Should I have radiation therapy?

FWIW, I was stage 2 unfavorable intermediate and had radiation (5 sessions of SBRT) with spacer gel in June 2024, along with six months of ADT. Starting in week 2, the side effects were tiredness (took naps in the afternoon for 2 hours), burning and slow urination (fixed with Flowmax for two months), and some mild discomfort in my prostate that took about four months to go away. The radiation side effects disappeared within 2-3 months. I've had no bowel or bladder issues in the nine months since. That doesn't mean I won't get SE's in the future. Also, I am taking 20 mg of Viagra every day for two years for blood flow. The side effects of ADT were far worse than the those from radiation. From what I've read, SBRT can also be a good treatment for lymph nodes.

Thank you for this information. Appreciate it.

Scott. If I were you I would have radiation. Living longer is a worthwhile goal. I am 40 months into my cancer treatment, G9, CR, had Robo and ADT and Erleada for a year. My PSA is still good which surprises my doctors some and they remark that I haven’t even had radiation yet. Hence, that is probably in my near future and When the PSA goes up, and if they recommend radiation, I am mentally ready for it. I am keeping my eye on the ball and the ball is extending my years as much as reasonably possible. Good luck to you.

johnernest, scottbeammeup and hbp are giving really good advice.
Scott's 5 fraction is an excellent option. Get opinions from several radiation oncologists. My unqualified opinion is that you need radiation to the right pelvic node be sure that the radiologist see the original imaging as well as the most recent. BRCA positive mutations are associated with more aggressive cancers.
ADT is amazing in the way that it shrinks the tumor.
With a equivocal node we were advised that if it disappeared on ADT it should be treated because the disappearance means that it was cancer. If the node did not disappear it would mean that it was not cancer and would not need treatment. Radiation is said to be whole prostate so you don't need worry about the tumor edges being missed with radiation.
Here I am arguing with your gut. I don't think you actually have a choice.

I was diagnosed at 62 in 2010. I found out I Had BRCA2 4 years ago. I had surgery in 2010 and 3.5 years later, it came back so I had salvage radiation. I was not put on ADT and 2 1/2 years later it came back. It’s come back two times since then, but the drugs I have taken have given me many years.

The only side effects I had from seven weeks of radiation was some incontinence after about five years. It has never become a major problem. I’ve never had to use more than one pad a day.

What I’m getting at is that fearing salvage radiation is not logical. It seldom causes anything but minor issues. In your case with BRCA2 it could make a lot of sense. In the PCRI conference last week this statement was made “ Seeds for metastasis were already there when surgery was done, waited to grow.” You want to kill those seeds With radiation and ADT if you can.

Now you can go on ADT and it will suppress the growth of those mini metastasis, Or you can do radiation and then wait until the metastasis come back years later. In both cases with a Gleason nine You should be on ADT for at least 18 months if not two years according to the NCCN.

As for using the PARP inhibitor, Some doctors recommend using it early to try and turn Off prostate cancer from the beginning. My oncologist has always downplayed my taking a PARP inhibitor, Because of it’s very strong side effects.

When My cancer came back after Radiation I was put on Lupron which kept me undetectable for 2 1/2 years. When it came back again And I became castrate resistant. I went on Biclutamide And it kept my PSA down for about a year. At that point, I went on Zytiga. It gave me another 2 1/2 years with almost no PSA rise. And then I went on Darolutamide Which has kept me undetectable for the last 16 months. When that drug fails me, I will start with a PARP Inhibitor.

You worry about radiation being an issue, in your case, I think it would be beneficial Since BRCA2 usually results in cancer, coming back over and over.

They told me in 2021 that my oligometastatic stage-4 cancer would become castrate-resistant in 18–24 months. I'm at 3½ years now, and there's no sign of it happening yet.

New drugs like the -lutamides have torn up the old playbook (I was put on Apalutamide together with ADT right from the start in 2021, per the findings of the TITAN study).

So yes, if you otherwise have a reasonable chance of living into your 80s (or beyond), it's worth it. The ADT side effects are annoying, but they don't keep me from leading a an almost-normal, joy-filled life, and my outlook is way better now than it seemed in 2021 when I had my first talk with the oncologist.

No mortality data collected more than 5 years ago counts any more, provided your care team follows the latest best practices and puts you on the newer drugs. And every extra year you survive gives you a better chance of living to see the *next* miracle treatment.

@johnernest

All good suggestions above. Not all radiation is alike. Built in MRI radiation machines such as the MRIdian or Elekta Unity use narrow margins of 2 mm vs 3-5 mm for other types of radiation machines. The larger the margins, the more healthy tissue exposed and the greater the toxicity and side effects. Here is a link to an article about the mirage randomized trial on how built in MRI reduced side effects SIGNIFICANTLY.
https://www.urologytimes.com/view/mirage-trial-margin-reduction-with-mri-guided-sbrt-reduces-toxicity-vs-ct-guided-sbrt
I had 5 treatments with the MRIdian in 2023. I had slight decrease in urination flow after my third radiation treatment but fixed quickly with Flomax. No other side effects.

Johnernest, I agree with all the great comments here, and I too, feel that the prolonged ADT is more of a concern than radiation. It’s really not bad if you have an excellent team well versed in the newest technology.
The 5 session SBRT - Cyberknife or MRIdian - is excellent.
Also, don’t discount the older EBRT( also called IMRT and other acronyms) of 25 -39 treatments. With your already present spread there could be other areas around the prostate and in the pelvic nodes which would be missed by SBRT since it only targets the gland and an area directly around it. Not disagreeing with anyone, just giving you a heads up should your RO mention it. Best
Phil

I wrapped up 28 sessions of EBRT on 12/31/24. Side effects (urgency and frequency of urination) started in mid-December and persisted for about a month after the end of treatments. Not a big deal for me, but every individual's experience is different.

I had 6 months of ADT (on Orgovyx) that just ended a couple of weeks ago. I found the side effects of the ADT more bothersome than the radiation therapy. Hot flashes and chills persist after a couple of weeks off the drug, but seem to be lessening. It's still "wait and see" on the sexual side effects. And I have about 20 pounds of fat to get rid of!

The side effects from radiation treatment for prostate cancer are real. Twelve months after my radiation treatment I had to go to the emergency room because I could not pee. That was seven years ago and now I still have strictures in my urethra and have to use disposable catheters to keep my urethra from becoming totally blocked. There are other issues, like leakage, no bladder sensation and penis pain. Supposedly, the probability for my issues was very small. I keep reminding myself that I am lucky but it has definitely required a big adjustment to my lifestyle.