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.