Can cancer come back if it is really gone?

I'm still trying to decide between prostatectomy, HDR brachytherapy, or HDR + IMRT. I'm not finding some information that would be helpful in my decision. If in some instances the cancer come back but it others it can't, I would naturally lean toward the one that keeps it out. So some questions:

1. If the cancer is still contained inside the prostate, and the prostate is surgically removed, can the cancer ever come back? Since the prostate is gone, I can't see how it would come back. I do know that sometimes we think it is gone, but there are still microscopic cancer cells left, but the question I'm asking is assuming the cancer is completely gone once the prostate is removed.

2. Same question regarding radiation - If the cancer is still contained inside the prostate, and the radiation is totally successful in eradicating the cancer can it come back after the radiation? In this case, the prostate is still there, so even though it was irradiated, could it later re-develop cancer (and is this likely?)?



Separately, if I choose radiation therapy, is the prostate left in good enough condition to actually function? Will it stay in place, even though irradiated? If so, this would seem to indicate that urinary function might be better after radiation than after surgery. Perhaps this is part of the reason that urinary and ED symptoms show up later for radiation therapy than for surgery.

I'm not yet sure if my cancer is contained, but my urologist thinks it may be. I've input my data into a tool somewhere that says the chance of it being outside the prostate is about 51%, but a very low chance of it being outside the immediate area around the prostate. For that reason, I'd like to make sure any choice I make will kill all the cancer in the immediate area.

Sorry to be so ignorant. I'm learning as much as I can as fast as I can. I do appreciate the help and feedback I'm getting here. I wish my the doctors I've visited were as accessible as you guyz are.

thanks,
Greg.

Greg,

As far as I could figure (and I went with surgery, so I may well suffer from "confirmation bias" or whatever the proper term for "justify what I did" is...)

IF it was "really" all there, it should be "gone;" Also one of the reasons I chose not to watch and wait. What I could find out from the available research implied that (given my age) I'd VERY likely get to a nasty one if I waited, and I opted to take it out while I was younger and more prone to recover, and it was small and boring and prone to hopefully be removed completely, resulting in, I hope, a "cure" - tell you in 10-20 years if that worked out.

People who have had radical prostatectomy with negative margins have, none the less, showed up later with "biochemical failure" or a relapse. I'm not clear how common that is, and it presumably means that something slipped by pathology (a margin was not really negative) or was not really contained at the time of removal. At that point, if it comes, you can go back and have the area irradiated. Still hoping I avoid that point.

As far as I understand from what I read, with a G7 you'll probably get scheduled for radiation as soon as you heal from RP if the margins are positive (ie, if they know they left some).

As far as I know, radiation is better at getting stuff "nearby" (in the prostate bed is commonly referred to) and the prostate more or less ends up as a mass of scar tissue. But let someone who had it tell you what that's like. Actually, several would be better - nobody's experience is the same.

My summation from a few months ago is that there are many options, and they are all bad. That applies regardless of the fact that some people get through treatment (surgical or radiation) with "no side effects" - results are not typical, your mileage may vary, etc.

99+% of us started out ignorant. Ignorance can be cured - you're doing that. Of course, the more you know, the more you know you don't know.

It is most likely to be gone after surgery. The cells sometimes migrate before treatment, though. There have been rare cases of pca coming back 25 years after surgery, I read.

If you have RT then the gland ends up as a lump of scar tissue, thus very difficult todo surgery in that area as healing of any wounds etc very complicated, may never heal in fact. Scar tissue also means ahrd for surgeon to tell what's what to remove right stuff without also removing more of the tissue around gland as well.

Also I need to honest here. my opinon is biased as I chose surgery as first treatment. one reason was that I wanted to have two strings to bow, ie surgery then RT as other order was not an option.

see:
cancerhelp.cancerresearchuk.org/type/prostate-cancer/treatment/radiotherapy/side-effects-of-prostate-cancer-radiotherapy
Alf

A client of mine had surgery nearly 16 years ago followed by 15 years of undetectable PSA. Then, earlier this year his PSA started to rise indicating cancer. He is now on hormone therapy.

As John T mentioned, PCa can take a long time to be detected. Thus a recurrance can also take a long time to show as well. In my client's case, it is obvious that some cancer was out of the surgical area and survived, then started multiplying to the point of being detected, albeit 15 years later. It is the same cancer, not a new cancer.

Last year my wife had a bout of breast cancer in the same breast where cancer was found and treated (lumpectomy, chemo, radiation, amd Tamoxifen) 16 years ago. However, her's was a new cancer, not a recurrance of the original cancer. Thus cancer can do very crazy things.

I have read of PCa cells finding homes in the bones and lying dormant for many years before growing. Also, many doctors (including Snuffy Myers and my own urologist) contend that PCa is so commom and so very blood borne that 50% of the men at age 50 have blood borne PCa cells that can be detected by a simple blood test. Meyers had a test done on his blood drawn from his arm and it showed PCa cells in the blood. This clearly indicated that the cancer was outside of the prostate. If any of the cells could find a new home and start growing, then the metastis would not have been detected nor treated by the original surgery or radiation.

Thus, when the surgeon or pathologist says they got it all, either from a clinical examination or a pathology showing all negative margins, what they are really saying is "we got everything we could see where we looked". There is never a guarantee that the cancer wasn't already systemic even when the Gleason was low, the tumour small, the PSA low, and the pathology favorable. Hence, as Zufus coined the phrase, the Twighlight zone.

Regarding the effects of radiation, I had HDR and IMRT. I discussed this with my rad-onc last week on my one year followup. He said that some of the cells (both benign and malignant) were immediately killed by the radiation and most (hopefully all of the PCa cells)many were mortally damaged, but not immediately killed. He said the life span of a benign prostate cell is about two years. If it has been unable to repair the DNA damage from the radiation it will continue to live for up to that time but will not function or multiply and then die. The PCa cell may continue to live, but also not multiply and thus is no longer a problem. He said PSA flare at about 2 years following the radiation is probably the inflamation caused by the cells finally dying and throwing off some PSA. He said as cells die they are mopped up by the lymphatic system and disposed of. The initial kill of cells at the time of radiation turns into scar tissue. In either event, after the kind and amount of radiation I had, there is little chance that the gland will ever again function, though there is a good chance that a very small amount of the cells will survive and function for some time. The same can be true of surgery. There is little chance that absolutely 100% of the prostate gland cells can be removed and allow other functions to continue.

Regarding John Ts' information about recurrance rates after 30-40 years, I don't think we will have very good information since most treatment is on men in their 60s and 70s and very few will be alive 30-40 years out to detect a long term recurrance or be of statistical importance. As we have more men treated in their 40s and 50s, if they are followed followed it still would be that recurrance after 30-40 years would take most of them past the normal lifespan and may not yield meaningful information.

HD_Rider,
This is one area where I differ from JohnT's wording. "Failed" is a defeatist term. having a PSA relapse after a therapy does not mean necessarily the treatment failed to help. We all hope that our treatments work to the point of permanent remission but that's a "failed" thought process. For many seeking total cure the term "fail" is if a PSA rises. For others "success" is disease control for a period of time or disease control that does not result in mortality.

So if someone wants a story to look bad they will take the statistics to mean something literal. But the glass is half full, too...

If SRT is only 30% effective does that mean that the 70% of patients were not aided by the therapy ~ absolutely not. In fact these patients will likely still die of something else other than prostate cancer.

Another note: The one article/excerpt I saw the 30% figures that where taken from patients treated in the late 90's early 2000's.

Things have changed drastically in the radiation world in that timeframe.

Tony

Sorry for my own interpretation but when I see a study on biochemical failure that's all it will mean to me. Not treatment failure. The object of treatment is not just to control biochemical failure.

At least in my eyes.

Tony

The term I've heard is biochemical recurrance (BCR) not biochemical failure.

I think surgery could perhaps be described as a failure if the first post surgery PSA was say 5 indicating that the surgery had not removed a massive bit of cancer (which would clearly have had to have escaped) Having a BCR several months or years after surgery indicates that the nasty cells that were left behind at surgery were firstly very small and secondly to a greater or lesser extent dormant.
I would even reckon that someone who stayed cancer free for say 15 years or so before having a BCR had perhaps been confronted with a second "attack". ie the prostae cells that were left behind at surgery were healthy when they were left behind, but some factor caused them to turn nasty at a later date.

Alf