PSA Doubling Times and Prostate Cancer Relapse

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If you or someone you're close to has prostate cancer, you'll hear a lot about the PSA blood test and the PSA doubling time (PSADT). PSA helps medical providers screen for and diagnose prostate cancer at an early stage.

But there's more to the test than just that. The PSADT—a measurement of how quickly the PSA is increasing—is especially important after you've been treated for prostate cancer.

This article will walk you through why the PSA doubling time is so significant, how it'll be monitored for recurrence, and what factors will play a role in how a recurrence is treated.

What is PSA?

PSA stands for prostate-specific antigen. It's a protein produced by cells in the prostate gland. The PSA test measures levels of this protein in the blood. High levels can be a sign of prostate cancer.

Radiologist consoling a patient at MRI scan.
skynesher / Getty Images

Why PSA Is Important

PSA plays many different roles. The most common is determining prostate cancer risk.

PSA Levels and Prostate Cancer Risk
Low <10
Intermediate 10-20
High >20

It's also used for determining the stage of a newly diagnosed prostate cancer. Staging is a measurement of how advanced the disease is.

The PSA doubling time can also detect a relapse after surgery or radiation. Cancer can come back slowly or rapidly.

The the time it takes for PSA blood levels to double gives your medical team an insight into how aggressive your prostate cancer will be in the future. 

That can guide your treatment plan, which may include:

Recap

The PSA and PSADT are important for prostate cancer screening, diagnosis, and—in the case of a relapse—determining the best treatment plan.

Detecting a Relapse

PSA is vital for detecting a relapse of prostate cancer after surgery or radiation. 

After surgery, PSA is normally undetectable. Even small rises could point to a recurrence. 

After radiation that cures the disease, the PSA generally stays under 1.0 long-term. However, there are exceptions.

Sometimes, the PSA level drops slowly after radiation. It can take years to reach its lowest point.

Or, younger people may have a short-term PSA rise that's not cancer-related. That's more common after the seed-implant type of radiation. This temporary rise is called a "PSA bump" or "bounce." It can develop between one and four years after treatment.

It may be linked with anti-cancer activity in the immune system, which is a good thing. However, it's sometimes mistaken for a recurrence, which can lead to fear, stress, and unnecessary hormone therapy. 

What Guides Treatment

When cancer comes back, the PSADT shows how fast it's growing. Ultimately, relapse treatment is guided by: 

  • The PSADT
  • Your original (pre-treatment) risk category
  • The tumor's location
  • Whether you originally had surgery or radiation

Your age, other illnesses, and overall health will also be considered.

PSADT

The PSA doubling time has a big influence on treatment. For example, in a recurrence of prostate cancer that hasn't spread:

  • PSADT of 10+ months: Observation is generally preferred. Secondary hormone therapy can be considered.
  • PSADT of three to 10 months: Treatment with Erleada (apalutamide), Orgovyx (darolutamide), or Xtandi (enzalutamide) is preferred. Other secondary hormone therapy is also recommended.
  • PSADT of three months or less: Treatment should be aggressive, such as six cycles of Taxotere (docetaxel) along with Lupron. Some medical providers may consider new drugs like Zytiga (abiraterone acetate) or Xtandi.

Original Risk Category

Your original risk category will also play a role in treatment decisions. Risk categories are:

  • Low risk: Cancer is confined to the prostate, PSA is less than 10 and grade group 1; or the tumor is very slow-growing.
  • Intermediate risk: Cancer is confined to the prostate, PSA is between 10 and 20, or grade group 2 or 3.
  • High risk: Cancer extends outside the prostate, PSA is higher than 20, or grade group 4 or 5; or the tumor is very aggressive and has spread to other areas.

The higher the risk, the more aggressive the treatment. For example, if you were originally low risk, treatment may include either cryotherapy, radiation, or Lupron alone.

If you were originally in the high-risk category, treatment may mean Lupron plus pelvic lymph node radiation.

Recap

After surgery or radiation, medical providers watch for a cancer relapse with PSA and PSADT test results. Those numbers plus your original risk category are considered together when deciding what treatment course to follow—the faster the PSADT and the higher your risk category, the more aggressive treatment will be.

Tumor Location

If you have a rising PSA after surgery or radiation, your doctor will likely order imaging studies to find the cancer's location.

Common scans are:

Cancer in the prostate or prostate bed is considered a "local" recurrence. Cancer that's spread outside of that area is called "metastatic."

Metastatic recurrence is treated differently depending on where it is and many other factors.

With a local relapse, disease suppression with Lupron is an option. That's especially true if you have a:

  • High PSA
  • Short PSADT
  • Otherwise long life expectancy

Lupron alone is almost never a cure but it often controls the disease for more than a decade.

Insurance Coverage

Some of the newer, more accurate PET scans may not be covered by your insurance. Be sure to check on your coverage before you opt for one of these expensive tests.

Post-Surgery

Generally, if you were low-risk or intermediate-risk before surgery and develop a PSADT of between six months and 12, your recurrence has a good chance of being cured with radiation treatment to the prostate bed.

Radiation is most effective when the PSA level is low and the PSADT is long.

If you want to avoid radiation side effects, another option is to suppress the PSA with an intermittent, six-month course of Lupron.

If your PSA doubling time is faster—for example, under six months—your medical provider is likely to recommend pelvic-node radiation plus Lupron for as long as 12 to 18 months.

If you were high-risk before surgery, treatment will often be node radiation with 12 to 18 months of Lupron. Your medical provider may suggest adding more powerful drugs like Zytiga, Xtandi, or Taxotere.

Post-Radiation

For a rising PSA after radiation, a popular approach is cryosurgery (freezing cancer cells). Newer scans help the cryosurgeon focus on cancerous areas rather than treating the whole prostate. 

This is called focal cryotherapy. It offers much fewer side effects than freezing or removing the whole gland.

Another alternative is prompt treatment with Lupron. This can suppress the local disease. It's considered reasonable when:

  • The PSADT is longer than six months
  • The original risk category was either low or intermediate

If you were originally high risk, a local relapse should be treated aggressively with cryosurgery or seed implantation. Lupron alone is less likely to work.

The prostate is rarely removed after radiation due to high rates of incontinence and erectile dysfunction. 

Recap

Oncologists and other medical providers use multiple scans, including some newer types, to find where cancer has recurred. Once it's located, PSA, PSADT, original risk category, and other factors are used to determine treatment.

Treatment courses depend largely on whether your original cancer was treated with surgery or radiation.

  • After surgery, radiation and Lupron are options.
  • After radiation, cyrotherapy or Lupron are common choices.
  • Lupron alone is recommended when PSA and PSADT indicate more aggressive cancer.

Summary

Deciding on a treatment for a PSA relapse is complex. The choice is based on factors including your original risk category, PSA doubling time, and scan findings. The location of recurrent cancer may remain uncertain, even with the best scans. 

Treatment with cryosurgery or radiation alone is reasonable when:

  • Scans indicate that cancer hasn't spread to the nodes.
  • The previous risk category was low or moderate.
  • The PSADT is long.

Microscopic metastases in the pelvic nodes don't always show up on scans. They're more likely if:

  • The PSADT is fast.
  • The previous risk category was high.

In these situations, pelvic lymph node radiation plus an extended course of Lupron is usually recommended.

A Word From Verywell

Cancer is always serious, but your overall outlook is positive. Most people with prostate cancer have a good 15-year prognosis.

Sometimes, prostate cancer can be cured. Even when it's not, it can be controlled for years and even decades.

Being sure to keep up on your monitoring tests, including the PSA doubling time, is a key component of staying well in the long term.

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