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Salvage radiation therapy after radical prostatectomy
Prostate Cancer | Last Active: Nov 13 8:13am | Replies (90)Comment receiving replies
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.
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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