Salvage radiation decision: with or without hormone therapy?

I forgot to include a key piece of info in my post: I had a PSMA/PET scan done last week and it was negative for signs of prostate cancer. But again, my PSA is low (0.2) so that is the result my Oncologist expected. Again, my question is: radiation therapy + hormone therapy?

Did you get a Decipher test? That would give you an idea of the cancer’s inherent aggressiveness. ut I would probably get one or two second radiologist opinions and follow their advice.

A Decipher test sounds like a good idea. Thanks for the suggestion. My Oncologist is with Methodist Hospital in Mpls, and I'm going to get a second opinion from Mayo Radiation Oncology.

Had a recent PCRI conference they mentioned that salvage radiation was only successful in 1/3 of the cases. I know that for me after salvage radiation I got 2 1/2 years before I had a reoccurrence, so maybe that’s what they were referring to. I did have a 4+3 like you and was not given ADT..

It is most likely that micro metastasis would appear in the prostate bed before anywhere else, that’s what they do it.

If they find metastasis in the PET scan that you can treat with the SBRT, then treat it before you do the salvage radiation, it may not be necessary. See what happens to your PSA.

The NCCN recommends six months of ADT for somebody with your Gleason score.

In addition to PSA being so low, that a PSMA PET scan might miss any prostate cancers (as in your case), there are about 15% of prostate cancers that are “PSMA-negative” - they produce no PSMA such that a PSMA PET scan won’t see them, even though you know there’s a problem due to a rising PSA.

In those cases of PSMA-negative prostate cancers, the fallback is to use one of the older types of PET scans that aren’t reliant on PSMA - usually the Axumin PET scan or the C11 Choline PET scan (like Mayo Clinic uses).

If it were me, I’d get the other type of scan first before receiving radiation blindly, not knowing where the recurrence is.

The reason? —> Dr. Kwon (of Mayo Clinic) indicates that only 1/3 of men who have recurrence following prostatectomy have recurrence only in the prostate bed, and that they should not get salvage radiation there unless they’re absolutely certain of the location of recurrence. He says to first confirm where the recurrence is. (See Dr. Kwon’s presentation about recurrence: https://youtu.be/Q2joD360_pI). He talks about this topic specifically starting at about time 3:15 and ending at about time 4:35 of his presentation.

Having just finished SRT at Sloan I would advise radiation to the prostate bed AND pelvic lymph nodes - 30% failure rate in SRT comes from neglecting the lymph nodes.
Also, I chose to have 6 months ADT (even after another RO said it was not necessary) to give me a chance at a better outcome - no matter what all the ‘experts’ say about it being overtreatment. How many freakin times do I wanna play with this?!
You will ultimately decide what’s best for you; I was G4+3 unfavorable at surgery so I knew I was dealing with a tougher strain of PCa and I wanted to hit it hard. Only time will tell if I will succeed. Best,
Phil

SPPORT trial supports whole pelvic radiation treatment (WPRT) including pelvic lymph nodes together with short term ADT.

And that was my Salvage Treatment in 2023 at age 73 recommended by my RO at Johns Hopkins (and by 2 different ROs at JH for each of 2 friends).

I was G 9 with EPE postop and first PSA was .19. So some here on MCC would cite protocol of 18 - 24 mos ADT.

For me, so far so good: PSA undetectable at < .02

The radiation was arduous (IMRT 37 txs) and ADT, well, it just sucks.

And exercise (walking and light weights) during treatment is challenging and absolutely helpful.

For the last 2 years however I have been able to return to normal activities.

And I would do it all again.

Best wishes.

The FDG scan is a good one to use to find prostate cancer that doesn’t Produce PSMA. The C11 scan is only available at Mayo From what I’ve heard. According to documentation I’ve seen the FDG scan is actually the preferred one to use to detect prostate cancer that doesn’t produce PSMA

There is a question about Doctor Kwon’s Claim, that you shouldn’t have salvage radiation unless you were sure that the cancer is in the prostate bed, it is a tough one, because the cancer frequently can’t be seen for a long period of time. Part of it’s due to the fact that the PSMA pet scan can’t see metastasis smaller than 2.7 mm and in many cases smaller than 5 mm. Yes, between Kwon and the Scholz Discussion about the same issue in the last hour and a half of the PCRI conference in March makes one think they should wait to find out if there are metastasis that can be seen. Scholz was really emphasizing the fact that using SBRT to zap metastasis was working really well for his patients.

I know that for me having salvage radiation did give me 2 1/2 years before my PSA started rising again. Yes, a metastasis did show up way outside prostate bed, But it was at least five years after having the salvage radiation before that happened. When I think about what was mentioned in the March PCRI conference the statement made by one of the doctors “ Seeds for metastasis were already there when surgery was done, waiting to grow.” Sure makes one think that doing salvage radiation may not be a mistake because that could be a place where some future Metastasis could be appearing. It seems that most doctors are still doing savage radiation for most patients that have had recurrence after prostatectomy, It should be interesting to see if this actually changes.

I’ve read that the FDG (Fluoro-2-Deoxyglucose) PET/CT scan being glucose-based, is great for brain, lung, lymphoma, and some other cancers that gobble up glucose for energy, but for prostate cancers (which gobble up testosterone for energy), it doesn’t work as well unless the prostate cancer is very aggressive.

Drs Moyad and Scholz discussed this at a PCRI conference a few years ago: https://youtu.be/-PyqazlkpCE?si=IQ3BCWkZqVkloCiC

And Dr Scholz here: https://youtu.be/zwvGb8XGDqg?si=YKMym483RGQmzu0a

The Axumin (F18-Fluciclovine) PET/CT scan is different. The Axumin scan works by exploiting the fact that prostate cancers absorb amino acids at a much more rapid pace than normal cells. Axumin is made up of a radioactive tracer linked to an amino acid. Cancer cells absorb the amino acids more avidly than normal cells, so when Axumin is used, the radioactive tracer concentrates inside the tumor cells. When the patient is imaged, the areas that have a high concentration of the imaging agent signal the location of the cancer in the patient’s body.

All this stuff I’m learning, I hope I never have to use!

Interesting, I found this contrary information. Let’s make this complicated! Don’t we love it when the experts disagree.

For prostate cancer that doesn't produce much PSMA, FDG PET/CT is often a good alternative for imaging, according to UroToday.com and the National Institutes of Health. FDG PET/CT uses a radioactive tracer that highlights areas of high glucose metabolism, which can be indicative of cancer spread, even if PSMA isn't expressed. While Axumin and C-11 choline PET scans are also options, they may not be as widely available or as effective as FDG PET/CT in this scenario.