Can We Stop PSA Testing 10 Years After Radical Prostatectomy?
Loeb: The vast majority remain cancer-free
The key word is “undetectable,” and it’s close to the heart of any man who has had a radical prostatectomy to treat prostate cancer. Once a year, he goes to the doctor, gets a blood test, crosses his fingers, and waits to hear that word. Even though he’s getting a PSA test, his real hope is that there won’t be any PSA to show up on the test. PSA is made by the prostate, and after surgery, when the prostate is gone, all PSA - making activity should be gone, as well.
If the PSA becomes detectable (and it’s not due to a mistake by the lab, which can happen; this should be ruled out first), this is known as “biochemical progression.” If it’s going to happen, biochemical progression will most likely rear its head in the first few years after radical prostatectomy. Studies at Hopkins and elsewhere have shown that if the PSA remains undetectable for the first five years after surgery, it is unlikely — although still possible — that later biochemical recurrence will occur.
So, what happens after 10 years? You’ve sweated it out for a decade. Are we done yet? This is a question that Stacy Loeb, M.D, Ashley Ross, M.D., Ph.D., and Patrick Walsh, M.D., were curious to answer. If a man’s PSA remains undetectable for 10 years after radical prostatectomy, is he still at risk of recurrence? To find out, they studied the records of 1,593 men who underwent radical prostatectomy at Johns Hopkins, who had gone at least 10 years after surgery without recurrence.
So, what happens after 10
years? You’ve sweated it out for
a decade. Are we done yet?
While the vast majority — 94 percent — of these men remained cancer-free, biochemical recurrence later occurred in 6 percent of these men, more than 10 years after their surgery. This is called “late biochemical recurrence.” Note: This was more likely to be found in men who underwent surgery in the early years after PSA testing first became available, and in men whose cancer was more aggressive (involving the surgical margin, seminal vesicles, or lymph nodes). “The good news here is that these men did very well,” says Loeb. “Of the men who did recur, by 20 years after surgery only eight developed metastatic disease, and none died from prostate cancer. This study shows that if the PSA stays undetectable for 10 years after radical prostatectomy, there is an exceedingly low risk of later prostate cancer recurrence. In the few cases where late recurrence did occur, there was a very low risk of the cancer spreading to the bone, and no one died from prostate cancer. In the future, we may be able to tell men that it is safe to stop or decrease the frequency of PSA testing if they have made it 10 years after surgery without recurrence.”
One limitation of the study, Loeb notes, is that all of the radical prostatectomies were performed at a high-volume academic center, and the results may not apply to all centers. However, these findings are so encouraging, that, if confirmed, “annual PSA testing may be unnecessary after 10 years for men with a prostatectomy Gleason score of 6 or lower, and/or those whose life expectancy is limited due to age or other health problems.”
The Bottom Line:
No man with an undetectable PSA at 10 years died from prostate cancer within 20 years after radical prostatectomy. In this study, cancer returned in only 6 percent of men more than 10 years after radical prostatectomy. Of these men, by 20 years after surgery, only eight developed metastatic disease, and none died from prostate cancer.