BCR Prostate cancer. Need Opinions

Thank you! I appreciate your feedback. Man what a trip!

I’m going with web265. I had 25 salvage tx and 6 months Orgovyx. Just finished everything about 6 weeks ago. Feel great - fatigue less every day - SE’s wear off quickly with Orgovyx,
Also agree with jeffmarc that I would do the radiation and ADT now while it is still in the prostate bed and pelvic lymph nodes, hopefully. Be sure your radiologist is going to radiate those pelvic nodes since any salvage radiation treatments usually fail for failing to treat the pelvic node area.
If you wait for your PSA to get much higher and it gets out of the localized bed and node area, it could spread to areas that are completely unknown, and there will be no way to have salvage radiation. At that point if metastasis flare up you’ll only be able to play whack-a-mole with SBRT and that’s certainly no fun.

Greatly appreciated! I am leaning towards Radiation for sure.

I had BCR / Persistent PSA .19 90 days after RP.
My Salvage Treatment was 37 IMRT radiation sessions (66.6 gy) and 4 mos short term ADT Orgovyx.
As others have written, I would have radiation to the whole pelvic floor region and pelvic lymph nodes (see SPPORT trial).
ADT seems to have evolved into a judgement call. I had it, but I was G 9 w/ EPE. I treated at Johns Hopkins .
A friend who is 5 yrs post RP just began salvage radiation treatment w/out ADT at a COE.
Best wishes on your choices.

Thank you for your wisdom! Greatly appreciated!

Hope my side effects go away in 6 months. I m on ADT til April depending on PSA then. The nap, hot flashes, joint pain, weight gain are exactly what I have to deal with daily. GOOD ADVISE for everybody.

Thank you. All the best!

Only because you are 22 years away from your RP and have a 67 month doubling time, with a negative PSMA, it is not clear to me why all the PCa cells are in the prostate bed and not more likely elsewhere. While I appreciate that standard BCR protocol includes radiation to the prostate bed, you are not the typical BCR patient and 12 years removed from the timeframe that salvage radiation is typically used for BCR.

Therefore, I would go with @jeffmarc’s recommendation of taking Orgovyx, unless two different doctors could convince me with data that the PCa cells are likely confined the prostate bed and that radiation therapy has the potential to be curable or a significant life extension over only Orgovyx.

Interesting thank you so much!

Well, with the clinical data you describe, doing nothing, or what I call actively monitoring through continued labs and consults is an option. I mean GG1, GS 6....

You can plug your lab values into MSKCC nomograms to gather additional data in making a decision - https://www.mskcc.org/nomograms/prostate

You can image with a PSMA PET, it may or may not locate recurrence.

If after gathering all the additional clinical data and discussing with your medical team, the decision is to treat then you have choices:

the PSMA PET is positive, you can do SBRT only to the identified location(s) and then see what happens. There is discussion about SBRT used as Metastatic Directed Therapy delaying the need for systemic (ADT) therapy. Think of it as "spot welding" or "whack a mole."
You could add short term ADT to the SBRT- as others have said, use Orgovyx vice say Lupron. The advantages are:
No flare
Faster to castration
Higher sustained castration rates
Lower CV side effect profile
Faster recovery of T when stopping
No trek to the doctor's office to get the shot, of course, if you get the six months shot vice say a 90 day one...

It does require self-discipline to take it every day and there may be financial toxicity associated with it depending on your insurance. The side effects of no T are familiar, the severity is the question. I've done both, Lupron and Orgovyx, going to say qualitatively, the severity of the side effects were less with Orgovyx.

If the PSMA PET is inconclusive, what then?

Well, back to the do nothing option,,,
Or,,,
You could do radiation to the prostate bed only- SRT
You could include the WPLN with the SRT to the prostate bed.
You could either of those and include short term systemic therapy

Another factor is life expectancy, some studies point to eight years or more before metastases develop.

I have had SRT, WPLN and SBRT, zero side effects, testimony to the advances brought about by medical research in planning and delivery of radiation as well as my radiologist and her team.

Keep in mind statistics, Bell Curve, Standard Deviations, Mean, Mode, Average, Linear Regression. There are guidelines such as the NCCN, AUA. they are based on science but are population based and may lag behind data emerging from ongoing medical research.

The art of medication is applying the science to your PCa.

I can't "tell" you what to do, that's a discussion between you and your medical team. There is no "right" decision from my experience, only good decisions based on the clinical data and the tradeoffs between one decision and another. When faced with a decision, we can easily get mired in "paralysis by analysis...!"

If that was my clinical data, I would do nothing, continue to do labs and consults, wait for a definitive rise in my PSA, three or more consecutive ones spaced three months apart, image between .5-1.0, then decide. In the interim, I would just go about my life, free of the side effects of ADT!

Kevin