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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.

Guide 17

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.

Guide 18

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

the treatment.

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.