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Cancer: Prostate Message Board

Cancer: Prostate Board Index

bwhitney, I think I can help with a practical explanation. Think of it this way as two scenarios...

(1) Surgery first option scenario — Surgery is generally considered for the low-risk cases where there is a strong belief (with as much supporting clinical evidence as is practical) that the cancer is fully contained within the prostate (organ confined). The surgeon fully removes the prostate during the operation, and the expectation that removing the prostate also removes the cancer. Visualize the surgeon's scalpel removing the prostate gland, and nothing else.

After surgery, the patient undergoes a series of PSA tests (for example, 6-weeks after surgery, 3-months after surgery, 6-month, 1-year...). If the cancer was indeed fully removed, the PSA result will be essentially zero. If it remains essentially zero, there is no further action required by the patient.

On the other hand, if there is a positive post-surgery PSA reading, then some of the PC has likely (unexpectedly) escaped the capsule of the prostate and was "left behind" after surgery...your words were "the cancer comes back." It doesn't "come back" per se, but it might be just a little bit left behind, perhaps immeasurable at first, but then over time the cells double, and double again, then eventually (either right away, or some time later) become measurable in PSA blood tests.

When this occurs, the typical next step is a radiation treatment to the prostate bed area to attack the remaining PC. Keeping in mind that this patient was originally low-risk and thought to have had the PC fully contained, the spread is probably slight and the follow-up radiation it typically very highly successful in suppressing the PC and driving the PSA down to an acceptably low level. However, even though the dose is lower than if radiation were selected as the primary treatment, the absence of the prostate results in the bladder and/or rectum being a part of the targeted field, possibly leading to other words, this solution doesn't exist without risks. The follow-up radiation treatment is known as "salvage therapy", also known as "Plan B." Of course, there are lots of variations to this "typical" case which can lead down other paths.

(2) Radiation first option scenario — Radiation used to be the "second choice" of treatments, mostly used for those too old or unhealthy to undergo surgery, or for patients with advanced PC cases for whom surgical removal of the prostate would not completely solve their situation. This is [U]no longer the case[/U], and with advances in radiation doses, targeting and other delivery advances, radiation therapy is also considered by many as a "first choice" alterative option for low-risk cases.

There are, or course, a very wide range of PC cases for which it is difficult to generalize, but I believe the 2nd part of your question seeks to address similar low-risk cases who have chosen radiation first over surgery, but have found that the radiation treatment (RT) does not succeed in fully suppressing the cancer. The RT measurement goal is to drive down the PSA to an acceptably low value, and have it stay there for a very long time or for the rest of the patient's life.

Keeping in mind the visualization that radiation impacts the "targeted" tumor, plus some (small) "margin" area around it, as opposed to the surgeon's scalpel. A salvage surgery is possible after RT, but it is reportedly done infrequently because it is more technically challenging (after radiation, the tissues become stiff), and because of a higher incidence of severe complications. A more specialized surgeon is needed/desired. A surgeon would probably only operate if, even after failing RT as the primary treatment, he still somehow thought the cancer was organ-confined. If the patient would have been an excellent candidate for surgery before undertaking radiation as the "first option", then the likelihood of successful salvage surgery is higher.

After radiation as the "first option", the more typical "Plan B" is probably hormone therapy, or cryotherapy (although the salvage results are generally not as good), or other solutions or combinations, largely because the PC is not likely, at this point, organ confined. Lots of possible variants.

Each case is unique, and depends on the personal circumstances which define the diagnosis...both the initial circumstances, and the subsequent "Plan B" circumstances. My reply is a combination of first-hand and learned knowledge. It got a little long-winded as I tried to be careful with words. Does this description help answer your question?

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