Can men hold off on treating recurring prostate cancer?

Experts question immediate treatment for cancers that show up only on the most sensitive imaging scans.

What happens if PSA levels start rising after surgery or radiation for prostate cancer? Up to a third of men treated for the disease will eventually confront this problem. If there’s no accompanying evidence of cancer on imaging scans, then men have what’s called a biochemical recurrence. This means that PSA — the biochemical marker in this case — is flagging the presence of cancer cells that doctors are still unable to see. Biochemically recurring cancer is asymptomatic, and it can take years for visible metastases to appear. Sometimes men live the rest of their lives with a rising PSA without ever developing metastases. Now, an ultra-sensitive scanning technology is raising new questions about biochemical recurrence and how to manage it. Test results influence treatment decisions This scan works by illuminating a protein on cancer cells called prostate-specific membrane antigen (PSMA). A PSMA scan can reveal small tumors in the body that older, conventional imaging technologies, such as bone scans or magnetic resonance imaging, are unable to detect. Doctors have coined a new term for this condition: (PSMA) + BCR. When a man has biochemical recurrence as it's traditionally defined, with no evidence of cancer on conventional imaging, doctors base treatment decisions on additional factors, such as how fast PSA levels are rising. If treatment is initiated, then a standard approach is to give drugs that block testosterone, a hormone that drives prostate cancer to grow and spread. But doctors might also delay that treatment, since biochemical recurrence tends to proceed slowly, if at all. What if a man has (PSMA) + BCR? Then things get a bit more complicated. Since the scan does show metastases, many doctors are inclined to treat aggressively without delay, in some cases using powerful combinations of hormonal therapies that have considerable side effects.

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