Slow-growing prostate cancer is different from other cancers in one critical way: People who experience a relapse, or a return, of their disease after surgery are more likely to die from old age than from prostate cancer.

With most common cancers—such as colon, breast, brain, melanoma, or lung—the cancer’s return likely means a poor outcome and often leads to death. But with prostate cancer, remission can last up to 10 years. The overall survival rate is 98%.

This article explains three types of prostate cancer relapse and how they are treated. It discusses the importance of the prostate-specific antigen (PSA) test in assessing these relapses.

Symptoms of Prostate Cancer Recurrence

In many cases, symptoms of a recurring prostate cancer are similar to those you experienced with the original diagnosis. They can include:

  • Urinary frequency, urinating often, even during the night
  • Urinary urgency, the sudden need to urinate
  • Urinary hesitancy, with delays in starting or stopping flow of urine
  • Blood in your urine, called hematuria
  • Bone pain near the prostate region
  • Unintentional weight loss

Diagnosis of a Recurrence

After your initial treatment for prostate cancer, you will continue care with your healthcare provider, likely a urologist who specializes in urinary tract conditions. They will monitor PSA levels to watch for any recurrence.

PSA Doubling Time

Prostate specific antigen is a protein produced by the prostate gland. The PSA test measures levels of this protein in the blood. Higher than normal levels can signal either prostate cancer or a benign prostate condition. After prostate removal (prostatectomy), PSA levels can signal that cancer cells are still present.

The PSA doubling time (PSADT) represents the amount of time it takes for the PSA level in the body to double. A faster doubling time may suggest a developing or fast-growing cancer.

The sensitive PSA test is able to detect a recurring prostate cancer when there are still relatively few cells. This microscopic level of detection is key for those using the PSADT to see if prostate cancer comes back.

When prostate cancer does recur, the PSADT can guide your health care team in developing a treatment plan. These plans will differ, depending on what kind of relapse you may experience.

Other Tests

They may want to do a prostate biopsy if the level reaches cause for concern or there are other signs of recurrence. A pathologist will view the tissue sample taken from the biopsy to see if cancer cells are again present. A digital rectal exam also may be part of your examination.

PSA Levels and Prostate Cancer Relapse

For people with relapsed cancer, the threshold to determine relapse will change based on whether surgery or radiation was used to treat it:

  • PSA levels drop to zero after surgery. The cancer has returned if PSA levels are over 0.2 nanograms per milliliter (ng/mL).
  • PSA levels are low but present after radiation. A relapse has occurred when the PSA levels rise 2 points higher than the lowest score achieved after radiation.

Imaging may be used to diagnose a prostate cancer relapse. These scans rely on positron emission tomography (PET) but may also include magnetic resonance imaging (MRI) or computed tomography (CT).

Some imaging tests used specifically for prostate cancer include:

  • Newer F18 PET bone scans that detect much smaller cancers
  • PET scans using axumin, C11 acetate, or choline
  • MRI or CT scans that can show any spread to pelvic lymph nodes

Types of Recurrence

Three different grades are used to describe prostate cancer relapse: low, intermediate, and high. Your treatment options will depend on which grade of relapse you experience.

Your healthcare provider also will consider the risk level determined at your original diagnosis when developing a treatment plan.

How Is Prostate Cancer Recurrence Treated?

Your treatment for prostate cancer relapse will depend on your PSADT and a number of other factors. Some relapses are so low-grade that no treatment at all will be required.

For example, someone with a PSADT of more than 12 months and a PSA level of less than 10 ng/mL may be monitored with repeat PSA tests. Or, relapse may occur in an older person whose life expectancy makes treatment unlikely or unnecessary.

Treatments for prostate cancer relapse may include surgery, radiation, and medication. Keep in mind that the treatment strategy is tailored to the level of relapse: low, intermediate, or high.

It also will depend on whether your initial prostate cancer was treated with surgery or radiation.

Low and Intermediate Risk

Radiation to the prostate bed, a common site for recurrent prostate cancers, may be a treatment strategy for people who were low or intermediate risk before their surgery.

People in these risk categories also are likely to have a PSADT doubling time of six to 12 months or less. Their diagnostic scans show no evidence that the prostate cancer has metastasized, or spread, to other parts of the body.

Hormone therapy is another treatment option, alone or after radiation. Lupron (leuprolide acetate) is the most commonly used of the hormone therapy medications, but others include:

  • Trelstar (triptorelin pamoate)Firmagon (degarelix)Zoladex (goserelin)Orgovyx (relugolix)

Hormone therapy medications work because prostate cancer cells need testosterone to survive. These drugs “starve” the cells by blocking the testosterone.

High Risk

People with prostate cancer relapse and a PSADT of less than six months are at much greater risk of the cancer spreading. Your healthcare provider will likely choose a more aggressive treatment approach as a result.

As with many types of cancer therapy, the earlier treatment is started the better it works.

Radiation therapy may be combined with Lupron hormone therapy for as long as 12 to 18 months in these cases. Other powerful drug options, including those used to treat prostate cancer that may have spread, include:

  • Zytiga (abiraterone acetate)Xtandi (enzalutamide)Taxotere (docetaxel)

In some cases, your healthcare provider may give you one or more drugs and then treat you with radiation a few months after the drugs are started. The radiation targets known sites where the cancer has spread. It also may target common sites of spread, such as pelvic lymph nodes and the prostate bed.

Milder Hormone Therapy

Sometimes, when people are older or more frail, they may be given mild forms of hormone therapy such as Casodex (bicalutamide).

There is often less difficulty with common side effects, which include:

  • FatigueWeaknessWeight gainBreast growth

Other Treatment Options

There are other treatment possibilities for prostate cancer, and researchers are working to advance these options for people with an initial cancer or one that recurs. These options include:

What Is Intermittent Therapy?

In some cases, hormone therapy drugs can be used at intervals in order to reduce the effects of having low testosterone. The PSA usually drops to less than 0.1 ng/mL within six months of starting therapy, so the drug treatment is then stopped. The drug is restarted after a “break” when PSA levels rise again.

  • Chemotherapy drug combinations
  • Cryotherapy, a treatment that relies on extreme cold to freeze tissue
  • Immunotherapy drugs, such as Provenge (sipuleucel-T) and Keytruda (pembrolizumab)
  • Targeted therapy drugs, including Olaparib (lynparza)

Summary

Prostate cancer relapse happens when your previously treated cancer returns. How it will be assessed and treated depends on your initial cancer diagnosis, whether it was treated with surgery or radiation initially, your recent PSA doubling time, and factors including age and overall health.

Your symptoms may be similar to your initial cancer, and techniques used to diagnose prostate cancer relapse can include blood tests, digital rectal exam, a biopsy, and imaging tests.

Your healthcare provider can assess your recurring cancer as low, intermediate, or high risk. There are different treatments for each group, including radiation, hormone therapy, and other medications.

A Word From Verywell

Treatment for prostate cancer relapse after surgery is never a one-size-fits-all approach. Be sure to follow up with your provider so that your PSADT times are closely monitored for signs your cancer has returned.

Frequently Asked Questions

  • Is the PSADT different from a Gleason score?
  • Yes, very much so. The Gleason score is used to grade, or describe, existing prostate cancers and how advanced they are, using a sample of cells removed in a biopsy. Pathologists examine the prostate cells under a microscope and assign a score from 1 to 5. The higher the score, the less the concern over prognosis and treatment.
  • Learn More:
  • How PSA Tests Differ From the Gleason Grading System
  • Is there a “normal” PSA level?
  • Yes—and no. Your levels may vary depending on age, level of sexual activity, what medications you take, or how much (and when) you engage in exercise, such as biking. Historically, a PSA over 4 ng/mL is associated with a higher risk of cancer, but some people with lower levels have cancer, and sometimes people with higher levels don’t.
  • Learn More:
  • Understanding Your PSA Results

Yes, very much so. The Gleason score is used to grade, or describe, existing prostate cancers and how advanced they are, using a sample of cells removed in a biopsy. Pathologists examine the prostate cells under a microscope and assign a score from 1 to 5. The higher the score, the less the concern over prognosis and treatment.

Yes—and no. Your levels may vary depending on age, level of sexual activity, what medications you take, or how much (and when) you engage in exercise, such as biking. Historically, a PSA over 4 ng/mL is associated with a higher risk of cancer, but some people with lower levels have cancer, and sometimes people with higher levels don’t.