Video: Local Relapse after Surgery or Radiation for Prostate Cancer | Prostate Cancer Staging Guide

The Staging Guide Video Series | Transcription

Hi, I’m Dr. Scholz. Let’s talk about prostate cancer.

In this video we’re going to review what we call “Low-Indigo.” Indigo is a category of relapsed prostate cancer, but there are many types of relapses. You can have cancer that comes back just in the prostate area or in the prostate, and that’s what we call “Low-Indigo.” You can also have early spread into the lymph nodes, which we call “High-Indigo.” And then you can kind of have a grey area in-between where you’re not quite sure if there’s microscopic disease in the lymph nodes; that’s Basic-Indigo.

So this video is just about Low-Indigo.

So how do you know if you fit into the Low-Indigo category?

Well you have to have a relatively low PSA. If you’re relapsing after surgery the PSA needs to be less than .5. If you’re relapsing after previous radiation the PSA needs to be under 5. Also the PSA can’t be rising too quickly. What we call the “PSA doubling time” which is a cutoff point of around 8-10 months. We arbitrarily pick eight as the cut point. So if the PSA is doubling in less than eight months, then you’re up to a Basic-Indigo--not a Low-Indigo. You will only qualify for a Low-Indigo if your original stage (that is [to say] prior to even getting surgery or radiation) is at least a Basic-Teal or less. This is because if you’re a High-Teal or an Azure (something of that nature) the chances of microscopic disease goes up a lot and you can’t treat these individuals like a Low-Indigo. So original stage prior to treatment is also incorporated in the decision making process. Lastly, if someone has had previous radiation and now they’re relapsing often they’ll undergo a multiparametric MRI to try and determine if there’s cancer in the prostate and where it’s located. Men that have proven cancer that has spread into the seminal vesicles (the little rabbit ears on top of the prostate) are not Low-Indigo; they’re going to be either a Basic or a High-Indigo.

So a variety of criteria are necessary to be a Low-Indigo, but if men meet this criteria it means in all likelihood the cancer is still in the prostate area (after surgery we call it the “surgical fossa”) or in the prostate itself in men that have had previous radiation and now are relapsing.

So let’s take each of these situations one at a time.

For men that are relapsing after previous surgery they can have a rising PSA, as we’ve already mentioned, or they can also have what’s called a positive margin. So after surgery the pathologist removes the gland and looks at the exterior surface to determine if there’s any cancer up at the edge. If there is, that’s called a positive margin and unfortunately it means that the cancer remains in the body. Some cancer is still in the body even though the PSA may be zero.

So this creates a dilemma.

Should these men undergo immediate radiation as a precaution or should they wait and see if the PSA is going to rise later?

Interestingly sometimes men who have positive margins--maybe as many as 50% of men--don’t relapse. The PSAs remain zero and they are in essence cured without any radiation. This is an important issue because studies have shown that early radiation right after surgery increases the risk of long-term erectile dysfunction. So if people can safely postpone radiation, then they have a better chance of recovering normal sexual function. So how do we make this decision? (Since this is an important question whether you should have immediate radiation when margins are positive--so called Low-Indigo.) Several studies have shown it is safe to postpone radiation and watch the PSA very closely as long as the radiation gets started before the PSA rises above .5. So you can wait for the PSA to rise, but don’t let it rise very far because the cure rates will start to deteriorate. But thankfully the studies do show that if the PSA is less than .5 the cure rates will be the same as if the men had had immediate radiation when the PSA was zero. By pursuing a watchful waiting approach, a very careful one, then a lot of men that are never going to relapse can avoid radiation all together.

What about the situation for men who have had previous radiation and now it appears that the cancer is coming back inside the prostate?

This can be determined by men that have rising PSAs, they may have had a biopsy, or maybe a scan shows a suspicious spot that is targeted with a biopsy. The problem, of course, is that there is a danger of giving of giving too much radiation if you decide to do radiation again. Of course there is a lot of discussion about how difficult it is to do surgery after radiation, and I’m glad that discussion is ongoing because in most cases, in my professional opinion, surgery is a really bad idea after radiation, and there’s a variety of other options: Focal freezing called “cryotherapy,” high-intensity focused ultrasound, electroporation. And as it turns out you can do salvage seed implants. This is more feasible when people have had some times since their original radiation, and of course if you use this type of approach you gotta go to experts--whether I’m talking about focal or salvage seed implants--after radiation this is a tricky situation and you need to seek out a center of excellence to do this kind of work.

So for Low-Indigo, whether it be a relapse after surgery or radiation, there’s a sort of sequential approach that you need to implement if you want to try and cure it, and in most cases that may be the preference.

There is another option, however, and that is to simply temporize with intermittent testosterone inactivating pharmaceuticals. Another name for that is “androgen deprivation” or “hormone blockade.” These medicines are very effective at keeping the disease in check; unfortunately they don’t generally cure the disease and repeated cycles may be necessary. It is safe, studies clearly show, that you can take hormone blockade (or testosterone inactivating pharmaceuticals so-called TIP) for a short period of time, take a holiday, [and] see how things go. There are a variety of side effects of TIP and we’ve talked about that in other videos. All these different factors need to be weighed in the selection of the kind of treatment you decide to do.

So as we have emphasized many times over, precise staging is essential if you want to be guided to the best possible treatments. Once you figure that our, you need to find really skilled doctors to help you implement the treatment if you want to minimize the side effects and maximize the cure rates.