Salvage radiation decision: with or without hormone therapy?

...per Dr .Kwon's referenced PCRI.org Conference comments the choline based PET-CT scan is only available at the original Rochester campus of the Mayo Clinics. It has to do with the radioactive short life of choline. They produce it themselves; I suspect the other methods can outsource their radioactive tracers.

Is Mayo using PSMA and C11 imaging? My doctor thought Mayo is starting to use PSMA technology more as it improves.

Yes, yes, yes!! I totally agree that the seeds of metastasis were probably already there - meaning in the bed and the nodes.
How can these experts advise someone to wait for it to spread outside the area, so badly in fact, that it can be seen on a PET scan?! And if that one can be seen how many other unseen ones are getting ready to reveal themselves?
This is what I meant, Jeff, when I said I found Scholtz cavalier in his views. He downplays many things which seem crucial for successful treatment and all the videos I’ve watched have only left me with more questions than answers….sorry to rant…
Phil

I don’t know if you’ve noticed, but I’ve had a hard time telling people not to get salvage radiation and to wait for the metastasis to show up. I’ve mentioned it as an option, but not as a replacement without talking to their doctor.

I ,like you, am not 100% comfortable with it. Too Many mini metastasis could be there.

I agree, I never wanted to comment about Scholtz videos since many people really like him and follow his recommendations, but to me many things sounded more like "promo" videos for his practice and rubbed me the wrong way. He is an expert in his field but something about his nonchalant comments about some issues just do not sit well with me.

Yup…He and his sidekick questioner engage in a blowsy back and forth that’s more a scripted routine than a frank discussion…and those neckties??! Ugh!

Well, more clinical data could assist the forum in responding.

Pathology report
PSA results - you lost two but usually after surgery they are every three months for the first two years. That will also provide PSA doubling and velocity.

You say the PSMA PET was negative, statistically, you had a 1/3 chance of it locating any recurrence at that PSA.

Does a negative PSMA indicate no systemic activity, not necessarily, there may be, just too small to be detected.

Question is, what to do? Starting point may be the guidelines, NCCN, AUA, ASCO...those are generally the science though caveat emptor, they are population based and may lag behind data emerging from medical research, clinical trials.

You have choices, from congestive to aggressive.

You could do nothing, there is some data that says it could be up to 8 years for metastases to "appear."

Next step, SRT to the prostate bed only. This is today generally not considered a good choice.

You could do the SRT to the prostate bed, add whole pelvic lymph node and short term ADT, 6-24 months.

You could forgo radiation and do doublet or triplet therapy, an ADT + ARI, adding taxotere. The latter is generally for high, not intermediate risk.

If radiation is a decision, then hypo-fractionated may a possibility.

The good news, you have choices. The contrary to that is you have choices. Is there a "right" decision, likely not. There are good decisions though SRT to the prostate bed only might not be a good decision.

What would I do if I were you and the clinical data you describe? I would do radiation to the prostate bed, pelvic lymph nodes and six months ADT, Orgovyx.

Keep in mind I'm 11+ years into my journey. When I had BCR after surgery, I let my medical team talk me out of including the PLNs and short term, epic failure.

Again, if you have issues with radiation, then consider doublet therapy.

Do some homework, read through the guidelines, look through the literature from various sources, discuss with your medical team.

Kevin

I was in a very similar situation as you except I had a 3+4/ 7 Gleason with a family history of prostate cancer. A PSMA test showed no spread. When my PSA got to 4.5, I had RP. I had a positive margin. My PSA after surgery started at .02 and slowly crept up to .17. Some folks consider "undetectable" as any PSA score less than .1. I don't - to me any score no matter how low is detectable. That said my PSADT was less than a year so I chose (after securing multiple opinions) to take 6 months of Orgovyx and RT to the prostate bed and lymph nodes at approximately one year after my RP. I am now undetectable (< .006) and hoping it continues to stay at this level for a long time. I do have some manageable incontinence and ED issues. I'm grateful for the early success and comforted that I chose the aggressive path I did. Good luck. There is no looking back.