Salvage radiation decision: with or without hormone therapy?

I was Gleason 9 and a very high Decipher as well. All signs that the cancer was aggressive. Had surgery- removed prostate, seminal vesticles, and 7 lymph nodes. 1 node was positive. There was some positive margin after surgery. I had followup pelvic radiation and have been on ADT (Orgovyx) for 2 1/2 years. My PSA has been < 0.01 since (for 2 years).

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.

@jaacm1 You mentioned you have manageable incontinence and ED. I also have these issues following RP surgery and I never fully recovered. As I'm considering ADT, I've read that it could have significant side effects regarding incontinence and ED. Was your incontinence and ED a result of your RP surgery, or did it happen after starting Orgovyx? If it was a result of RP, did it get worse after starting Orgovyx?

@jaacm1 You mentioned you have manageable incontinence and ED. I also have these issues following RP surgery and I never fully recovered. As I'm considering ADT, I've read that it could have significant side effects regarding incontinence and ED. Was your incontinence and ED a result of your RP surgery, or did it happen after starting Orgovyx? If it was a result of RP, did it get worse after starting Orgovyx?

ADT reduces testosterone levels, and androgens play a role in maintaining the strength of pelvic floor muscles. When these muscles weaken due to ADT, it can lead to urinary incontinence.

The ED problems occur after surgery, The ADT drugs take away the desire, Which can’t affect the ability to get an erection, But the real problem is that many men after RP just can’t get it up without assistance from drugs or a pump.

Jeff - thanks for all the information you have been providing on the questions I've been asking. You are very knowledgeable about the current research and treatment options. After reading the messages from you and others, it seems like ADT slows down cancer growth, but doesn't kill the cancer cells. And the only way to actually kill the cancer cells is through surgery or radiation. Also the cancer cells can mutate to make them ADT resistant. So it seems there is a high probability after ADT treatment that the cancer will eventually come back, and could become castration resistant.

I'm 64 and currently have a PSA of 0.2 after 4 years post RP, PSADT of 1 year, post RP clean margins and lymph nodes, and a negative PSMA/PET scan. I didn't have a decipher test done at the time of RP surgery. In a Dr. Kwon video, his recommendation was to wait until a scan positively identifies the cancer spot and then kill it with radiation. I'm hoping to get into Mayo soon to have a Choline 11 scan done. If that is also negative, does the current body of research support waiting until a scan identifies the cancer? Are there stats showing the effectiveness of waiting to identify the cancer and using radiation to kill it? For example, after this treatment plan, how many patients have their PSA increase again and have additional radiation treatments?

I believe I saw a statistic that salvage radiation to the prostate bed is about 30% effective at killing all remaining cancer cells with a PSA around 0.2 - is that correct? Are there stats showing how much more effective adding the ADT therapy on top of the radiation is?

Lots to consider and I appreciate your help and everyone else who is contributing to this forum! I will continue to share my treatment plan and effectiveness as well. A Huge Thank You To Everyone!!

Jeff - thanks for all the information you have been providing on the questions I've been asking. You are very knowledgeable about the current research and treatment options. After reading the messages from you and others, it seems like ADT slows down cancer growth, but doesn't kill the cancer cells. And the only way to actually kill the cancer cells is through surgery or radiation. Also the cancer cells can mutate to make them ADT resistant. So it seems there is a high probability after ADT treatment that the cancer will eventually come back, and could become castration resistant.

I'm 64 and currently have a PSA of 0.2 after 4 years post RP, PSADT of 1 year, post RP clean margins and lymph nodes, and a negative PSMA/PET scan. I didn't have a decipher test done at the time of RP surgery. In a Dr. Kwon video, his recommendation was to wait until a scan positively identifies the cancer spot and then kill it with radiation. I'm hoping to get into Mayo soon to have a Choline 11 scan done. If that is also negative, does the current body of research support waiting until a scan identifies the cancer? Are there stats showing the effectiveness of waiting to identify the cancer and using radiation to kill it? For example, after this treatment plan, how many patients have their PSA increase again and have additional radiation treatments?

I believe I saw a statistic that salvage radiation to the prostate bed is about 30% effective at killing all remaining cancer cells with a PSA around 0.2 - is that correct? Are there stats showing how much more effective adding the ADT therapy on top of the radiation is?

Lots to consider and I appreciate your help and everyone else who is contributing to this forum! I will continue to share my treatment plan and effectiveness as well. A Huge Thank You To Everyone!!

You have had a lot of important points, Chuck. With your low PSA it sure seems you should wait until you have a fast Doubling time, and your PSA is higher, before you start worrying about the options below. You are at .2, How fast did it get there?

Here are Some things that relate to having Reoccurrence with or without metastasis

At the recent PCRI conference it was mentioned that only 1/3 of the people that get salvage radiation benefit from it, In that they have no further remission.

Both Dr. Kwon and Dr. Scholz Are real enthusiasts about using SBRT to just zap the metastasis and you can go home happy and not worrying about it.

These two things sort of collide together. Currently the SBRT scan cannot see metastasis smaller than 2.7 mm and in some case even at 5 mm It can’t always be determined (from recent UCSF conference).

That means you could be waiting for metastasis to show up while many other mini metastasis are growing. Because the prostate is removed the area around there is the most likely place that something could have microscopically spilled and be spreading. As was mentioned in the PCRI conference “Seeds for metastasis were already there when surgery was done, waiting to grow.” That’s where salvage radiation becomes to make some sense.

It could be the C11 scan can detect smaller Metastasis.

Dr. Scholz was real emphatic, At the PCRI conference, about using the SBRT technique to keep his patients in remission.

So now you have a little bit of both sides of that story.

As for adding ADT if you’ve had a metastasis or remission, ADT is normally the recommended treatment. Even an ARSI may be used at the same time if the cancer looks like it could be aggressive.

Here is a treatment guide I got from one of the Conferences.. Anti—hormones is referring to drugs like ADT.

That is AWESOME news!!! Love the PSA. I've had a very similar path. My Gleason was 8-9. Had surgery to remove the prostate. All 11 lymph nodes clear. First PSA was .2 so so obviously some cells still there. PSA then rose to .8 after 6 months so radiation and ADT was the plan of attack. Eight months after, my PSA is at .01.

My question, was does the a positive lymph node mean going forward? Really new here. Thanks everyone!!!

There is a study published by Dana Farber about the timing of salvage radiation. A simple Google search should find it. It suggests that starting SRT prior a recurrent PSA after RP reaching .25, in certain circumstances, can lead to better results.