Salvage radiation decision: with or without hormone therapy?

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.

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

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 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.

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