Salvage radiation therapy after radical prostatectomy

Salvage radiation is considered to have about 2/3 success rate and side effects rated under 2-3% but many on the forum have reported more side effects which raises the thought if one is low risk (Gleason 7 and PSA-DT>12 months) to wait and watch? Feel for firespooks...

Both of my doctors, urologist and oncologist, agree. That the next treatment would be Lupron injections. But they want to wait until doubling time gets more frequent. Then I would possibly have another PSMA done. And maybe radiation if cancer is found in a different part of my body.

Can you ask them would it have been okay to wait and not do Salvage Radiation Therapy in 2013? or What would have been the outcome since your Gleason is 7 and doubling time is >12 months.

I’ve noticed, through my own research , that treatments and doctors’ recommendations were different back in 2013 than they are today.

Low versus high risk: the EAU analysis — The prognostic value of a biochemical recurrence following curative-intent treatment for prostate cancer was subsequently addressed in a systematic review of 77 studies conducted for the European Association of Urology (EAU) [57]. All of the 14 studies that compared biochemical recurrence versus no biochemical recurrence found biochemical recurrence to be an independent risk factor for the development of distant metastases, prostate cancer-specific mortality, and to a lesser extent, overall mortality. In the meta-analysis, among males undergoing radical prostatectomy, the main prognostic factors for distant metastases, prostate cancer-specific mortality, and overall mortality were a short PSA-DT (in most studies, < 12 months) and a pathologic Gleason score of 8 to 10. For males undergoing primary RT, the strongest prognostic factors for distant metastases, prostate cancer-specific mortality, and overall mortality were a short interval to biochemical failure (with most studies using < 18 months as the cutoff associated with an increased risk of clinical disease recurrence) and a biopsy Gleason score of 8 to 10.

These data prompted the EAU Prostate Cancer Guidelines Panel to propose a biochemical recurrence risk stratification system to predict which patients might progress after a biochemical recurrence [58]:

●Low-risk biochemical recurrence – PSA-DT >12 months and pathologic Gleason score < 8 after radical prostatectomy; interval to biochemical failure >18 months and biopsy Gleason score < 8 after RT.

●High-risk biochemical recurrence – PSA-DT ≤12 months or pathologic Gleason score ≥8 after radical prostatectomy; interval to biochemical failure ≤18 months or biopsy Gleason score ≥8 after RT.

The prognostic value of this risk grouping was externally validated in a series of 1040 males with a biochemical recurrence after radical prostatectomy [59]. After five years, metastasis-free survival was 99.7 percent in the low-risk group (95% CI 99-100 percent) and 86.7 percent in the high-risk group (95% CI 83.4-90.1 percent).

Despite the lack of prospective data validating the use of these specific risk groupings to decide whether and when to initiate salvage treatment, the EAU Prostate Cancer Guidelines Panel recommends offering close surveillance and possibly deferred salvage treatment to males with a low-risk biochemical recurrence [58]. They also recommend against offering early ADT to males with a low-risk biochemical recurrence. For a high-risk biochemical recurrence, restaging and early salvage therapy are indicated.

Clinicians still need to make individual decisions with individual patients. It is not always possible to defer initiation of salvage therapy in males with "low-risk" PSA-recurrent disease (eg, due to patient anxiety, a PSA-DT that is "close to" 12 months, or Gleason 4+3 = 7 disease rather than ≥8 on the pathology from radical prostatectomy). Careful use of intermittent ADT in males with a PSA recurrence is at least one way to balance the benefits and risks of salvage ADT.

Dear Friends...Thought I will give you an update...

I rechecked my PSA as I was scheduled to start Salvage radiation therapy. Last PSA reading came at 0.16
So the plan to is to hold off radiation for now and recheck PSA in 3 months. What I have noticed it PSA has been fluctuating and lab calibration could be an issue. It has ranged from 0.14 to 0.26 but more readings are below 0.2. Threshold to treat is above 0.2. Keeping fingers crossed.

Also, European data considers active observation in low risk group. (Doubling time >12 months, Grade Group below 4)

Thanks. Hope you all are keeping well.

I am concerned about when is “right” time to do radiation therapy after biochemical recurrence?
I am 75 and in good health. I had a robotic-assisted radical prostatectomy in 09/2020. I had right and left apex and left inferior non-limited (> 3mm) positive margins, however, no adjuvant radiation treatment. Gleason score was 3+4, pT2, pN0. My PSA history is: 12/28/20 & 10/08//21 < 0.1, 04/05/22 .05, 10/07/22 0.05, 03/30/23 0.06, 10/02/23 0.08, 12/26/23 0.11, 2/26/24 0.10, 3/12/24 0.09, 4/30/24 0.09, 9/28/24 0.11, 10/22/24 0.11. My Decipher score is 0.36 (low risk). I had a PSMA PET scan on 3/12/24 that found nothing.
Given these findings, should I undergo salvage radiation therapy (SRT), and, if so, when should I start? I fear that SRT poses inherent risk to urinary control, bowel function and e.d.. I already have e.d. from the prostate surgery; it is the other side effects (possibly, for the rest of my life) that I really fear. Does anyone know where one can find statistics for how many people suffer long lasting side effects after SRT?
My local radiation oncologist wanted to start SRT last spring. He felt that the PSA readings: 0.05, 0.06,0.08, and 0.11 constituted a biochemical recurrence. I postponed SRT until this fall because my next PSA readings: 0.1, 0.09, 0.09, 0.11 were generally stable and the PSA value was rather small (0.11). I met the same radiation oncologist in early October and he again wanted to start SRT. I recently got a second opinion from a radiation oncologist (from Mayo) who reviewed my case and suggested it was too early to start SRT and active surveillance was called for. So I postponed SRT until at least January 2025, when we will reconsider the course of action based on future PSA results. I feel that treating the recurrence too early leaves me open to possible side effects for a longer period of my life. On the other hand, I have read that undergoing SRT while the PSA is very low increases chances of eliminating the cancer.
I am sure many readers of Mayo clinic connect have faced this dilemma. Any advice or sharing of similar experiences would be really helpful to deciding if, and when, to start SRT. Thank you,

Dear friend...
First, my best wishes towards your journey...
Generally, PSA level above 0.2 are consistent with biochemical recurrence and fortunately, you are below that.
You also have favorable risk profile (Low risk), low gleason, long doubling time.
Your concern about salvage radiation therapy side effects are reasonable.
Radiation oncologist will look towards trying to cure but side effects are something else, they report it to be wide range, overall considered low but some do have significant. Unfortunately, cure is not free.
It then comes to individual choice whether you are comfortable monitoring or try to do early therapy.
My surgery was in Feb 2020 and last PSA is 0.19. My radiation oncologist did recommend therapy at one point but since it is below 0.2, he thinks it is reasonable to monitor. At some point, it looks like I will need it but I am avoiding as long as possible.
Best regards...

Hey Jackie, I totally get where you are. I hit the magical .2 myself a few months ago - 5 yrs post surgery.
I am currently on ADT for 6 months (not so bad so far after 3 months) and will have 25 sessions of radiation in about 10 days. I am impotent already from the surgery so it’s not a concern for me any longer😩
My scans were all negative ( no Decipher score) as my RO predicted they would be. I have the same fears as you but my fear of the cancer is worse….period!
To me - given my personality - it’s not a choice to wait; I am compelled to act sooner rather than later.
You may be different, less excitable and that may prompt your decision to wait. Your Decipher score is definitely in your favor - they did not have this in 2019 - but you still had a Gleason 3+4, which is not considered aggressive but in this gray intermediate area.
At age 75 it might be a coin toss since it could take many years to actually spread and something else could get you by then, right?
You seem to be closely monitored now so you are OK with waiting but if your PSA suddenly accelerates you will probably have to do something.
Best to you Jackie!

Good question. What’s best for me? I’m also 75 and had surgery three years ago. My cancer was diagnosed in one lymph node— 3+4. I have been monitoring this every three months. I rather do this than have radiation. Good luck your decision.