Why PSA Monitoring Matters After a Prostate Cancer Diagnosis

Men newly diagnosed with prostate cancer face a range of treatment options, from robotic surgery and focal therapy to radiation and active surveillance. Because prostate cancer grows slowly, patients usually have time to learn about those options, get a second opinion and make a decision they are comfortable with, according to Dr. Manuel Ozambela Jr.

In an interview with CURE, Ozambela, a urologic surgical oncologist at Baptist Health Herbert Wertheim Cancer Institute (formerly Miami Cancer Institute), associate professor at the Florida International University (FIU) Herbert Wertheim College of Medicine and associate program director of the FIU and Baptist Health residency program, discussed recovery after surgery and focal therapy, how active surveillance works, what a rising prostate-specific antigen (PSA) level means and why speaking with patients in their native language matters.

This interview has been edited for length and clarity.

CURE: What treatment options are available for men with localized prostate cancer?

Ozambela: I'm a surgeon, so I manage prostate cancer surgically, and I work with colleagues from radiation oncology and medical oncology for multidisciplinary care. We offer the entire spectrum of prostate cancer treatments, including radiation and surgery. From a surgery perspective, that includes open and robotic surgery with multiple different robotic surgery platforms, including a single-port robot and multiport robots. I also have a big practice in what we call focal therapy for prostate cancer, which is a less invasive approach to treat prostate cancer in select patients with localized disease that meets certain criteria. We can do an organ-sparing procedure to ideally cure their cancer but minimize any functional consequences to their quality of life.

What is recovery like after robotic prostate cancer surgery?

Ozambela: The most common procedure we do would be multiport robotic prostatectomies [surgery to remove the prostate]. Those patients do very well. They stay in the hospital usually 23 hours. We tend to keep them overnight for observation to make sure their pain is controlled and they're walking and eating, and generally they go home the next morning.

They go home with a catheter, and that catheter usually stays in the bladder for one week. That's probably the most bothersome part for the patient. Once the catheter comes out, usually after one to two weeks, they're feeling pretty much back to normal. We advise patients not to do any strenuous activity or heavy lifting for approximately four weeks, and usually by four to five weeks they're 100% back to their presurgical baseline.

How is single-port robotic surgery for prostate cancer different?

Ozambela: Instead of using multiple small incisions, we do the surgery through one single small incision, and the recovery is very similar. Particularly for patients who've had a lot of prior abdominal surgeries, the single-port robot is a nice approach because the operation can be done in a space outside of the abdomen, so it avoids having to deal with the patient's intestines. We also don't have to put the patient upside down in what's called Trendelenburg position. During the anesthetic, the patient can be flat, and that's usually a little bit better for patients, especially if they have a higher [body mass index] or they have issues with their lungs.

What is focal therapy for prostate cancer, and what does recovery involve?

Ozambela: We offer two different treatments. One is high-intensity focused ultrasound, called HIFU. It's not for every patient. It's for well-selected patients that meet certain criteria. There are no incisions, and we don't remove any tissue. The patient is put under anesthesia, and we deliver the treatment through an ultrasound probe that goes in the rectum. We are able to target the part of the prostate that has the cancer in it while sparing the rest of the prostate. Those procedures are outpatient, so they go home the same day. We leave them with a catheter for five to seven days to give time for the prostate to recover from the swelling of the procedure. As soon as the catheter's out, they're back to normal. They don't have any restrictions. They can swim, exercise, what have you.

The other focal therapy that we do is called NanoKnife, or IRE, irreversible electroporation. It's delivered using needles instead of an ultrasound probe. Needles are placed into the prostate, and electricity is delivered between the needles, which allows us to treat or ablate [destroy] a certain portion of the prostate that we select based on the patient's imaging and biopsies. The recovery is the same. It's an outpatient procedure, they keep a catheter for five-ish days, and once the catheter is out, they're back to their baseline.

How do doctors help patients choose a prostate cancer treatment?

Ozambela: There's a big spectrum in terms of aggressiveness of disease, and there are a lot of different options, including surgery, radiation therapy and observation. When a patient first comes in with a new diagnosis of prostate cancer, it's our job to help them understand their risk. How likely is this cancer to continue to grow and spread and cause problems for this patient, or is this a low-grade cancer that can be safely observed? Then we walk them through all the different options and have an honest conversation about the patient's goals and risk tolerance. We look at not only the patient's health, like whether they're healthy enough for surgery, but also the cancer's characteristics, and that helps us guide the patient to what we think is the most appropriate option.

Sometimes there's not a perfect option. There's a couple of options, and we have to help the patient make that decision and make sure we select the correct treatment for the correct patient, versus treating everyone who walks through the door with the same exact modality. We try to personalize the experience so that the patient feels like they made a decision that they're comfortable with.

What are the goals of prostate cancer treatment?

Ozambela: There are two main goals. The first goal is cure. We want to cure you of your cancer. We want you to live a long, healthy life and put this cancer in the rearview mirror. But all the treatments for prostate cancer have side effects, so the second goal is to minimize those side effects so that the patient can have the best functional recovery that they possibly can, with good control of their urine and normal sexual function. Those are two big things that are impacted by prostate cancer treatment.

We don't only focus on curing the cancer. We also focus on what happens after you're cured. Our team is multidisciplinary. We have reconstructive urologists on our staff and men's health specialists who focus on sexual health and sexual medicine, so patients immediately get started on treatment for recovery of their function.

What does active surveillance for prostate cancer involve?

Ozambela: Active surveillance has become more common as we've understood more about the disease. Some prostate cancers are very indolent [slow growing]. Very low-grade prostate cancers grow so slowly that they don't have the ability to metastasize, meaning spread to the bone or the lymph nodes, and we know that we can safely observe them. The first step is helping the patient understand the distinction between a low-grade prostate cancer and what we call a clinically significant prostate cancer. Those are two different entities.

It's not like we say, "Hey, you're good. Come back as needed." We follow them closely. This involves checking blood tests every three months to track their PSA, getting imaging periodically to make sure the cancer is not progressing and often repeating biopsies. Patients go from surveillance to active treatment if their PSA is climbing quickly, their physical exam is changing, their MRI looks more concerning or a repeat biopsy shows that the cancer appears to be behaving differently.

Does delaying treatment on active surveillance affect prostate cancer outcomes?

Ozambela: There have been a lot of clinical trials that show that for patients who do deferred treatment, meaning instead of getting treated the first day they waited two years on surveillance and then got treated, the long-term outcomes from a cancer perspective are the same. They live just as long, and they don't die from their prostate cancer, but they got to live two extra years without the side effects of treatment. That's the benefit.

We also emphasize that from all these studies, we know that about 50% of men who start on surveillance eventually end up needing treatment. A lot of those men will eventually progress and need treatment, but we're able to defer that treatment for maybe three years, maybe five years. Some men maybe never need treatment.

Some patients are so uncomfortable with the knowledge that they have a cancer and they're not doing anything about it. After they understand all the risks, benefits and alternatives, they will elect to go ahead and have treatment, either surgery or radiation, even for a low-grade prostate cancer.

What does a rising PSA level mean for patients with prostate cancer?

Ozambela: For patients on active surveillance, if that PSA test is stable, meaning it's not rising, that's a good sign. If it's going up and up, then we start getting worried that maybe we underdiagnosed the cancer or the cancer is progressing. That will typically trigger another biopsy or imaging study, and if those demonstrate that the patient's risk of progression has increased, we may offer the patient definitive treatment, meaning surgery or radiation.

For patients who have already been treated with surgery, their PSA goes to zero and becomes undetectable. Once the PSA is undetectable, it becomes a very good surrogate for disease recurrence. We monitor that patient's PSA quarterly initially and then biannually thereafter. As long as the PSA stays below 0.2, or remains undetectable, we're very confident the patient has no evidence of disease.

If that PSA starts to climb, then we worry about what's called biochemical recurrence, meaning the PSA is telling us that the cancer may be back already. That may trigger additional imaging, like PET scans and MRIs, to identify where the PSA is coming from and whether the patient needs additional treatment, which might be radiation therapy or medications used to treat prostate cancer. The PSA is probably the best biomarker in oncology because it's so good at telling us response to treatment in patients with prostate cancer.

How does speaking the same language as their doctor help patients with prostate cancer?

Ozambela: Spanish is my native language. My family's from Cuba, and we have a big Spanish-speaking population here in Miami. I think patients often will seek me out for that reason. It makes communication much easier. They understand me better versus through a translator or communicating in English, where they may not totally capture the nuances of what's being discussed. There are a lot of options and a lot to talk about in these initial visits. Being able to talk to the patient in their native language helps tremendously. It builds confidence and a better relationship with the patient.

I think it lowers decisional regret. When you have five options and you choose one option and then you have a certain outcome that's not the outcome you wanted, you start thinking maybe I should have picked a different option when I had the chance. My hypothesis is that if you're able to communicate in the patient's native language, there's less decisional regret.

How much time do patients have to decide on prostate cancer treatment?

Ozambela: Prostate cancer is a slow-growing cancer. It's not a rapidly growing cancer, so patients have time to seek information, get educated on the subject, get multiple opinions and talk to a doctor they feel comfortable with. The first conversation I have with patients is often a teaching visit where I'm going to walk you through what this means and what your options are. In fact, I'm going to have you go see a radiation oncologist so you can get someone else's perspective, and then I want you to come back in a few weeks and talk about this one more time. You're going to have more questions, and we'll make a final decision in a couple of weeks.

Don't feel like you have to make a decision on the first conversation you have with a new diagnosis. Take your time, do your homework, go to a place you feel comfortable and get a second opinion if you need to. I certainly encourage that, even with my own patients. When you come back, we'll make a final decision, and you're going to feel better about that decision.

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