11 May 2023

By Bernard Riley
Head of Telenursing and Supportive Care Programs

“Why are my PSA levels rising again, even though I’ve had my prostate removed? Does the speed at which my PSA is rising mean anything? How can I manage PSA anxiety?” These are all questions PCFA’s Telenursing Service frequently receive from men after treatment for prostate cancer.

PSA, or Prostate Specific Antigen, is a protein produced by both normal and cancerous prostate cells. Its primary role prevents semen from clotting so that sperm can “swim” freely. PSA can move from the cells into the blood stream where it can be detected using the PSA blood test. 

There’s a common misconception that once you’ve had your prostate removed, or undergone other treatment, PSA won’t be detectable anymore. But this isn’t always the case. We answer the most commonly asked questions to help you understand more about PSA levels after treatment.

What happens to my PSA after prostate cancer treatment?

You can expect different effects on PSA results with different treatments.

After surgery, the main source of PSA, the prostate, is removed and within 4-6 weeks the PSA is expected to fall to very low levels (less than 0.1) and often to an undetectable level.

After radiation therapy, PSA levels will drop steadily and may take 18 months or more to reach the lowest level (the nadir). Radiation therapy does not kill cancer cells right away. It may take a number of days or weeks of treatment before DNA is damaged enough for cancer cells to die. Then, cancer cells keep dying for weeks or months after radiation therapy ends. If you had hormone therapy at the same time as radiation therapy, the PSA level will drop much faster, approaching very low levels by 6 months.

Less commonly, men who have focal therapies, like laser treatments, HIFU, Nanoknife or IRE- PSA, may not be a reliable indicator of the effectiveness of treatment and may result in further investigations such as MRI and biopsy to determine efficacy.

What does it mean if my PSA starts to rise again after surgery or radiation?

In some cases, after surgery, your PSA may rise months or years later. We’re often asked where the PSA is coming from if the prostate has been removed. The most common reason is the PSA is being produced by prostate cancer cells somewhere else in the body. These cells may have been dormant for a period of time before beginning to produce a level of PSA detectable on a blood test. Less commonly, at very low levels there may be a protein misread by the testing technology as the PSA protein giving a false result or it may be caused by benign tissue at the edge of the tissue removed producing PSA.

After radiotherapy and brachytherapy, there can be a ‘PSA bounce’ in the first few years after treatment, where the PSA temporarily rises and then subsequently falls. This does not mean that the cancer has recurred and does not increase the risk of the cancer returning in the future.

If the PSA does continue to rise (e.g. 2.0ng/ml above nadir), this usually indicates that you still have prostate cancer cells in the body. Not all men who have a rising PSA will develop prostate cancer that affects their health, and further monitoring may be recommended.

Can my PSA results differ depending on what pathology lab I visit?

It can be beneficial to have your PSA testing done through the same pathology provider, lab or centre. While variations in PSA results can be small between pathology reports when these are used to change treatments or initiate further investigations it is important to consider if the PSA test was done using the same technology.

Different laboratories use testing technology produced by different companies. There can be advantages of using different testing kits and machines. Some detect PSA more accurately at very low levels but may not do so at very high levels.

Does the speed of the rise in my PSA indicate anything?

Yes, the speed at which the PSA rises is important. A PSA doubling time (PSA-DT) is a measure of consecutive PSA results which gives and indication of the activity of the prostate cancer cells. The more rapidly a PSA is doubling the more likely you are to need further treatment especially if your PSA reaches or approaches the threshold to commence further treatment. Your specialist will calculate your PSA-DT and there are various online calculators to do this.

If you PSA is taking longer than a year to grow it is an indication that at this time the growth is slow. If however, your PSA-DT is less than 3 months this may indicate more active cancer cells and warrant further investigation and or treatment

If my PSA rises after treatment, what’s next?

For those who have had surgery a PSA or biochemical recurrence (BCR) is defined as a PSA of greater than or equal to 0.2ng/ml. For those who have had radiotherapy a PSA recurrence is defined as 2ng/ml above the nadir (the post treatment lowest PSA level) or 3 consecutive rises in PSA.

However, if you PSA has risen above the detectable limit and rises on consecutive tests then your specialist may look to investigate this with a PSMA- PET scan which may be able to detect deposits of prostate cancer at low levels. As the PSA rises however the sensitivity and accuracy of this scan becomes more reliable.

For men who have had surgery, if the PSMA PET scan shows an area of activity then it may be recommended to have a course of radiotherapy to treat this area when the PSA rises to around 0.2ng/ml. For men who have had radiotherapy, there may be options to give further radiation if the cancer recurs outside the existing radiation area, commence hormone therapies to slow the growth or less commonly surgery to remove the prostate.

How can I manage the worry and anxiety I get before each PSA test?

Anxiety is a common and normal response to a diagnosis of prostate cancer.  It usually occurs when we feel a lack of control over a stressful situation, and cancer is well known to be one of the most stressful experiences we can have in life. Throughout a cancer experience, anxiety also tends to peak at certain time points – at diagnosis, the commencement of treatment, again at the conclusion of treatment, and particularly around the time for follow up scans or with regular PSA testing.

It is normal to experience a range of emotions such as fear and worry, increased irritability, difficulty sleeping, and difficulty with recurring intrusive thoughts. Whilst you can never completely get rid of these feelings when a scan or PSA result date is approaching, there are some strategies you can adopt that are known to be helpful.

Talk things through with your treating team, a Prostate Cancer Specialist Nurse, speak to other men who’ve been through a similar experience through a support group or PCFA’s MatesCONNECT program. Call PCFA’s Telenursing service who can help you understand your result and help you through these difficult moments. Our Prostate Cancer Counselling team also have a range of strategies to help you manage these stressful moments. It may also be helpful to:

  • Try to maintain your normal routine.
  • Keep your focus on the things that ARE under your control e.g. taking care of tasks around the home, and practical activities that keep you occupied.
  • Limit alcohol intake and aim to eat healthily. Reducing unhealthy foods such as refined carbohydrates and processed foods, and increasing your fruit, vegetable, wholegrains, and healthy fats intake, keeps your blood sugar stable and lowers the likelihood of mood swings and slumps in energy.
  • Increase your exercise if you can. When we exercise, we release pent up adrenaline and cortisol (our stress chemicals), and activate our endorphins (our natural painkillers and mood elevators).
  • Practice relaxation techniques. Our counselling team can help you with these.
  • Use distraction to good effect: Spend time with friends and family, get out into nature, clean out the garage, volunteer to help a friend, listen to talk back radio or your favourite music, do some gardening, play cards, read a good book, watch a good movie, or tackle a project.

Whatever your situation and questions, we are here to help. Please reach out with any questions either via phone or email.

Freecall: 1800 22 00 99

Email: telenursing@pcfa.org.au

 

References:

Al-Mansouri, L., Arasaratnam, M., & Gurney, H. (2021). Continuing cabazitaxel beyond 10 cycles for metastatic castrate-resistant prostate cancer: is there a benefit?. European journal of hospital pharmacy : science and practice, 28(2), 83–87. https://doi.org/10.1136/ejhpharm-2019-001955

Chapman, C. H., Burns, J. A., & Skolarus, T. A. (2019). Prostate Cancer Surveillance After Radiation Therapy in a National Delivery System. Federal practitioner : for the health care professionals of the VA, DoD, and PHS, 36(Suppl 1), S16–S21.

Greenberg, S. A., Washington, S. L., 3rd, Lonergan, P. E., Cowan, J. E., Baskin, A. S., Nguyen, H. G., Odisho, A. Y., Simko, J. P., & Carroll, P. R. (2021). Residual Benign Prostate Glandular Tissue after Radical Prostatectomy is Not Associated with the Development of Detectable Postoperative Serum Prostate Specific Antigen. The Journal of urology, 206(3), 706–714. https://doi.org/10.1097/JU.0000000000001793

Odisho, A. Y., Washington, S. L., 3rd, Meng, M. V., Cowan, J. E., Simko, J. P., & Carroll, P. R. (2013). Benign prostate glandular tissue at radical prostatectomy surgical margins. Urology, 82(1), 154–159. https://doi.org/10.1016/j.urology.2012.12.063

Van den Broeck, T., van den Bergh, R. C. N., Briers, E., Cornford, P., Cumberbatch, M., Tilki, D., De Santis, M., Fanti, S., Fossati, N., Gillessen, S., Grummet, J. P., Henry, A. M., Lardas, M., Liew, M., Mason, M., Moris, L., Schoots, I. G., van der Kwast, T., van der Poel, H., Wiegel, T., … Mottet, N. (2020). Biochemical Recurrence in Prostate Cancer: The European Association of Urology Prostate Cancer Guidelines Panel Recommendations. European urology focus, 6(2), 231–234, https://doi.org/10.1016/j.euf.2019.06.004

https://uroweb.org/guidelines/prostate-cancer/chapter/treatment

https://prostatecanceruk.org/prostate-information-and-support/treatments/follow-up-after-treatment

PCFA’s Understanding Series- Advanced prostate cancer, Surgery and Radiotherapy