What does having recurrent prostate cancer mean?

Having recurrent prostate cancer means that your cancer has returned after a period of time after treatment, such as surgery (radical prostatectomy) or radiotherapy. Your cancer may have returned:

• In your prostate gland, if you did not have it removed by surgery.

• In the area where your prostate gland used to be (the prostate bed), if the gland was removed by surgery.

• In other areas of your body such as the lymph nodes or bones. It is much less common for prostate cancer to spread to other areas such as the liver or the lungs.

If your cancer has returned in the prostate gland or in the prostate bed then you may be offered further treatment aiming to cure the cancer. If your cancer has spread to other parts of your body then treatment is usually aimed at controlling the cancer rather than curing it.

Why does prostate cancer come back?

We do not know exactly why prostate cancer returns, but possible reasons include:

• The cancer was more advanced than your doctor originally thought. Sometimes the cancer cells are too small in number to be detected by scans.

• Not all of the cancer cells were treated during your initial treatment.

We do not know for certain which men will experience a recurrence, but there are some risk factors that affect the likelihood of your cancer coming back. These aredescribed below.

How do I know if I may be at risk?

Some men are more at risk of a recurrence than others. Your specialist team cannot say whether or not your cancer will return but may be able to tell you about your risk of recurrence. This may be determined by your Gleason score (see page 22) and the stage your cancer had reached when you were diagnosed. If you do not know this information your specialist team will be able to tell you.

The risk of recurrence is:

• Low, if your prostate specific antigen (PSA) level at diagnosis was less than 10ng/ml, your Gleason score was less than 7 and your cancer had not spread outside the prostate gland (localised prostate cancer or clinical stage T2 or less).

• Medium (or moderate), if your PSA level at diagnosis was between 10 to 20ng/ml or your Gleason score was 7, and your cancer did not appear to have spread outside the prostate (localised prostate cancer or clinical stage T2).

• High, if your PSA level at diagnosis was over 20ng/ml or your Gleason score was over 7, or your cancer was outside the capsule of the prostate gland, or into the seminal vesicles (locally advanced prostate cancer or clinical stage T3).

If you would like more information about staging and grading of prostate cancer, please see our Tool Kit fact sheet How prostate cancer is diagnosed.Recurrent prostate cancer 6

The risk of your cancer coming back is higher if you have been told you have ‘positive margins’ or have been diagnosed with locally advanced prostate cancer after surgery (radical prostatectomy).

If you have had surgery, the tissue removed is looked at by a pathologist (a doctor who studies cells). The pathologist will look at the tissue under a microscope to see what the cancer cells are like and their position in the prostate gland. If cancer cells are found at the edge of the prostate this is described as having ‘positive margins’. If cancer cells have broken through the capsule of the prostate gland, but are not found in the lymph nodes or the bones, then your cancer stage will be changed to locally advanced prostate cancer.

How do I know if my prostate cancer has come back?

If your cancer has come back, you are unlikely to experience any symptoms at first so it is important to have regular follow up appointments with your specialist team. They can check your progress and monitor the prostate specific antigen (PSA) level in your blood. This will let them see:

• How you are responding to treatment

• Any signs that your prostate cancer has come back

Follow up appointments usually begin at around six weeks to three months after treatment. In the first year after treatment you may have appointments every three or four months. If your specialist team is happy with your progress this may be changed to every six months. Speak to your specialist team if you are concerned about the frequency of your follow up appointments. If your cancer comes back – risk and treatment 7

Your PSA level

Usually the first sign that your cancer may have returned will be a rise in the level of PSA in your blood. Although the PSA test may not always be accurate at helping to diagnose prostate cancer, regular testing is a very effective way of checking its progress once you have been diagnosed and had treatment.

Your specialist team will monitor your PSA regularly to try and get an accurate picture of how the cancer is responding to treatment. They will look out for changes in your PSA, depending on which treatment you had first:

• PSA level after surgery (radical prostatectomy) After surgery your PSA level should drop to an undetectable level (less than 0.1ng/ml) because the prostate gland, which produces PSA, has been removed. If your cancer has returned there should be a detectable and rising PSA.

• PSA level after radiotherapy or brachytherapy Following radiotherapy or brachytherapy your PSA should drop to its lowest level (nadir) after 18 months to two years (usually to below 1.0ng/ml), although some PSA is still produced. This is because healthy prostate tissue will continue to produce PSA and it does not mean that your cancer has come back. A sign that your cancer may have returned is if your PSA level has risen by 2ng/ml or more above its lowest level. Sometimes men may experience a rise and fall in PSA at around one to two years after treatment. This is called ‘PSA bounce’ and does not indicate that cancer has returned. If you have had hormone therapy alongside radiotherapy or brachytherapy, see the next page. Recurrent prostate cancer 8

• PSA level after radiotherapy or brachytherapy with hormone therapy Most men are now given hormone therapy before radiotherapy and, very occasionally, before brachytherapy. This means your PSA level should drop to a lower level quite rapidly. It may even be less than 1.0ng/ml by the time you start radiotherapy or brachytherapy. If you continue to have hormone therapy after radiotherapy, your PSA level may continue to fall further. When you stop hormone therapy your PSA level may begin to rise naturally but a rise of more than 2ng/ml from your lowest level (nadir) may indicate that your cancer has returned.However, even when there is a rise of more than 2ng/ml from your lowest level your doctor may wish to know how quickly (or slowly) your PSA is rising before deciding on the best course of treatment for you. In this case you may be advised to have your PSA monitored for at least six months before another treatment is considered.

Other tests

In some cases men may need to have a biopsy to confirm whether prostate cancer has come back. Scans may also be needed (such as a CT, MRI or bone scan) to find out more information. Your specialist team will be looking to see:

• If the cancer is still within the prostate gland (if you have had radiotherapy or brachytherapy).

• If it has spread to other parts of the body.If your cancer comes back – risk and treatment 9

This process is known as re-staging and is similar to what happens when you are first diagnosed.

If you are having radiotherapy after surgery you may not need any further tests. Again, your PSA level and rate of rise is also taken into consideration when deciding on which tests you will need.

What treatment options will be available to me?

Treatments for recurrent prostate cancer are called ‘second-line’ or ‘salvage’ treatments. The treatments available to you will depend on several factors including:

• Where your cancer has come back

• Which treatment you have already had

• Your age, your general health and any other medical conditions you may have

The results of tests to re-stage your cancer will also help the doctor to decide which treatments you will be offered. You may not need any further treatment straight away, particularly if your PSA level is rising slowly.

The table overleaf shows the treatment options that may be available to you based on the first treatment you had. If you are unsure if a treatment is suitable for you it is important to discuss your options with your specialist team. If your prostate cancer has spread to other areas in your body (advanced prostate cancer), you will be offered hormone therapy to control your cancer.Recurrent prostate cancer 10

If you had brachytherapy as a first treatment, it is unlikely that you will be offered HIFU as a second-line treatment because doctors have found that there is a higher risk that you may develop a fistula (an opening between the urinary system and the bowel).

Surgery is very rarely performed as a second-line treatment because radiotherapy and brachytherapy affect the nature of the prostate tissue. This makes it very hard for a surgeon to remove it. Some surgeons may occasionally consider this treatment. Speak to your specialist team if you wish to discuss this possibility.

Clinical trials

You may be able to take part in clinical trials of new treatments or new combinations of existing treatments. If you would like to know more about clinical trials or any of the treatments mentioned above.

When will I be offered treatment?

The timing of second-line treatments will vary from man to man. If the treatment you are offered is aimed at curing your cancer then your treatment (radiotherapy, HIFU or cryotherapy) may begin soon after assessment.

If you are going to have hormone therapy there are several things which will determine how soon you will need treatment such as:

• If your prostate cancer has spread to other areas in your body

• If you have any symptoms from your prostate cancer

• How quickly your PSA level is rising (your specialist team will consider the time taken for your PSA level to double)