Dr. David Samadi explains what happens if prostate cancer returns after surgery

Prostate cancer recurrence after radical prostatectomy to remove the prostate gland seems inconceivable. So how could prostate cancer return once the prostate gland is gone? 

Cancer does not return in the vast majority of men I’ve treated for prostate cancer using robotic radical prostatectomy. But, like any cancer, there can be rogue cancerous cells that escape the confines of the organ before the surgical procedure is done to remove the prostate gland. These cells migrate to another location in the body and are called metastases or biochemical relapses. 

How frequently does prostate cancer recurrence occur after surgery?

Surgical removal of the prostate gland will cure prostate cancer.  To date, I have performed over 9,000 robotic prostate cancer surgeries with 90% of my patients who have remained cancer free. My success rate is due to my own development I’ve called SMART (Samadi Modified Advanced Robotic Technique) surgery, using the da Vinci Robotic System. This minimally invasive technique helps me achieve three goals for my patients – complete removal of the cancerous cells, preservation of sexual functioning, and urinary continence. 

However, cancer cells are sneaky and can metastasize before the surgery beyond the prostate gland to other areas. The three most common sites of prostate cancer recurrence following surgery are:

• The bed of the prostate (this is where the prostate was before removal) – 80% of recurrence cases
• Lymph nodes – 15 % of recurrence cases, usually to the pelvic lymph nodes
• Bones – 5% of recurrence cases

Other possible sites of recurrence may be the spine or bladder, but the rogue prostate cancer cells can spread wherever they want in the body.

How do I know if prostate cancer returns after surgery?

All of my cancer patients will have regular checkups following prostate removal. The purpose is to detect any signs of a recurrence and if so, to treat it as quickly and aggressively as possible. At these follow-up visits, a prostate-specific antigen (PSA) blood test will be done to check for any rise in PSA levels. 

Once the prostate gland is removed surgically, PSA should be undetectable. But, if PSA results show a rise greater than 0.2 ng/ml, this is a biochemical recurrence. If the PSA level rises to 0.5 ng/ml or higher, then it is a clinical recurrence. 

The reason for continued follow-ups for men, even after the prostate is removed, is to keep checking the PSA levels in case a recurrence has happened. Typically, there are few signs of a rise in the PSA unless the level has topped more than 20 ng/ml. 

At this point, some men will likely be experiencing bone pain, extreme fatigue, or problems urinating and may not realize it’s because cancer has returned.  That’s why it’s important for men who’ve had surgery to remove their prostate to keep all follow-up appointments. If prostate cancer returns after surgery, catching a rise in PSA levels early is important for discussing salvage treatment going forward to fight it back successfully.

Are there certain men who are more likely to have a prostate cancer recurrence?

The chances of prostate cancer metastasizing after robotic prostatectomy are more likely in men initially diagnosed with high-grade (aggressive) and a higher stage (extent) of cancer found. Aggressive and advanced prostate cancers are more likely to migrate away from the prostate. Typically, the men who are at higher risk include men who had:

• A Gleason score of 8-10
• A high clinical stage of T3-4
• Surgical margins were positive, meaning the tumor was already at the edge of the prostate gland

It will be vital for any man diagnosed with aggressive prostate cancer to return for all follow-up visits after surgery for regular checkups and PSA testing. 

What types of treatment will be used for prostate cancer recurrence?

When it’s been determined your prostate cancer has returned, then it’s time to make decisions about treatment. Treatments for recurrent prostate cancer are referred to as second-line or salvage treatments. 

Your doctor should work closely with you on making treatment decisions. There are several choices offered but each has its own disadvantages, advantages, and side effects. Be sure to ask questions of your medical team to thoroughly understand each treatment possibility. 

When choosing a second-line of salvage treatment after prostate cancer recurrence, there are two types to consider: a treatment that aims to destroy cancer and a treatment meant to delay cancer growth but does not cure it. 

Here are the main treatment options when prostate cancer returns after surgery:

• Radiotherapy: Used most commonly, this type of radiation delivers radiotherapy energy to the prostate bed, the most common site of prostate cancer recurrence. Men treated with this method will have an 80% cure rate.

• Active surveillance: Men with a very slow-rising PSA rate or elderly men may be good candidates for this option. Active surveillance involves frequent follow-ups with men whose cancer has returned of a “watch and wait” approach before choosing a more aggressive treatment.

• Hormonal therapy: This treatment is sometimes used for men with a biochemical recurrence of a rise in PSA level after surgery. This is especially true if the PSA level has doubled in less than three months. Hormonal therapy can have many side effects including, erectile dysfunction, hot flashes, low libido, loss of bone density, bone fractures, and loss of muscle mass and physical strength. Men need to know that hormonal therapy does not cure cancer but does help control the extent of recurrence while lowering the PSA level. 

Dr. David Samadi is the Director of Men’s Health and Urologic Oncology at St. Francis Hospital in Long Island. He’s a renowned and highly successful board certified Urologic Oncologist Expert and Robotic Surgeon in New York City, regarded as one of the leading prostate surgeons in the U.S., with a vast expertise in prostate cancer treatment and Robotic-Assisted Laparoscopic Prostatectomy.  Dr. Samadi is a medical contributor to NewsMax TV and is also the author of The Ultimate MANual, Dr. Samadi’s Guide to Men’s Health and Wellness, available online both on Amazon and Barnes & Noble. Visit Dr. Samadi’s websites at robotic oncology and prostate cancer 911.