Salvage radiation therapy after radical prostatectomy

Age 72 RP Aug 2022
Nov 2022 1st PSA 90 day postop .19
Called Persistent PSA and considered BCR.
Began Salvage Treatment February 2023 - 37 radiation treatments together with short-term ADT.
4 subsequent uPSA tests all undetectable < .02
Radiation side effects went away 2 - 4 weeks after radiation treatment ended. No additional side effects from radiation.
Now 74.
My understanding is that the sweet spot for Salvage treatment is PSA .2 - .4/.5
See SPPORT trial.
Seems that ADT may or may not be prescribed; some evolving philosophies and protocols.
Best to you with your choices.

Thank you for sharing your experiences with me. I probably will have radiation at some time, but I am still just watching PSA carefully. If PSA shoots up to around 0.2, I will probably do salvage radiation. It is good to hear that you seem to have no lasting side-effect from the radiation and that is got your PSA in check. I do have two questions however. 1) What is the SPPORT trial? Where can I find that? and 2) what kind of radiation machine was used? Perhaps a Varian True beam or a Varian Halcyon?

Thanks again for your reply. It was helpful in my overall decision-making process.

When I search "SPPORT trial", a number of articles appear, including one from NIH.
My layman summary is that radiation to both the pelvic bed (where the prostate sat before removal) and to the pelvic lymph nodes together with a course of ADT was the most effective treatment for my BCR. Now those are my words and I am not a Dr.
My Radiation Oncologist at Johns Hopkins recommended and treated me with 37 Radiation treatments (66.6 Gy) to the whole pelvic region and 25 of those treatments included the pelvic lymph nodes.
The radiation was IMRT at JH.
I also was prescribed a 4 mos course of ADT and I chose Orgovyx, an oral tablet.
Best wishes for successful treatment.

I had surgery in Dec-17, then salvage radiation around May of 2020 after two years of ADT. I had my local urologist recommend radiation of the prostate bed. I think Mayo would have suggested waiting a bit longer to see where a PET scan would have lit up to be more precise. In hindsight, I wish I had been seeing Dr Kwon at Mayo then ( transitioned over a couple years ago).

For sexual help, I use a vacuum devise for 20 minutes up to 3X a week, plus trimix injections about 1X a week to keep the blood flowing. I am actually using a lower dose of Trimix now than in 2018 (only 2 units out of a 100 unit syringe). For fatigue and mood from ADT, which I really don't have much, I credit diet and daily exercise.

I am wrapping up ADT and have slight leakage sometimes due to one or a combination of: when I stand or walk/hike too long (i.e., hiking rough terrain or standing for a couple hours at a party), drink too many fluids/caffeine/alcohol, and when tired, so I do Kegels 3X a day. My Dr. at Mayo told me his approach is to hold each Kegel for as long as you comfortably can 10X, 3X per day. I hope the leakage gets better after the ADT, but not sure what is driving it longer term.

No bowel issues. Lot's of fiber (i.e., 10-12 servings of fruit/veggies/nuts/beans/grains, etc. a day).

I wish you the very best of luck!

Also there is a webinar on the Prostate Cancer Foundation website (pcf.org) from Jan 2023 that discusses rising PSA after primary treatment of RP or Radiation that might be helpful.

So I've been reading this thread and I've spent hundreds of hours reading all kinds of info and discussions after being diagnosed 2 and a half years ago. One thing that always stuck out is you can tell there is quite a range in how much "homework" PCa patients did along the way. For example, there's a big difference typically between getting robotic surgery at a Center of Excellence from a surgeon with over 500 if not 1000 RARPs behind him versus a non-robotic at a smaller center with a less experienced surgeon. The same goes for Radiotherapy. Nowadays if you are getting conventional or moderately fractionated EBRT instead of SBRT (hypofractionated - 5 treatments 2 days apart) it's because you aren't going to a Center of Excellence. You can now even get SBRT for salvage radiotherapy to the prostate bed but this only became available I think in the last couple years at very few places in the country. Some Urologists probably don't even know it's an option now. Go read some studies on SBRT in both the initial treatment and salvage setting.

Also, doing a PSMA Pet Scan at less than 1.0 PSA (yes a 1 before the decimal not after) is a waste of time and money. It only has 60% sensitivity and so it will miss a lot. Anyone recommending it below that level is not very knowledgeable and/or is just trying to make more money for their center.

You should base your decisions on consulting with both a Urologist and Radiotherapy Oncologist and reading some applicable clinical studies yourself. I would only consult with a doctor listed on Castle Connolly. They are all the best ones in the country many of which were part of many clinical studies. Your life depends on their expertise so why not consult with the best?

I guess my main point is the experiences of individuals in this discussion can vary drastically from what yours will be as there is a huge range of variables for each individual. It is valuable for emotional support though to connect with other PCa patients. Base your decisions solely on the top specialists and recent study information, not anecdotal good/bad stories from people that may have had very different circumstances than yours.

Also, an ultrasensative PSA of .03 with a successive reading of 0.03 or above is confirmation of biochemical recurrence.
https://www.nature.com/articles/s41391-023-00646-6
0.2 has traditionally been the cutoff for most studies to be considered biochemical recurrence and still to this day is the level that triggers a recommendation from the Urologist for salvage therapy at most institutions. However many patients are choosing to proceed with salvage therapy at 0.05-0.1 since BCR is confirmed at .03. The only reason to delay after 0.1 is practically just to put off potential side effects of salvage radiation treatment which Grade 2 SE's for urinary and bowel are in less than 5% in most studies when using SBRT to the prostate bed with no Grade 3 (for patients with no pre-existing urinary or bowel issues.) If you already have urinary issues due to a poor surgical outcome and/or age-related then you would probably have a greater chance of side effects. In general patients that have persistent PSA > 0.03 90 days after surgery typically can wait until 0.2-0.4 to let their urinary function be restored to closer to normal to minimize the potential side effects of salvage radiotherapy. At those levels (PSA < 1.0) a PSMA PET scan would still be practically worthless. If you have one or more high risk features, Gleason 8+, persistent PSA after surgery, positive surgical margins, seminal vesicle invasion, extracapsular extension, I would seriously look into Whole Pelvic Radiotherapy (WPRT) or lymph node targeted followed by a SBRT Boost to the prostate bed.
https://www.frontiersin.org/journals/oncology/articles/10.3389/fonc.2014.00278/full
There was a European Doctor, can't remember the name that said they have found that the cancer doesn't recur in the areas within the field of radiation. So if they did Whole Pelvic, if the cancer returned it was going to be somewhere else such as the bones or other part of the body. Whole Pelvic comes with a higher chance of side effects though and of course increases the chance of other cancers developing later in areas that were irradiated but I don't believe the increase is very significant from what I've read. If you did early SRT to the whole pelvic area at 0.1 PSA or lower, you'd really be rolling the dice that the expanded field would catch anything that a scan wouldn't see in the pelvic area versus having unnecessary increase in side effects because typically at that low of PSA the recurrence is confined to the prostate bed and hasn't spread yet. I've seen reports of patients going very aggressive early such as doing ADT+ Doxatel+Salvage Radiation at PSA 0.1-0.2 to try to wipe it all out early. That's got to be pretty brutal to go through. But there is thought process that after surgery you really have only one more chance to fully eradicate the cancer so why not "go big or go home." Well, no one wants to endure serious side effects unnecessarily but the problem is there is no imaging that can show where micro metastases are.

In my opinion the earlier the better as logic dictates if you have confirmed recurrence the longer you wait to do salvage therapy the higher chance the micro metastases will spread outside the prostate bed beyond the field of radiation. They typically don't recommend it < 0.2 because of the studies that have shown adjuvant SRT months after surgery at PSA < 0.2 had no long-term benefit to waiting for >= 0.2. But I would prefer to error on the side of caution and get it over with sooner than later at PSA of 0.1. This is the level the Doctor I consulted with at UCLA about potential future radiotherapy recommended based on the theory sooner is better (Dr. Kishan). But if you are still healing from surgery, it's better to give yourself more time to get your urinary function back closer to normal. As far field of radiation and adjuvant hormone therapy it should be based on your post-surgery pathology and PSA dynamics and if you can afford it genomic testing such as Decipher. Also Xtandi alone or in combination with another ADT drug like Lupron (I would choose Relugolix over Lupron) has actually been shown to be more effective combined with SRT than the other ADT drugs but you have to have < 9 month PSA doubling time for approval to use Xtandi with Salvage Radiotherapy in non-metastatic PCa patients)

This was a bit of a ramble but wanted to throw this information out there as food for thought. If your Oncologist isn't aware of all this, that's a bad sign. The Xtandi with SRT I wouldn't be surprised though if many Oncologists aren't aware.
https://www.nejm.org/doi/full/10.1056/NEJMoa2303974

So after reading your comments, I’ve come away somewhat discouraged by the current state of salvage treatment. Unless I am reading this incorrectly, it sounds as if anyone receiving salvage radiation - myself included - has been sold a bill of goods.
PSMA’s are basically useless until the PSA is so high that metastasis is almost guaranteed? It’s only done at .2 to make money?
And unless we are all treated early and aggressively post surgery with drugs more powerful than Lupron or Orgovyx we are probably not going to “kill” this disease - if that’s even possible.
My doctor at Sloan explained the PSMA to me as not a diagnostic tool, but an adjunct to see IF, even at low levels of PSA, metastasis may have occurred. IT DOES HAPPEN.
He also told me that I would be irrradiated in the pelvic area as well.
What has been your experience with PCa and what treatment have you received? Thanks.

You could do a PSMA at a PSA of 1.0 and studies show it is 60% sensitive. The likelihood you would have detectable metastatic disease at the low of level is very low. But, if any out of pocket cost to you is not a big issue, it can't hurt. 60% isn't 0% so it could be valuable if something lit up in your pelvis (most likely a lymph node), I would definitely opt for Whole Pelvic Salvage Radiation instead of just prostate bed. I'm sure most doctors just want more info and not more money but 0.2% vs 1%+ the scan is not going to find anything outside the prostate bed. I believe in past years some Urologists didn't recommend salvage treatment until something showed up on a scan. This has completely changed. If you are doing whole pelvic I'm not sure why they would do a PSMA PET if you are < 1.0 PSA unless they would do additional targeted radiation if in the unlikely chance they found any spots outside the prostate bed. It seems the whole pelvic would cover the entire area where it would most likely detect something?

My understanding is yes, your salvage treatment is your 2nd and final chance to eradicate the cancer completely. It's a matter of data combined with expert advice combined with personal preference on how aggressive you want to be with your salvage treatment. Some may be very wary of potential lifelong urinary issues going aggressive when they don't have "bad" post surgical pathology and/or are older and may die from something else. Others may want to risk increased side effects to try to increase the likelihood salvage therapy is curative. It's a tough decision. Because of my young age I believe it's wise to lean towards the modestly more aggressive route.

At 53 years old I had a PSA of 31. Negative bone scan. Negative PSMA scan for cancer outside the prostate. 3+4 Gleason score with 20% grade 4. Cribriform (small) morphology (most Urologists won't even look for this even though it's a risk factor for recurrence), tumor was "medium" size (between small/medium/large) according to my Urologist.

I had robotic surgery by the Chief or Urology at University of Washington/Fred Hutchinson Cancer Care in Seattle. It was 90% nerve sparing even though other Urologists recommended unilateral nerve sparing as the tumor was mostly on one side. My surgeon said he'd make the decision during surgery. He's done over 1,000 of them. My post surgery pathology was good. No positive surgical margins (he got the whole tumor), no seminal vesicle invasion, no extracapsular extension. I did have perineal invasion which is a relatively lower risk factor for recurrence than the other things like positive margins. I did also get extended lymph node removal, think it was 12-15 lymph nodes in my pelvis. None of them had cancer. 90% of nerves spared - my urinary function was 95% back to normal a year later, 80% back to normal 6 months later, Erectile function is about 80% normal, I can get erections but hard to maintain them during sex. A 5mg dose of Cialis makes me as good as I was before surgery (if not a little better lol.)

I had undetectable PSA (< 0.02) for 18 months and it hit 0.02 a year ago. My last PSA was checked at about my 2 year point a little over 4 months ago and it was still 0.02. I have my next one next week (stressful). I am expecting it to be higher but fingers crossed (this is because 0.02 usually is 90% confirmation of BCR but centers use two successive at 0.03 or above as confirmation just to be sure as to not risk overtreatment.) My Urologist said at this rate if it keeps going up it could be 10 years before I reach 0.2. But I will get salvage scheduled as soon as I hit 0.05 or higher. University of Washington doesn't recommend salvage until 0.2. And as I mentioned my Radiologist who I consulted with all along the way when making treatment decisions said no problem waiting until 0.1. I am of the opinion the longer after confirmed BCR you wait the more time for micrometastases to migrate outside the prostate bed. There are no studies that back up any benefit of doing salvage at that low of a level but if I'm only doing prostate bed, being fully healed from the surgery, the only benefit to waiting would be having another couple years maybe of not having a small set back in urinary and erectile function from the radiation.

I will forego ADT with salvage radiation for a couple reasons. Studies have shown it has no to very little significant benefit for people with favorable post surgical pathologies like me and very slow PSA rise. My initial PSA of 31 does technically put me in the "high risk" group but the post surfical pathology findings add a lot more clarity as to your situation. The high initial PSA meant I'd probably have a recurrence but my post surgery pathology means I have a high chance of the salvage radiation being curative with no evidence of cancer on the margins of the removed tissue or in the lymph nodes. The other reason I would forego ADT is I believe personally it starts the cancer on a path of morphing to no longer being androgen sensitive. So I will save the ADT until much later if salvage therapy fails to buy me time in hopes of future more successful treatments being developed.

While I would forego Lupron or Orgovyx or Bicalutamide (forgive spelling errors) during salvage therapy, I am curious about maybe doing a short course of Xtandi during salvage as it has shown even by itself to be more effective than those other drugs. Unfortunately I wouldn't qualify for insurance coverage unless my PSA DT was < 9 months which it looks like it won't be but it could accelerate. Until recently Xtandi was really only used much later in the cancer progression.

I hear everything you’re saying and you sound EXACTLY like me as I watched my post surgical PSA slowly climb from 0.0 to .18 5 years post-op.
I badgered, cajoled and begged to start salvage treatment at .1. It’s obviously going UP, what are we waiting for??!! All the docs said NO; it could even be a few normal cells left over
from the nerve sparing surgery that were contributing PSA.
I was terrified by the idea of metastases occurring while the experts watched.
My RO at Sloan laughed out loud when I told him I WANTED the hormones. “I have to fight with men to get them to take them - they make all the difference!” But I knew I was down to my last at bat with this thing; if I didn’t kill it NOW, it was a lifetime of Xtandi or other really powerful, life altering drugs. I was placed on a 6 month course of Orgovyx combined with 25 salvage treatment of radiation - less than the usual 39 but at a higher dose for each.
The Orgovyx has not been a problem at all; side effects, but tolerable. PSA dropped to < .05 and T went from 610 to 5…in one month! Now in my second week of radiation.
I was 64 at diagnosis, Gleason4+3 with perineural invasion. Surgical pathology clean except for small break in capsule, which, my surgeon said was not significant since margins were negative.
I totally understand your aggressive stance given your age, etc. BUT, I don’t understand why you would forego a 6 month round of Orgovyx when it DOES weaken cancer cells significantly and makes them more vulnerable to the killing effects of radiation. If your Decipher score was low you probably DO NOT need them, but don’t know if you had this test. I did not over 5 yrs ago so I am taking no chances.
All the best in whatever course you take.
Phil