prostate cancer- survivorship

Following treatment, patients should undergo ongoing assessments for treatment-related side effects, as well as preventive and general health care. Therefore, it is important for cancer specialists and primary care providers (PCPs) to clearly communicate who will take responsibility for the different aspects of cancer surveillance and thresholds for referral to back to specialty care. This may be done in the form of a treatment summary (from the treating providers to the PCP) or may be contained in the surveillance portion of a survivorship care plan. However, all clinicians involved in surveillance should refrain from duplicate evaluations (including prostate-specific antigen [PSA] testing or digital rectal examinations [DREs]).

In addition, general guidelines for the follow-up of cancer survivors, including encouragement of a healthy lifestyle, should also be discussed with patients. These include:

●Dietary modification towards micronutrient-rich and phytochemical-rich vegetables and fruits, low amounts of saturated fat, at least 600 international units of vitamin D daily, and adequate amounts of dietary sources of calcium (ie, not to exceed 1200 mg/day) per American Cancer Society Nutrition and Physical Activity guidelines for cancer survivors Detailed below. Dietary modification may also be associated with improved prostate cancer.

●Physical activity has been correlated with improved quality of life, decreased prostate cancer recurrence, and improved prostate cancer-related and overall survival, primarily in observational studies. Consistent with American Cancer Society Nutrition and Physical Activity guidelines for cancer survivors, survivors without physical limitations or contraindications should aim for at least 150 minutes per week of moderate-intensity exercise or 75 minutes per week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate and vigorous-intensity aerobic physical activity, which may include routine weight-bearing exercises.

Follow-up for recurrence — Most relapses after localized treatment happen within five years; however, late recurrences may also occur. Therefore, posttreatment follow-up of prostate cancer survivors is important.

●Repeat PSA testing – Surveillance PSA testing is used to detect prostate cancer recurrence after any form of definitive treatment or to monitor patients on undergoing observation (ie, active surveillance, watchful waiting). There is limited evidence to inform optimal surveillance intervals for testing. However, we concur with guidelines from expert panels, including the National Comprehensive Cancer Network (NCCN), and the American Cancer Society, which recommend PSA testing every six months for five years followed by annual testing.
All survivors with an elevated or rising PSA level after treatment should be referred back to their primary prostate cancer specialist for further follow-up, evaluation, and treatment if necessary. In lieu of an in-person referral, provider-to-provider discussion or electronic consultation with their primary oncologist may be more efficient.

●Digital rectal examinations – DREs should be performed annually after definitive therapy in patients who received radiation therapy (RT), which should be coordinated among providers so as to avoid duplicate examinations being performed. The DRE may be omitted after radical prostatectomy if the PSA is undetectable.

●Active surveillance patients – For men undergoing active surveillance, follow-up should also include repeat prostate biopsies, usually one year following the original diagnosis and then at selected intervals (eg, every two to four years) to monitor for evidence of progression.

Approach to the abnormal PSA — For men being followed by their PCP, a common dilemma is the approach to an abnormal PSA result and whether it represents recurrent disease (ie, a biochemical recurrence).

In interpreting any value, prior treatment should be taken into consideration:

●For patients treated by radical prostatectomy, any PSA level >0.2 ng/mL is abnormal and raises concern for recurrent or progressive prostate cancer. The approach to and management of these patients are discussed separately.

●For patients who underwent RT and who previously had a low PSA level ("nadir" usually <1.0 ng/mL), a rising PSA level, particularly >2 ng/mL from the nadir, indicates disease recurrence [95]. Men treated with RT (including both brachytherapy and external beam RT) may experience a rise in the PSA up to 30 months following the end of treatment, called a "PSA bounce." This rise is usually temporary and does not necessarily represent a recurrence.

●The evaluation of a patient with an abnormal PSA may include a nuclear medicine bone scan, biopsy of the prostate bed, PSA kinetic assessment (for doubling time as an indicator of disease aggressiveness), and/or cross-section imaging. Of note, for patients treated with radical prostatectomy, less than 5 percent are expected to have a positive bone scan when the PSA is below approximately 40 ng/mL.

DIET — Prospective studies of diet and chronic diseases have facilitated major advances in our understanding of the contribution of diet to the pathogenesis of disease . They suggest that changes in dietary patterns might help reduce the risk of many common diseases in the United States, including some cancers. The potential impact of dietary patterns upon prognosis in patients with cancer has also been widely studied, especially in survivors of breast and prostate cancers, with some data also available in colorectal and gynecologic survivors.

Prostate cancer — There appears to be an association between dietary fat intake and outcomes for men with prostate cancer. However, the impact of dietary interventions aimed at reducing fat intake on cancer outcomes has not been tested in the setting of large-scale clinical trials. Therefore, as in breast cancer, dietary change has not been uniformly recommended as part of the treatment strategy for men with prostate cancer.

A number of reports have evaluated the relationship between dietary factors and prognosis in men with prostate cancer. A 2008 review of the literature suggested that soy intake or consuming a low-fat vegan diet may have a favorable impact on prostate-specific antigen [PSA] or PSA doubling time. Other reviews suggest that high intake of saturated fat may be associated with an increased risk of prostate cancer progression, while a plant-based diet could be linked to a lower risk of progression.

Two prospective observational studies found that prostate cancer patients with higher intake of saturated fat had worse disease-specific survival or PSA failure after prostatectomy. In one of these studies, higher body mass index (BMI) and higher intake of saturated fat were both independent predictors of biochemical failure, whereas total caloric intake was not associated with prognosis. Other notable findings were that:

●Men who were both obese and consumed a diet high in saturated fat had the shortest biochemical failure-free survival (19 months).

●Men who were not obese and who consumed a diet low in saturated fat had the longest biochemical failure-free survival (46 months, p <0.001).

Key points of the recommendations include:

●Maintain a healthy weight and attempt weight loss if overweight or obese
●Adopt a physically active lifestyle engaging in at least 30 minutes of moderate to vigorous physical activity on five or more days of the week
●Consume a healthy diet, with at least five servings of fruits and vegetables per day and limited ingestion of processed foods and red meats
●Limit alcohol to no more than one drink/day for women and two drinks/day for men. more