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Follow-Up

1. Follow-Up Investigation/Monitoring

The purpose of post-treatment follow-up of prostate cancer patients is to: 

  • allow early diagnosis of recurrent disease in patients who may be amenable to salvage treatment (e.g. post-prostatectomy radiation therapy, cryotherapy, or rarely, post-radiation therapy prostatectomy) or to early androgen withdrawal 
  • monitor for acute and late side effects of treatment 
  • provide outcome information for the treating oncologist or urologist.

Although it would be ideal, it is not usually possible for all follow-up to be done by the treating oncologist.  As a result, most patients will be referred back to their family physician or urologist for continuing follow-up, at some point after the treatment of their cancer is completed.

A.  Post- Radical Radiotherapy

  • 3-6 months after radiation therapy, to ensure acute side effects have settled (with the radiation oncologist). PSA is optional at this time. 
  • Every six months for at least five years. Initially with the radiation oncologist, later transferred back to the family physician. 
  • History & physical, digital rectal exam, and PSA should be monitored at each visit. 
  • Patients may require renewal of their hormonal prescriptions.
  • Other investigations (e.g. bone scans, prostate biopsies) only if clinically indicated or if required by a clinical protocol. 
  • Patients with biochemical and/or clinical recurrence may qualify for a clinical trial, and this should be discussed with the oncologist. Biochemical recurrence after radical radiotherapy is defined as three consecutive PSA rises from the nadir (lowest PSA level after radiation therapy) with a minimum value of 0.5 ug/L (ASTRO definition)22.  The nadir is typically achieved in 12-24 months after radiation therapy.
  • PSA "bounce" may occur 1-3 years after prostate brachytherapy with temporary rise of PSA to greater than or equal to 4 ug/L.
  • Long-term complications following radiation therapy are rarely severe but may include:
    • Urethral stricture may be seen in those who have had TURP or other urethral surgery prior to radiation therapy.
    • Urinary incontinence is very unusual (less than 1%). 
    • Changes in bowel habit and minor ano-rectal bleeding are common. 
    • Impotence can be a long term side effect.  This may be treated with medications or intracorporal injections as appropriate for each individual patient. 
    • Patients with chronic cystitis should be referred back to the urologist. 
    • Patients with severe ano-rectal bleeding or chronic proctitis should be seen by a surgeon or GI specialist.
  • Patients should be referred back to the Cancer Centre if their PSA rises to about 5ug/L to assess their eligibility for salvage therapy (e.g. cryosurgery, RP, ADT) or clinical trials.

B. Post- Radical Prostatectomy (RP)

  • Follow-up will be at the discretion of the treating urologist.
  • PSA is recommended at least every six months, but no other investigations are advised unless clinically indicated.
  • Patients with clinical and/or biochemical recurrence may be referred to the cancer clinic for consideration of radiotherapy or for an opinion on systemic treatment.
  • Biochemical recurrence after RP is defined as a persistently detectable PSA level at any time after surgery, or two successive increases to a level greater than 0.3 ug/L.

C. Known Metastatic Disease 

Patients who are on hormonal treatment or chemotherapy, and/or who are receiving palliative radiotherapy, will be followed at the cancer clinic as needed to assess the effectiveness of treatment. Otherwise, follow-up will be left in the hands of the referring physician(s).

Click the link below for Follow-Up Guidelines-Prostate Cancer, June 18, 2008.

2. Criteria for Referral to the Saskatchewan Cancer Agency

  • Radiation oncology
    • New histologic diagnosis of localized prostate cancer (from TURP, needle biopsy etc.).
    • Clinical (local or distant) or biochemical recurrence after previous radical radiotherapy or radical prostatectomy. 
    • Symptomatic local or metastatic disease.
  • Medical oncology
    • Clinical or biochemical progression while on systemic treatment.

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