRT). But when PSA levels are very low—especially early in a biochemical recurrence—a PSMA PET scan may not find the cancer. Your healthcare provider will discuss the option of an imaging test with you.
Talking with Your Healthcare Team
For many men, the first prostate cancer treatment will be the last. But it's important to understand that recurrence is not uncommon. If this happens, your healthcare team will recommend the approach that best fits your type of recurrence, overall health, and treatment goals.
After being diagnosed with prostate cancer, many men will undergo treatment with either surgery or radiotherapy. While both of these treatments are highly effective, a cure is not guaranteed. Because of this, it’s important to have periodic PSA blood tests after prostate cancer treatment (typically every three months for the first year, every six months for years 2 and 3, and annually thereafter). PSA is a very useful marker in men who have undergone prostate cancer treatment. When PSA levels rise following prostate cancer treatment, this is called a “biochemical recurrence.”
What Is Biochemical Recurrence of Prostate Cancer?
Biochemical recurrence means that your PSA level has started to rise after you’ve been treated for prostate cancer that was only in the prostate (localized).The definition of biochemical recurrence is different depending on whether your original treatment was surgery (radical prostatectomy) or radiation therapy.
When PSA begins to rise, your doctor may recommend more tests. These are to find out if the prostate cancer has returned and, if so, where it’s growing.
Why Might a PSMA PET/CT Scan Help?
In the past, doctors mainly used CT scans, bone scans, and MRI to look for prostate cancer after a rising PSA. These tests can still be helpful, but they may not be able to find very small areas of prostate cancer, especially when your PSA level is low.
A newer type of imaging test called a PSMA PET/CT scan can often find prostate cancer that can’t be seen with conventional imaging tests.
What is a PSMA PET/CT Scan?
A PET/CT scan combines two types of imaging:
- A positron emission tomography (PET) scan. This type of scan uses a small amount of radioactive material called a radiotracer to show areas of cell growth activity in the body.
- A computed tomography (CT) scan. This type of scan creates detailed pictures of the body's structures.
PSMA stands for prostate-specific membrane antigen. It’s a protein found on the surface of most prostate cancer cells.
For a PSMA PET/CT scan, you receive an injection of a small amount of a radioactive tracer that attaches to PSMA. A PET scanner can then detect where the tracer has collected. Because prostate cancer cells often have large amounts of PSMA, the scan can help doctors find areas of prostate cancer in the body.
PSMA PET/CT can be helpful when PSA levels are low and other imaging tests have not been able to find the cancer.
Three PSMA PET/CT tracers are commonly used in the United States:
- Piflufolastat F-18, also known by the brand name Pylarify
- Gallium-68 (Ga-68) PSMA-11, also known by the brand name Illuccix
- Flotufolastat F-18, also known by the brand name Posluma
All 3 options are FDA approved for use in men with prostate cancer, including men whose PSA has risen after treatment with surgery or radiation. The availability of each test can vary by area and medical center.
How Accurate Is a PSMA PET/CT Scan?
A PSMA PET/CT scan is generally better at finding recurrent prostate cancer cells than older types of imaging, especially when the PSA level is relatively low.
One key study was the CONDOR clinical trial. It included 208 men with biochemical recurrence whose conventional imaging tests had not been able to find prostate cancer. About two-thirds (68.8%) of the men in the study had PSA levels below 2.0 ng/mL. A Pylarify PSMA PET/CT scan found a possible cancer area in about 59% to 66% of the men. The scan results also changed the treatment plan for 64% of the men in the study.
What Do PSMA PET/CT Results Mean?
If you have a positive PSMA PET/CT scan result, it doesn’t mean you definitely have cancer. The scan can show a spot that absorbs the tracer. This may indicate prostate cancer, but it does not prove that cancer is present. Your doctor may advise having more testing, such as a biopsy.
And, a negative PSMA PET/CT does not prove that there is no cancer. Very small areas of cancer may be below the ability of the scan to detect. Your doctor will interpret your PSMA PET/CT results together with your PSA level, previous treatment, biopsy results, and other information about your prostate cancer.
How Might a PSMA PET/CT Change My Treatment Plan?
Knowing where prostate cancer may have returned can help your doctor choose the best treatment. For example, the scan may show:
- Cancer that appears to be only in the area where the prostate used to be
- Cancer in nearby lymph nodes
- Cancer in a small number of other places
- More widespread cancer
These findings can help your treatment team decide if treatments such as radiation therapy, hormone therapy, or other treatments may be right for you.
Talking with Your Healthcare Team
If your PSA begins to rise after treatment for prostate cancer, ask your doctor if a PSMA PET/CT scan would be helpful. The decision depends on several factors, including:
- Your PSA level and how quickly it’s rising
- Whether you originally had surgery or radiation
- Your original cancer's Grade Group and stage
- Your previous treatments
- What your doctor is considering for your next treatment
PSMA PET/CT can be helpful when your doctor needs to find out where a recurrence may be located before deciding on more treatment.
These interviews were produced with the generous support of Lantheus