NCCN Guidelines for Patients
Prostate Cancer, Version 1.2016
Treatment guide: Monitoring
Treatment after radiation therapy
After radiation therapy, PSA levels usually fall to 0.3
ng/mL or below. If your PSA increases by at least
2 ng/mL after falling to low levels, the cancer may
have returned. There are other changes in PSA that
may be a sign of recurrence. Thus, your doctor may
assess if the cancer has returned before the PSA
level increases by 2 ng/mL. Signs of cancer also may
be found by a DRE.
This section lists what health care is advised when
PSA scores or a DRE suggest there’s cancer.
Options are based on if you may be able to have
local treatment. Local treatment is an option if: 1) the
clinical stage was T1 or T2; 2) initial tests found no
lymph node metastases or weren’t done; 3) you’re
likely to live at least another 10 years; and 4) your
current PSA level is below 10.
lists treatment options for when local
treatment isn’t an option. You may not meet
the conditions for local treatment or may have
metastases. In this case, your options include ADT or
observation. Read Part 7 for more information.
lists test and treatment options for when
local treatment may be an option. To confirm that local
treatment is right for you, your doctors will assess
where the cancer has grown. A fast PSA doubling
time suggests spread beyond the prostate. A chest
x-ray, bone scan, and MRI of your prostate should
also be done. Possible other tests include a CT or
MRI scan of your abdomen and pelvis, a C-11 choline
PET scan, and TRUS biopsy of your prostate.
For prostate cancer, a radiotracer called C-11 choline
will first be injected into your body before the PET
scan. The radiotracer is detected with a special
camera during the scan. Prostate cancer cells appear
brighter in images than normal cells because they
use a lot of choline to quickly build their membrane.
Thus, PET can show even small amounts of cancer.
However, it is unclear 1) if such PET scans improve
outcomes in this setting, and 2) how results should be
used for decisions about health care.
A prostate biopsy may be done under the guidance
of MRI images combined with real-time ultrasound
images. This type of biopsy is called MRI-US fusion
biopsy and may help detect higher-grade cancers.
Higher-grade cancers include those with Gleason
score 7 through 10.
Sometimes the prostate biopsy and imaging tests
find no cancer despite rising PSA levels. One option
in this case is to continue observation until cancer
growth is confirmed. Another option is to start ADT.
When to start ADT should be influenced by PSA
velocity, your anxiety as well as your doctor’s concern
about cancer growth, and your feelings about side
effects. A third option is to enroll in a clinical trial.
There are four options if cancer has returned in the
prostate but has unlikely spread to distant sites. The
first option is to continue observation until further
cancer growth is found. Another option is radical
prostatectomy with PLND. Be aware that the side
effects of prostatectomy following radiation therapy
are worse than when it used as initial treatment.
Other options for local treatment include cryotherapy
and brachytherapy. Which treatment you will receive
needs to be based on your chances of further cancer
growth, treatment being a success, and the risks of
After treatment, testing to monitor treatment results
will start again. These tests include PSA with either a
DRE or physical exam. If the tests suggest the cancer
is growing or spreading, imaging tests are advised.
Imaging tests should include a chest x-ray, bone
scan, and CT or MRI of your abdomen and pelvis. CT
and MRI can be done with or without contrast. A C-11
choline PET scan may also be helpful.