Prostate cancer recurrence

Prostate cancer recurrence is when prostate cancer comes back after treatment. It can happen if some cancer cells hide in the body and start growing again.

Prostate cancer recurrence most often happens in the first five years after treatment. But it can happen at any time. It can occur after any type of treatment, including surgery, external beam radiation therapy, brachytherapy and hormone therapy. For every 10 people treated for early-stage prostate cancer, studies show that 3 to 5 have a prostate cancer recurrence.

The first sign of a prostate cancer recurrence typically is rising levels of prostate-specific antigen (PSA) in the blood. Sometimes the PSA rises, but the cancer doesn't show up on imaging tests. Healthcare professionals call this a biochemical recurrence.

When imaging tests show recurrent prostate cancer, healthcare professionals call it a radiographic recurrence. Prostate cancer can come back in the prostate area or in other parts of the body.

Many treatments exist for prostate cancer recurrence. When the cancer comes back in the prostate area, treatments may offer the chance for a cure. When prostate cancer spreads to other parts of the body, treatments may help control the growth of the cancer and extend your life. However, metastatic prostate cancer treatments usually do not cure the cancer.

Prostate cancer recurrence often doesn't cause symptoms when it's found early. If the cancer comes back, it's usually detected on a blood test. A prostate-specific antigen (PSA) test might find the cancer before it causes symptoms or before it can be found with imaging tests.

Symptoms of prostate cancer recurrence can happen if the cancer grows without being detected. In time the cancer can cause:

• Accidental leaking of urine.
• Back pain.
• Blood in the urine.
• Bone pain.
• Extreme tiredness.
• Weakness in the arms or legs.
• Weight loss without trying.

When to see a doctor

Make an appointment with a doctor or other healthcare professional if you have any symptoms that worry you. If you have regular checkups with the healthcare team that treated your prostate cancer, tell the team about your symptoms. If you no longer see that care team, tell your usual healthcare professional about your symptoms.

Prostate cancer recurrence can happen if one or more cancer cells remain in the body after treatment. Sometimes this is caused by cancer cells that break away from the original growth in the prostate before treatment. The cancer cells can hide for many years before they start to grow again.

Factors that increase the risk of prostate cancer recurrence include:

• Higher cancer stage. The cancer's stage tells the healthcare team about the extent of the cancer. Having a higher stage when first diagnosed with prostate cancer increases the risk of recurrence.
• Higher Gleason score. A Gleason score is a number that tells the healthcare team how different the cancer cells look from healthy prostate cells. It helps the team understand if the cancer is likely to grow slow or fast. Having a high Gleason score before treatment increases the risk of prostate cancer recurrence.
• Higher PSA level. People with prostate cancer often have elevated levels of prostate-specific antigen (PSA) in their blood. Having a high level of PSA when first diagnosed increases the risk of prostate cancer recurrence.
• High-risk DNA changes in the cancer cells. Prostate cancer happens when healthy cells develop changes in their DNA. Certain changes may make the cancer more aggressive or more likely to resist treatment. Your healthcare team might recommend testing to look for these changes.

There's no sure way to prevent a prostate cancer recurrence. Some studies show that healthy lifestyle choices are linked to a lower risk of recurrence. You may try these approaches if you're concerned about prostate cancer recurrence. They also can help reduce the risk of other conditions, such as heart disease, which is common in people with prostate cancer.

Get regular exercise

Studies of physical activity in people with prostate cancer show that those who exercise the most have the lowest risk of dying of the disease. Exercise also helps lower your risk of heart disease.

Healthcare professionals generally recommend:

• Aerobic activity. Get at least 150 minutes of moderate aerobic activity a week. Or get at least 75 minutes of vigorous aerobic activity a week. You also can get an equal mix of the two types. Aim to exercise most days of the week. For even more health benefits, get 300 minutes a week or more of moderate aerobic activity.
• Strength training. Do strength training exercises for all major muscle groups at least two times a week.

If you haven't been exercising regularly, get the OK from your healthcare professional before you start. Start slowly and gradually add more exercise as you go.

Eat a healthy diet

Research supports the idea that a generally healthy diet full of fruits and vegetables and whole grains is linked to improved survival after prostate cancer treatment. There's little evidence that certain foods or vitamins provide benefit.

Healthcare professionals generally recommend:

• Choosing healthy foods. Choose healthy foods such as fruits, vegetables, whole grains, legumes and nuts. Other healthy foods include poultry, fish, low-fat dairy products and eggs.
• Limiting other foods. Limit the amount of red meat, processed foods and foods with added sugar.

Don't use tobacco

People who smoke tobacco have a higher risk of prostate cancer recurrence compared with those who never smoked. It's not clear if quitting after treatment helps lower the risk. But quitting tobacco has many other health benefits. It may lower your risk of developing another type of cancer. And quitting is good for your heart.

Avoid all forms of tobacco. If you use tobacco, talk with your healthcare professional about ways to quit.

To diagnose a prostate cancer recurrence, a healthcare professional may do a blood test and imaging tests. Sometimes a procedure to remove a sample of tissue is needed to confirm the diagnosis.

PSA test

A PSA test measures the amount of prostate-specific antigen in the blood. PSA is a protein that's made by healthy prostate cells and cancerous prostate cells. A high level of PSA can be a sign of cancer.

Healthcare professionals often monitor PSA levels after prostate cancer treatment to make sure they fall to low levels. This is a sign that the treatment has worked. Health professionals continue to monitor the PSA levels because rising levels are often the first sign that cancer has come back.

Prostate cancer treatments affect PSA levels differently. What your results mean may differ based on whether you had surgery or radiation therapy.

• After prostatectomy, PSA levels usually fall to zero or very close to it. Some prostate tissue may be left after surgery, such as near important nerves, and this may cause a very low level of PSA. Healthcare professionals don't agree on what PSA level means the cancer has come back. In general, a PSA level above 0.2 nanograms per milliliter (ng/mL) may be a sign of recurrence.
• After radiation therapy, including external beam radiation therapy and brachytherapy, the PSA levels start to go down. The level may keep dropping for a year or more. Radiation therapy doesn't remove the prostate tissue, so it can continue making some PSA. The level varies for each person. If the PSA goes up more than 2 ng/mL from the lowest point after treatment, it may be a sign of recurrence.

A rising PSA level after treatment doesn't always mean that cancer has come back. It's typical to have a short-term rise in PSA after radiation therapy. Healthcare professionals call it a PSA bounce. A rise in PSA also can mean that some healthy prostate tissue remains and continues to make PSA. Sometimes other healthy cells can make low levels of PSA.

If you have elevated PSA levels, your healthcare team may recommend having the test again in 3 to 6 months. If the PSA levels keep rising, it may be a sign of prostate cancer recurrence.

Imaging tests

Imaging tests can make pictures of the body that the healthcare team uses to look for signs that the cancer has come back. If your PSA levels have gone up, your healthcare team may recommend imaging tests to look for prostate cancer recurrence.

Imaging tests used to find prostate cancer recurrence include:

• MRI scan. A magnetic resonance imaging (MRI) scan uses a magnetic field and radio waves to create pictures of the inside of the body. It can help look for signs of cancer in the prostate or in the area where the prostate used to be.
• PSMA PET scan. A prostate-specific membrane antigen (PSMA) PET scan is a kind of positron emission tomography (PET) scan. It uses a radioactive tracer to find prostate cancer cells anywhere in the body. It's mostly used to look for signs that cancer has spread. This test can detect prostate cancer while the PSA is still very low.
• Other PET scans. Other kinds of PET scans also can look for prostate cancer recurrence anywhere in the body. These other scans include choline C-11 PET scan. They may be used if PSMA PET and other imaging tests don't find the cancer.
• Other imaging tests. Other tests used to look for prostate cancer recurrence include bone scans and computerized tomography (CT) scans. These tests often can't detect prostate cancer recurrence until the PSA level gets much higher.

Not everyone needs every test. Which imaging tests you have may depend on your PSA level, your previous treatments and your symptoms.

Biopsy

A biopsy is a procedure to remove a sample of tissue for testing in a lab. Biopsy procedures that might be used to diagnose a prostate cancer recurrence include:

• A biopsy for cancer in the prostate. A prostate biopsy removes tissue from the prostate for testing. It's often used in people who had radiation as the first treatment. The results can show whether an area of concern in the prostate is cancerous. The results also may help the healthcare team choose a treatment. For those who had surgery as the first treatment, a biopsy can remove tissue from the area where the prostate used to be.
• A biopsy for cancer that spreads. If the cancer comes back in other parts of the body, a biopsy may be used to get some tissue for testing. How the healthcare professional does the procedure depends on where the cancer spreads. Tests can confirm that the prostate cancer has spread and look for changes in the cancer cells' DNA. The results may help the healthcare team choose a treatment.

Not everyone needs a biopsy to confirm a prostate cancer recurrence. The healthcare team sometimes uses the results of other tests to make the diagnosis.

Genetic testing

Genetic testing uses a sample of blood or saliva to look for variations in the DNA. Genetic testing also can involve testing the cancer cells for variations. Your healthcare team may recommend genetic testing if your cancer spreads. Some metastatic prostate cancer treatments work better on cancer cells that have certain DNA variations. Sometimes genetic tests provide information about cancer risk that can be helpful for blood relatives.

Many treatments exist for prostate cancer recurrence. Your treatment options may depend on where the cancer is in your body and how quickly your PSA level goes up. Your healthcare team also thinks about your overall health when creating a treatment plan.

If the only sign of a prostate cancer recurrence is a rising PSA level, it's called a biochemical recurrence. It doesn't always need treatment right away.

When cancer comes back in the area of the prostate, it's called a local recurrence. Treatments may offer the chance for a cure.

When the cancer spreads to other areas of the body, it's called a distant recurrence. Treatments often can slow the growth of the cancer, but the cancer often can't be cured. Still, there are many treatment options that can extend your life.

Treatment for a biochemical recurrence

A biochemical prostate cancer recurrence happens when the PSA levels are rising but imaging tests can't find any cancer in the body. Not everyone needs treatment right away for a biochemical recurrence. For some people, the PSA rises slowly. It may be years before the cancer shows up on imaging tests.

Many factors go into deciding whether to treat a prostate cancer recurrence. When thinking about your treatment options, your care team may consider:

• Your overall health.
• How long it's been since your first diagnosis.
• Which treatments you had in the past.
• How quickly your PSA level goes up.

If you choose not to treat a biochemical recurrence, your healthcare team may recommend regular PSA tests and imaging tests to watch the cancer. If you have other serious health conditions or if your cancer has a low risk of spreading, your care team may recommend this approach.

If you choose to treat a biochemical recurrence, your healthcare team may do imaging tests to look for signs that the cancer has spread. If there are no signs that the cancer has spread, it may be treated as a local recurrence.

Treatment for a local recurrence

A local prostate cancer recurrence happens when the cancer starts growing again in the prostate area. Treatment options depend on whether your first treatment was prostatectomy or radiation therapy.

• After prostatectomy. If the cancer comes back after prostatectomy, treatment often involves external beam radiation therapy. The radiation may treat the area where the prostate used to be, called the prostatic bed, and the nearby lymph nodes. Treatment also may involve hormone therapy.
• After radiation therapy. If the cancer comes back after external beam radiation therapy or brachytherapy, treatment can involve surgery in certain situations. Other treatment options include brachytherapy, stereotactic body radiotherapy, cryotherapy, high-intensity focused ultrasound and hormone therapy.

Treatments used after other treatments have stopped working are sometimes called salvage treatments. Salvage treatments tend to have a higher risk of complications and side effects. For example, salvage radiation has a higher risk of causing urinary symptoms, bowel symptoms and erectile dysfunction than radiation given as the initial treatment. Salvage prostatectomy has a higher risk of urinary incontinence compared with having surgery as the initial treatment.

Talk about the risk of side effects with your healthcare team. Together you can compare these with the benefits of treatment and decide what approach is right for you.

Treatment for a distant recurrence

A distant prostate cancer recurrence happens when the cancer starts growing in other parts of the body. This also is called metastatic prostate cancer.

Treatment often starts with medicines to block the hormones that prostate cancer cells use to help them grow. Hormone therapy is often combined with chemotherapy. This combination of medicines often helps control the growth of cancer. Eventually the cancer cells may figure out how to grow without hormones and other treatments are needed to control the cancer.

Treatments for a distant prostate cancer recurrence include:

• Hormone therapy. Hormone therapy for prostate cancer also is called androgen deprivation therapy (ADT). It stops the body from making the hormone testosterone or blocks it from reaching the cancer cells. Many hormone therapy medicines exist. Healthcare professionals often use a combination of medicines to treat metastatic prostate cancer.
• Chemotherapy. Chemotherapy treats cancer with strong medicines. Chemotherapy medicines are sometimes used with hormone therapy medicines for metastatic prostate cancer. Chemotherapy also helps if hormone therapy stops working.
• Targeted therapy. Targeted therapy for cancer is a treatment that uses medicines that attack the cancer cells in a specific way that causes the cells to die. Targeted therapy medicines might be used if hormone therapy stops working. These medicines work best in people with certain DNA changes in their cells. To find out if these changes are present in your cells, your healthcare team may test a sample of your blood or saliva, as well as some of your cancer cells.
• Immunotherapy. Immunotherapy for cancer is a treatment with medicine that helps the body's immune system kill cancer cells. Immunotherapy might be an option if hormone therapy stops working. These medicines only work in people who have certain DNA changes in their cancer cells. Your healthcare team may test your cancer cells to look for these changes.
• Radiopharmaceutical therapy. Radiopharmaceutical treatments use medicines that contain a radioactive substance, called radiopharmaceuticals. The medicine delivers radiation directly to cancer cells. This treatment might be an option if hormone therapy stops working.
• Radiation therapy. Radiation therapy treats cancer with powerful energy beams. It can help manage metastatic prostate cancer that spreads to the bones. Radiation to the affected bone can help with pain and lower the chances that the bone might break.

Finding out your prostate cancer is back can cause a range of feelings. People with prostate cancer recurrence sometimes describe feeling disbelief, fear, anger and sadness. With time, many people find ways to cope. Until you find what works for you, here are some ways of coping that you can try.

Learn enough to feel comfortable making treatment decisions

Learn as much as you need to know about recurrent prostate cancer and its treatment to feel comfortable talking about your options with your healthcare team. Ask your healthcare professional to recommend some good sources of information.

Find a good listener

Finding someone who is willing to listen to you talk about your hopes and fears can be helpful. This can be a friend or family member. A counselor, medical social worker or clergy member also may offer helpful guidance and care.

Connect with other cancer survivors

Other people with prostate cancer sometimes are best at knowing what you're going through. They can provide a unique network of support. Ask your healthcare team about support groups or community organizations that can connect you with other people with cancer. Find support online through Mayo Clinic Connect, which is a community where you can connect with others for support, practical information and answers to everyday questions.

If you have symptoms that worry you, start by making an appointment with a doctor or other healthcare professional. If you still have checkups with the healthcare team that treated your cancer, tell the team about your symptoms. If you no longer see that care team, tell your usual healthcare professional about your concerns.

Because appointments can be brief, it's a good idea to be prepared. Here's some information to help you get ready.

What you can do

• Be aware of any restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
• Write down any symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medicines, vitamins and supplements that you're taking.
• Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information you get during an appointment. Someone who goes with you may remember something that you missed or forgot.
• Write down questions to ask your healthcare professional.

Some questions to ask about prostate cancer include:

• Is my prostate cancer back?
• What's my prostate-specific antigen (PSA) level?
• Where is the prostate cancer in my body?
• Has my prostate cancer spread beyond my prostate?
• If the cancer hasn't spread, what are the chances that it might?
• Will I need more tests?
• What are my treatment options?
• Is there one treatment option you think is best for me?
• Do I need cancer treatment right away, or is it possible to wait and see if the cancer grows?
• What are the potential side effects of each treatment?
• What is the chance that my prostate cancer recurrence will be cured with treatment?
• If you had a friend or family member in my situation, what would you recommend?
• Should I see a specialist? What will that cost, and will my insurance cover it?
• Are there brochures or other printed material that I can take with me? What websites do you recommend?

In addition to the questions that you've prepared, don't hesitate to ask other questions during your appointment.

Most people who have a prostate cancer recurrence have a biochemical recurrence at first. This means the PSA is rising, but imaging tests don't show any cancer yet. It can feel distressing to know the cancer is back, and you might wonder what it means for your future.

A biochemical recurrence raises the risk that the prostate cancer may spread or lead to death, but it doesn't make these outcomes certain. When metastases happen after a biochemical recurrence, they happen 7 to 8 years later, on average. One study followed people with a biochemical recurrence after prostatectomy and found the point at which half the people died of prostate cancer was more than 16 years later. Many people live for years after a prostate cancer recurrence.

If the cancer spreads to another part of the body, it may be harder to manage. The risk of metastatic prostate cancer is higher in those who have:

• A PSA level that's going up quickly. Healthcare professionals often measure the PSA doubling time in those with a prostate cancer recurrence. This is the time it takes for the PSA level to double. When the doubling time is less than 12 months, this is a sign of a higher risk.
• A higher Gleason score when first diagnosed. A Gleason score is a number that tells the healthcare team how different the cancer cells look from healthy prostate cells. Those who had a Gleason score of 8 to 10 when they were first diagnosed with prostate cancer have a higher risk than those with a lower score.
• A higher PSA level at the time of recurrence. In those treated with prostatectomy, a PSA above 0.5 nanograms per milliliter (ng/mL) is a sign of a higher risk.
• A shorter time since treatment. In those treated with radiation therapy, having a recurrence within 18 months of treatment raises the risk.

When cancer spreads, many treatments can help control it. But metastatic prostate cancer often can't be cured. The five-year survival rate for cancer that spreads is about 38%. This means that for every 100 people with metastatic prostate cancer, about 38 can expect to be living five years after diagnosis.

This survival rate comes from studying people who were treated for prostate cancer more than five years ago. They may not have had access to the latest treatments that are helping people with metastatic prostate cancer live longer. Clinical trials are testing many new treatments and new ways of using existing treatment.

Talk with your healthcare team about your prognosis and what factors may affect your personal outlook.