About 60,000 men a year relapse after surgery or radiation with a rising PSA. In the old days, a rising PSA after surgery was treated with radiation to the prostate fossa, the area of the body where the prostate was previously located. One-fourth of the time these treatments cause durable lowering of PSA levels, essentially a cure. The other three-fourths of the time the PSA keeps rising and the men are relegated to lifelong hormone therapy with Lupron shots. This article is about what to do for the three-fourths whose PSA keeps rising despite undergoing radiation to the prostate fossa.
While hormone therapy is the standard approach because it effectively suppresses PSA for over ten years, the quality of life on long term Lupron is often poor, because Lupron causes hot flashes, tiredness, joint aches, muscle atrophy and loss of sex drive.
In the old days crude attempts to improve cure rates were made by extending the radiation field outside the prostate to cover the pelvic lymph nodes. (The lymph nodes are the first jumping off place for prostate cancer when it metastasizes outside the gland.) As might be expected the closely surrounding intestines often are caught in the radiation crossfire, creating nasty digestive disturbances such as chronic diarrhea and intestinal bleeding. However, due to an amazing breakthrough in radiation technology, that occurred in the mid-1990s— intensity modulated radiation (IMRT)—now the radiation beam can be sculpted to target the nodes and miss the intestines.
Excitement about the potential for this new technology ramped up even further with the advent of new cancer scans such as Combidex and C11 PET scans that can accurately detect which lymph nodes are diseased.
Let me recount the story of a PSA-relapsed gentleman who has now passed his fifth anniversary off Lupron, with this revolutionary approach. Initially, in 1992, he underwent a prostatectomy, but by April of 2003 his PSA had risen to 0.07. He was treated with standard radiation to the prostate fossa. His PSA briefly dropped, but by February 2007 it was back up to 1.83 and in May 2008 his PSA was 7.3. A Combidex scan showed cancerous lymph nodes extending from the pelvis up through the abdomen all the way to the diaphragm. He started Lupron and Casodex and underwent another Combidex scan in June 2009 that showed substantial improvement but incomplete resolution of the cancerous nodes. He started IMRT directed at all the cancerous nodes in late July 2009. The Lupron was stopped in June 2009. At his last visit to my office in November 2014, testosterone was normal at 433 and PSA was 0.040.
Sometimes a “breakthrough” in medical care simply results from a new application of existing technology. This case illustrates how the results of targeted treatment with IMRT can be further enhanced with optimal scanning technology to achieve durable remission and freedom from lifelong dependency on hormonal therapy.