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Posted 10/15/2010 7:09 PM (GMT 0)

Two of my friends have experienced very late PCa recurrences.  One was about 15 years after SRT and the other was 17 years after BT.  Just how common is this?  Can anyone provide a link or some data about the frequency of late recurrences?  It seems that just about the time I get comfortable with my outcome, these things seem to crop up.

Carlos

Posted 10/15/2010 7:20 PM (GMT 0)
Carlos,
More common than I would like to see. It has always been my contention that 10 years studies are almost useless in prostate cancer. Very few men die of prostate cancer in the first decade after Dx. And that is good news for the median aged man at Dx. But for the guys well under that age, surviving prostate cancer is a different ballgame. My best friend here in Vegas has a father who is a survivor. He was diagnosed with an unknown Gleason in 1981 at the age of 54 and had a radical prostatectomy with orchiectomy. It was 29 years later earlier this year that it was discovered that his bladder was infested with the disease at Gleason 10. That is my longest time frame for relapse that I know of.

Tony
Posted 10/15/2010 7:57 PM (GMT 0)

Dr. Scardino has written on several occasions that biochemical recurrence after seven years is "rare."  For example:

 "Disease recurrence beyond the 7-year point is rare in our series.11"

The link to the entire article is:

http://jco.ascopubs.org/content/17/5/1499.full?ijkey=940fa0c330c55b370fb0581f462744ac77795689

Zen9

Posted 10/15/2010 8:25 PM (GMT 0)
Zen,
That study you quoted was completed in 1999 and set the basis for the nomograms used today by MSK. These nomograms have underwent many changes since this study including a 10 year probability of recurrence. The high end case in this study was 164 months and the median was 36 months.

Back to my statement in that this study is incomplete in referencing prostate cancer 11 years and beyond... And it has since changed quite a bit...

Tony
Posted 10/15/2010 8:59 PM (GMT 0)

Tony, Zen  Thanks for the replies and link.  From the link Zen provided, it would appear that if one's PSA remains undetectable for 5 to 7 years, it would be rare to have a recurrence.  As usual, high gleason scores seem to have a large impact also.  Again, thanks for the replies.

Carlos

Posted 10/15/2010 10:30 PM (GMT 0)

Tony,

As I clearly stated, Dr. Scardino has put forth his seven year rule of thumb on several occasions, not just the one paper in 1999.  That happens to be the only one I have bookmarked.

It is difficult to respond to the rest of your post, since you bounce back and forth between death from PCa and biochemical recurrence, which are too very different things (particularly to the patient smilewinkgrin ).  I understood Carlos to be asking about the latter.

Carlos,

I think your summary is a reasonably good one.  I would just add that - to state the obvious - "rare" is not the same thing as "impossible."  Hence Tony's 29-year example.

Peace,

Zen9

Posted 10/16/2010 12:28 AM (GMT 0)
According to this study not that common.

http://esciencenews.com/articles/2010/09/29/surgery.offers.long.term.survival.early.stage.prostate.cancer.patients

I don't know
Posted 10/16/2010 1:17 AM (GMT 0)
This topic is the hardest part of everything I have been through. I just passed the 1 year mark and am still in the 0 club (Thank God!). However, I never realized that this is an ongoing battle. I guess I thought having a prostatectomy was kind of like appendicitis--once it is out, it is gone forever. I try not to dwell on it, but over the months, the nagging fear is growing in my mind. The big complication for me is that I had a Gleason 9, though, no evidence that it escaped the capsule. Should I just get used to the idea that I will probably end up facing this again at some point in the future? I don't mean to sound morbid. I am just trying to wrap my mind around this new realization. Thanks for any insight. (I don't post very much, but I do check in and pray for guys that are really suffering. I guess I am not much of a "talker.")
Posted 10/16/2010 11:48 AM (GMT 0)
this is an interesting thread and obviously opinions vary as much as prostate cancer itself. It has been my contention from day one to just do what I can do to keep my self healthy and focused. There are too many studies out there for me to try and figure out. Thanks to you guys who do dissect them for us.

peace to you
dale
Posted 10/16/2010 11:52 AM (GMT 0)
Reedy

Did your dr. give you any idea of how much cancer you had. I also had RP at JH. I had tumor volume as moderate. Epstien told me it means not that much.  I have read that JH says measuring tumor volume is time consuming and difficult to do accurately. They also say there is. Not much prognastic value in it. I was just curious if moderate related to a volume cut off point like less then .5cc or something. Did your dr. elaborate on it?

Post Edited (ChrisR) : 12/28/2010 7:08:24 PM (GMT-7)

Posted 10/16/2010 12:38 PM (GMT 0)
First to Reedy: Welcome to one of the most helpful forums for info and support of a miserably confusing cancer.  Second: Congrats on the zero reading, and wishing you many more!  Third: My husband was thinking more or less the same thing: "I had cancer, they took it out, I don't have cancer anymore." 3 months of a great post Dx, pre-surgery diet and the addition of daily ground flaxseed has gradually slipped back to more red meat, higher fats overall, and rare flaxseed additions.  I've had to gently, then more firmly remind him that there are still prostate cells in his body, vulnerable to "going over to the dark side".  I would say to you what I say to him:  We don't know what will be coming down the pike, so we're going to welcome each day with gratitude and joy (and healthy lifestyle):-) and leave the future alone. Much easier to say than to do, but with what you and he have lived through so far, you can do anything you set your minds to...

Posted 10/16/2010 1:04 PM (GMT 0)
Thanks for the comments ChrisR. The only thing I see on my path report about volume is moderate. (The pre-surgery biopsy report show 40% cancer in one of the cores, if that helps answer your question.) My primary tumor was a 9 and the secondary one was a 6. Have you had much follow-up at JH? I haven't felt like that is a strong point for them--at least with my doc.
Posted 10/16/2010 1:09 PM (GMT 0)
Thank you for the encouraging word, NEIrish! You would get along great with my wife. Most days I am way too busy to think much about PCa, but strangely, every once in a while I wake up struggling with it. Maybe it has something to do with my one year anniversary. Anyway, I get what you are saying and give a hearty AMEN. My best to you and your husband.

PS Your comments about healthy lifestyle are right on. It is so easy to fall back into old (poor) habits.
Posted 10/16/2010 1:51 PM (GMT 0)
Not really any followup from them yet I did not have any problems.
Posted 10/16/2010 9:07 PM (GMT 0)
Most reoccurrances occur in the 1st 5 years. All treatment reoccurrance rates flatline or drop at 5 years with the exception of HIFU which remains steady. There is nothing I have ever seen that supports that reoccurrance rates rise at 5, 10, or 20 years regardless of treatment. The longer you go without a reocccurrance the less chance you have of getting one. There will always be some long term reoccurrances and I suspect that these are systemic and not due to any failed treatment. Some cancer cells excape into the bloodstream and depending on genetics, imune systems and lifestyle they at some point decide to grow. Since these are already outside the scaple or radiation beam at time of treatment they are not treatment related. If they were we would have many more cases of localized PC with long term reoccurrances.
A local reoccurrance occurs when prostate tissue is left behind or a positive margin leaves pc cells in the prostate bed. In radiation it occurs when the dose is not high enough or when there are dead spots in the delivery. These cells are left intact and continue to grow at their genetic programmed rate. These usually indicate themselves by rising psa within 5 years of treatment or as soon as the cell popluation grows enough to generate detectable psa.
JT
Posted 10/16/2010 9:23 PM (GMT 0)
The longest study I have seen is a Swedish study which ran for 20 years (and is still running as far as I know. The last aricle I saw that shows biochemical recurrence can occur at 20 years, but the majority of recurrences are in the first five years.

The one thing about this disease is that there is no certainty
Posted 10/17/2010 12:05 PM (GMT 0)
Thanks for all the great feedback on this topic. It has been very therapeutic. It seems to me that the bottom line is to take each day as it comes, live life to the fullest, and trust in God. Worrying never added a single day to anyone's life

post edited, removing scripture cite. Rule 11, which says, in part, Limited religious references are allowed (ie. "my prayers are with you" or a brief quote as part of a larger post), but the forums should not be used to convert others.

Post Edited By Moderator (James C.) : 10/17/2010 7:18:52 AM (GMT-6)
Posted 10/17/2010 1:07 PM (GMT 0)
moderator please edit the above post.
Posted 10/17/2010 5:46 PM (GMT 0)
John T (and anyone else):

OK, now I'm confused again. I put the question to the board about six months ago - rule of thumb (not carved in stone ...), everything else being equal, if you have biochemical recurrence within the first few years (as opposed to way down the road), is it more likely to be local or metastatic?

The answer I got was that other things being equal, early recurrences after surgery are more likely to be metastatic, later ones more likely to be local. Again, rule of thumb only. Some people responding included links to articles supporting that position.

I read your post as suggesting that early recurrences are more likely to be local, later ones more likely to be metastatic. Am I misreading your post? And in any event which is it? Anyone?

Thanks very much.

Zen9
Posted 10/17/2010 7:09 PM (GMT 0)
Zen,
There isn't a 100% answer only generalities. If psa doesn't go down immediately after treatment to levels that are considered curable then the reoccurrance is most likely systemic because psa is being generated elsewhere in the body and not in the prostate. Since about 30% of reoccurrances are cured by salvage therapies then we have to conclude that 70% of all reoccurrances are systemic. A local reoccurrance should always result in a rising psa with a short period after treatment, because cells are still growing in the prostate tissue. A systemic reoccurrance can lay dormant for years. I'm assuming that the vast majority of late stage reoccurrances are systemic because of how the cancer acts and most cases I have heard about entail wide spread PC.
JT
Posted 10/17/2010 7:56 PM (GMT 0)
John T,

Thanks for your quick response. So then you disagree with these representative answers I got to the same question posted earlier this year:

MichGuy (2/9/10): "Zen9, I haven't posted in quite a while, but I just saw your question wasn't really answered. My understanding is that the longer it takes for biochemical recurrence after surgery, the more likely it is that it is a local recurrence. It seems to me that a metastatic recurrence wouldn't necessarily have any timeframe relationship to surgery. So, if you have metastatic disease present, and then you have surgery, your PSA would drop as a result of the removal of the prostate, but your metastatic cancer would continue to increase PSA and be evident soon after surgery. On the other hand, if you didn't have metastatic disease, then after your prostate was removed, your PSA would drop significantly and any cancerous prostate tissue "left behind" would need time to grow to increase its PSA and become evident as a recurrence. This could take years perhaps, however it would still be local."

Casey59 (2/9/10): "MichGuy, you got it basically correct.

For this more detailed response, I refer to Dr Patrick Walsh's book, "Guide to Surviving Prostate Cancer", and specifically to the chapter "How Successful Is Treatment of Localized Prostate Cancer, and the sub-section on "What Should I Do If My PSA Comes Back After Surgery"...

Walsh references a study by Alan Partin which characterized men post-surgically prone to either local recurrence or distant metastases. Keep in mind that these were simply characterizations and not definative. The findings were:
Men prone to distant metastases generally have one or more of the following characteristics:

Gleason scores of 8 or higher,
cancer found in their seminal vesicles and lymph nodes during surgery, or
rise in PSA within a year after surgery.
Men more likely to have local recurrence of PC had one or more of the following:

Gleason scores of 7 or less,
no cancer found in seminal vesicles and lymph notes, or
increases in PSA several years after surgery.
--------------------------

I agree that the time-based element of MichGuy's response is basically correct; that is, the small amount of PC cells left behind locally may need some time to multiply enough times to produce measureable amounts of PSA in the bloodstream."

LV-TX (2/10/10): "So the short answer...if the psa comes back after being undetectable and there is no lymph node or seminal invasion, the disease can be considered local. This is the reason most surgeons want a psa test shortly after surgery, usually within 3 months."

Thanks again. I am really confused about this.

Again, the question is: all other things being equal, is a BCR years down the road more or less likely to be a local recurrence than a BCR shortly after surgery? I fully realize that each case is unique, I am asking statistically.

Zen9
Posted 10/17/2010 11:01 PM (GMT 0)
Zen,
I basically agree with what what everyone said when the reoccurrance is less than 5 years. For very long term reoccurrances I think it may be different. This is the reason for my thinking: If the reoccurrance were local then it would occur quickly, within years, because there has nothing that has been done to change the nature of the cancer cells. When cells circulate in the bloodstream it may take years for them to find a place to grow. I don't have any specific evidence to support this and I imagine that some very long term reoccurrances can occur locally.
It's an interesting question and it would be good to see some data on very long term reoccurrances.
JT
Posted 10/17/2010 11:08 PM (GMT 0)
John T,

I appreciate your quick responses, but I am still very confused. Probably just getting old ....

Anyone else care to weigh in?

Zen9
Posted 10/17/2010 11:14 PM (GMT 0)
This was published by the Mayo clinic:
Abstract
PURPOSE: Information regarding the clinical impact of delayed (5 years or greater) biochemical failure (BF) after radical prostatectomy (RP) is lacking. We undertook an investigation to differentiate the innocuous recurrence of serum prostate specific antigen (PSA) from that which heralds an eventual clinical failure (CF), and to determine if there is a period following RP when a patient is cured of clinical disease.

MATERIALS AND METHODS: Men with clinically localized prostate cancer (PCA) undergoing RP (1987 to 1995) were identified from our longitudinal PCA registry. Outcome measurements were based on the detection of post-RP serum PSA 0.4 ng/ml or greater, clinical identification of cancer recurrence and disease related death.

RESULTS: Following RP in 3,903 eligible men, 33% had a detectable PSA (median followup 8.8 years). Of these BFs 27% occurred after 5 or more disease-free years. Currently, 29% of all men with BF have clinical evidence of PCA, with 8% dying of PCA (median actuarial survival time from CF to death 9.8 years). Progression from BF to CF was not significantly altered by the disease-free interval (p = 0.544). A PSA doubling time less than 12 months significantly increased the risk of CF regardless of the interval from surgery. Risk factors for BF were significant throughout the duration of followup.

CONCLUSIONS: Patients are at prolonged risk for BF and CF following RP. Regardless of the timing of the initial PSA recurrence the PSA doubling time is the most powerful predictor of progression, stratifying patients with BF into high and low risk groups for CF.

PMID: 14532796 [PubMed - indexed for MEDLINE]


MeSH Terms, SubstancesMeSH Terms:AdultAgedAged, 80 and overCohort StudiesDisease ProgressionDisease-Free SurvivalFollow-Up StudiesHumansMaleMiddle AgedNeoplasm Recurrence, Local/bloodNeoplasm Recurrence, Local/diagnosis*Neoplasm Recurrence, Local/mortalityNeoplasm StagingProstate/pathologyProstate-Specific Antigen/blood*Prostatectomy*Prostatic Neoplasms/bloodProstatic Neoplasms/mortalityProstatic Neoplasms/surgery*Risk FactorsSurvival RateTreatment FailureTumor Markers, Biological/blood*Substances:Tumor Markers, BiologicalProstate-Specific Antigen
LinkOut - more resourcesFull Text Sources:Elsevier ScienceEBSCOOhioLINK Electronic Journal CenterOvid Technologies, Inc.Swets Information ServicesOther Literature Sources:COS Scholar UniverseMedical:Prostate Cancer - MedlinePlus Health InformationSupplemental Content
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Posted 10/17/2010 11:27 PM (GMT 0)
I'm beginning to change my mind about long term reoccurrances; here's a study from Germany published in European Urology:
Objectives: The ultimate outcome of patients after radical prostatectomy is often predicted from statistical projections of short-term follow-up. Only actual long-term follow-up can demonstrate true outcome.

Methods: One hundred thirty-one patients underwent retropubic prostatectomy for clinically organ confined prostate cancer and have been followed for a minimum of 22.5 years. Preoperatively, all but 12 had clinically palpable cancer.

Results: Overall survival in these patients was similar to an age-matched population, with 65% alive at 15 years, and 23% alive at 25 years. Thirty-seven percent of the patients recurred and 24% of all the patients died of prostate cancer. For patients with pathologically organ confined disease, 27% recurred, while those with extension outside the gland or positive nodes had an 83% recurrence rate. Although, the median time to recurrence was 7 years, recurrences occurred at a steady-state throughout the length of follow-up. Patients with higher grade tumors, even if organ confined, were significantly more likely to recur.

Conclusions: In a cohort of patients treated with radical prostatectomy for predominantly palpable disease, long-term follow-up (79% deceased) reveals that 37% will recur and 24% will die of prostate cancer. Almost half the recurrences occurred after 10 years, indicating that reports with shorter follow-up will underestimate the recurrence rate.
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