Options for Salvage Treatment After Failed Proton Therapy for Prostate Cancer

For prostate cancer stage 2b, if proton therapy has failed, what alternative treatments are available?

1.
I am 63 years old, diagnosed with prostate cancer T2b, grade group 2 (the measurable tumor is 1.3 cm, but there are scattered cells with approximately 80% on the left side and none on the right side).
My doctor suggested options including surgery, proton therapy, or CyberKnife.
2.
I later decided to undergo proton therapy.
Before treatment, my PSA was 10, and after three follow-up tests, the results were 6, 4, and 5.2 respectively (I am unsure if driving for over four hours and walking for about two hours the day before could have affected these results).
I chose proton therapy due to my fear of surgery.
However, my PSA increased abnormally in the third test, and my doctor assessed that there is a possibility of treatment failure.
Therefore, I received my first dose of ADT on January 19.
3.
I would like to ask Dr.
Lin what other salvage treatment options are available besides ADT.
Given that there may be adhesion issues after radiation therapy, I am uncertain about what other suitable options exist.
Foreign literature suggests that CyberKnife has fewer complications.
What is your opinion? Thank you! Happy New Year!

Mr. Yu, 60~69 year old female. Ask Date: 2024/02/09

Dr. Lin Wenxu reply Urology

Dear Mr.
Yu,
1.
The benefit of radical prostatectomy (surgery) is that all the tissue is removed, allowing for a more definitive pathological report (staging), but the risks are higher.
2.
High-intensity focused ultrasound (HIFU) has a lower risk, but preoperative prostate curettage may be necessary to avoid postoperative urinary retention requiring catheterization.
The cost of the procedure is relatively higher, and since not all tissue is available for evaluation, accurate cancer staging cannot be obtained.
3.
If you wish to have a chance for curative treatment (complete tumor eradication), surgical resection or HIFU may need to be considered, as androgen deprivation therapy (ADT) can only control the disease but does not achieve a cure.
Sincerely,
Dr.
Lin Wen-Hsu
Department of Urology, Nantou Hospital

Reply Date: 2024/02/09

More Info

After undergoing proton therapy for prostate cancer and experiencing a rise in PSA levels, it is understandable to seek further options for salvage treatment. In your case, where you have already initiated androgen deprivation therapy (ADT) due to the potential failure of the initial treatment, there are several avenues you can consider.

1. Surgical Options: One of the most definitive treatments for recurrent prostate cancer is surgical intervention. A radical prostatectomy can be performed, although it is more complex after radiation therapy due to potential scarring and tissue changes. This option may provide a chance for complete removal of any residual cancerous tissue, but it carries risks such as urinary incontinence and erectile dysfunction.

2. Salvage Radiation Therapy: If surgery is not feasible or if you prefer to avoid it, salvage radiation therapy is another option. This can be particularly effective if the cancer is localized. Techniques such as high-dose-rate (HDR) brachytherapy or external beam radiation therapy can be employed. However, the timing and specific approach depend on your individual circumstances, including the PSA level and the extent of the disease.

3. Focal Therapy: Emerging treatments like HIFU (High-Intensity Focused Ultrasound) can be considered. HIFU is less invasive and has been shown to have fewer complications compared to traditional surgery. It targets specific areas of the prostate and can be an option for localized recurrence.

4. Clinical Trials: Participating in clinical trials can provide access to cutting-edge therapies that are not widely available. These may include novel systemic therapies, immunotherapies, or combination treatments that could be beneficial in your case.

5. Combination Therapy: Some studies suggest that combining ADT with other treatments, such as radiation or newer systemic therapies, may improve outcomes. Discussing the potential for combination therapy with your oncologist could lead to a tailored treatment plan that addresses your specific situation.

6. Monitoring and Supportive Care: If you choose to continue with ADT, regular monitoring of PSA levels and overall health is crucial. Supportive care, including lifestyle modifications, nutritional support, and psychological counseling, can also play a significant role in managing the side effects of treatment and maintaining quality of life.

7. Consultation with Specialists: Given the complexity of your case, it may be beneficial to consult with a multidisciplinary team, including urologists, radiation oncologists, and medical oncologists. They can provide a comprehensive evaluation and help you weigh the risks and benefits of each treatment option.

In summary, while ADT is a critical component of your treatment plan following the failure of proton therapy, there are several salvage treatment options available. Each option has its own set of benefits and risks, and the best course of action will depend on your specific circumstances, preferences, and overall health. Engaging in an open dialogue with your healthcare team will ensure that you make informed decisions that align with your treatment goals.

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