A radical prostatectomy is the surgical removal of the entire prostate gland as a treatment for prostate cancer. It’s a major surgery that has potential side effects, but also offers the best chance to cure prostate cancer that is confined to the prostate. After a radical prostatectomy, the prostate-specific antigen (PSA) levels in the blood usually become undetectable within a few weeks.
What is PSA?
PSA is a protein produced by both normal and cancerous prostate cells. PSA levels are used as a screening test for prostate cancer, along with the digital rectal exam. Higher-than-normal levels may indicate the presence of prostate cancer or another prostate condition.
After treatment for prostate cancer, PSA levels give important information about whether all of the prostate cells were removed during surgery and if any prostate cancer cells remain in the body. Very low or undetectable PSA levels after surgery indicate a successful operation.
How quickly do PSA levels drop after surgery?
PSA levels usually become undetectable within a month after a radical prostatectomy. It takes at least 6 weeks for PSA to clear from the bloodstream after the prostate is removed. Most men will have an undetectable PSA level when it is first tested 4-6 weeks after their radical prostatectomy.
Here is a typical timeline for PSA levels after surgery:
- Before surgery: PSA elevated, often >4 ng/mL
- 1 week after surgery: PSA decreases but still detectable
- 2 weeks after surgery: PSA very low but often still detectable
- 4-6 weeks after surgery: PSA undetectable,
PSA should continue to be undetectable after this point if all prostate cells were removed successfully.
What does an undetectable PSA mean after prostatectomy?
An undetectable PSA following radical prostatectomy is very reassuring. It suggests that:
- The entire prostate was removed successfully.
- No prostate cancer cells were left behind.
- Prostate cancer has been eliminated from the body.
However, PSA is not a perfect test. Even if postoperative PSA is undetectable, there is still a small chance that a few cancer cells were not removed with surgery. Additional treatments like radiation therapy may sometimes still be recommended after surgery despite an undetectable PSA. Doctors have to weigh the potential benefits of extra therapies with the risks of side effects.
How long does PSA stay undetectable after prostatectomy?
In men who are cured of prostate cancer, PSA should continue to be undetectable for the rest of their lives. Once the prostate is surgically removed, there are no prostate cells left to produce PSA. As long as prostate cancer does not recur, PSA levels should remain at zero.
PSA is monitored using ultrasensitive tests that can detect levels as low as 0.001 ng/mL (1 pg/mL). Even these ultrasensitive tests should not detect any PSA after a successful radical prostatectomy.
Can PSA levels rise again after prostatectomy?
Yes, PSA levels can sometimes start to rise again after initially becoming undetectable. This is known as a PSA recurrence. A PSA recurrence indicates that prostate cancer has recurred in the body.
PSA recurrence affects 10-30% of men in the first 10 years after a radical prostatectomy. There are two main causes of rising PSA after prostatectomy:
- Residual prostate cancer cells – Not all cancer cells were removed with the prostate, and remaining cells continue to secrete PSA.
- Cancer recurrence – Undetectable cancer cells outside the prostate spread and form new tumors that produce PSA.
Distinguishing between residual cancer cells and new recurrence is challenging. Both scenarios are possible, especially when PSA rises soon after surgery.
How quickly can PSA recur after prostatectomy?
PSA can recur at any point after radical prostatectomy, but earlier recurrences are more common. Here is the approximate timing when recurrences are likely to occur:
- 45% within 1-2 years after surgery
- 64% within 3 years after surgery
- 72% within 5 years after surgery
The rapidity of PSA rising again points to the likelihood of residual cancer cells versus new tumor growth. A fast PSA rise within the first year suggests remaining prostate cancer cells were left behind, while a slower rise after 2-3 years is more consistent with recurrence developing over time.
What PSA level indicates recurrence?
Any reliably detected PSA level, even as low as 0.01-0.02 ng/mL, is considered evidence of recurrence after a radical prostatectomy. This is well below what would be considered normal. Essentially, even a “whiff” of PSA is abnormal and suggests prostate cancer is still present.
However, PSA results can occasionally fluctuate slightly near the lowest detection limits. A single low PSA value by itself does not necessarily mean cancer is back. Doctors look for a definite upward trend over multiple lab tests before diagnosing a recurrence.
What causes PSA to rise again after surgery?
There are a few possible reasons why PSA may start to recur after being undetectable:
- Residual prostate cancer cells – Not all cancer was removed during surgery. Remaining cells continue dividing and secrete PSA.
- Cancer spread before surgery – Small amounts of cancer had already escaped the prostate gland but were undetectable at the time of surgery.
- Cancer recurrence – Years later, lingering cancer cells or micrometastases eventually begin growing and secreting PSA again.
- Benign prostate cells – Rarely, benign prostate glandular tissue left behind after surgery starts producing PSA again.
Distinguishing between residual cancer cells and new tumor growth is difficult. Multiple factors are considered including the speed of PSA increase and location of any tumors seen on imaging.
How is recurrent prostate cancer treated?
Rising PSA after prostatectomy requires additional treatment to attempt to eliminate remaining prostate cancer cells. Common options include:
- Radiation therapy – External beam radiation to the prostate bed area to destroy local cancer cells. Six months of hormone therapy is often added.
- Hormone (androgen deprivation) therapy – Lowering testosterone slows prostate cancer growth and PSA rise. Often used along with radiation.
- Surgery – Removal of lymph nodes or distant metastases may be possible if imaging locates tumors.
- Chemotherapy – Used for widely metastatic prostate cancer along with hormone therapy.
- Immunotherapy – Newer agents may boost the immune response against prostate cancer. Still being studied.
If prostate cancer recurrence is detected very early when PSA is still very low, radiation therapy offers the best chance for long-term cure. Once PSA climbs higher, hormone therapy and chemotherapy become more important to control the cancer.
Even if prostate cancer returns and PSA rises, results can often be improved for many years with additional treatments. However, recurrent prostate cancer is not considered curable once it extends beyond the pelvis.
What is the prognosis once PSA recurrence is detected?
The prognosis after PSA recurrence depends strongly on where any cancer spread is located and how extensively tumors have formed. Important factors include:
- Gleason score – Higher scores have worse prognosis.
- Time to recurrence – Faster recurrence indicates more aggressive cancer.
- PSA doubling time – Quickly rising PSA predicts poorer outcomes.
- Tumor spread – Prognosis declines once cancer grows outside pelvis into bones, etc.
Clinical studies have analyzed prognosis starting from the point when a recurrence is first detected by rising PSA:
- 5-year survival: 75-95% (excellent initial prognosis despite recurrence)
- 10-year survival: 54-70%
- 15-20 year survival: 20-47%
The overall 15-20 year prostate cancer specific survival after recurrence is 30-40%. However, outcomes for individual patients vary greatly based on the characteristics of their recurring tumors. Close monitoring and timely secondary treatments for recurrence optimize long-term chances.
Should PSA be monitored for life after prostatectomy?
Yes, nearly all doctors recommend lifelong monitoring of PSA levels after radical prostatectomy. Annual PSA tests are advised for at least 10-20 years after surgery. PSA monitoring allows early detection of any cancer recurrence while it is still potentially curable.
PSA testing every 3-6 months is standard for the first 5 years after surgery when recurrence is most likely to occur. Testing frequency can decrease somewhat after the first 5 years if PSA remains undetectable.
Any significant rise in PSA should prompt urgent evaluation and consideration of imaging tests and biopsies to determine treatment options. Catching a recurrence soon after it begins producing PSA again provides the best chance for successful salvage therapy.
Takeaways
- PSA levels typically become undetectable within 1-2 months after radical prostatectomy.
- Undetectable PSA indicates complete prostate removal and no remaining prostate cancer cells.
- 10-30% of men develop recurrent cancer detected by rising PSA within 10 years after surgery.
- A fast PSA rise suggests residual cancer while a slower rise indicates new tumor growth.
- Additional treatments like radiation or hormone therapy can control recurrent prostate cancer for many years in most men.
- Lifelong annual or biannual PSA testing is standard after prostatectomy to monitor for potential recurrence.
| Time after Surgery | PSA Level | Interpretation |
|---|---|---|
| Before surgery | >4 ng/mL (often much higher) | Elevated due to prostate cancer |
| 1 week after | Detectable but decreasing | PSA decreasing but not yet cleared |
| 4-6 weeks after | Undetectable, prostate removed successfully | |
| 6 months after | Still undetectable, no recurrence | |
| 5 years after | Rising to 0.2 ng/mL | Biochemical recurrence, requires salvage therapy |
Conclusion
PSA is an important biomarker to monitor for prostate cancer recurrence for life after radical prostatectomy. Undetectable levels for the first months and years after surgery indicate successful removal of all prostate cancer cells. However, PSA monitoring must continue because recurrent cancer will be signaled by any rise in PSA from its nadir of zero. Additional therapies can often control recurrent prostate cancer for many years if detected early when PSA levels are still low. While prostate cancer recurrence is common and cannot always be prevented, prompt action at the first sign of rising PSA provides patients with the best odds of long-term survival.