Did you start radiation immediately or wait until PSA was 0.2 ng/ml

MO in my post was standing for Medical Oncologist and RO stands for Radiation Oncologist

My husband’s pathology report stated positive margins and also stated MO.

You asked...

So, please reply with "when" you started your post-op RP radiation therapy;

At the time, 2015, the definition of BCR was two consecutive increases of PSA .2 or higher. The first PSA of was in September 2015 when after PSA test results of < .1, my urologist hesitated before turning to look at me and said, "Kevin, this doesn't mean your cancer is back, but your PSA is .2..." Then, 90- days later, it's .3. My surgery was in March 2014, so 18-21 months. I started SRT in March 2016.

What your original Gleason score was; GS 4+4

And what features were reported in your surgical pathology report (EPE, Surgical Margins, Cribriform Glands, Seminal Vesicle invasion, etc.).

Pathology Report:
GS 4+4 = 8
T2CNoMx
ECE - Negative
SV - Negative
Margins - Negative
10% Prostate Involvement

I think when we ask for other experiences, we have to consider their answers in the context of time. At my time, PSMA PET imaging was not in mainstream clinical practice, nor were USPSA. Both have changed the landscape and discuss around SRT vs ASRT.

While medical researchers are able to determine "benefits" of one treatment over another using criteria such as PFS, RPFS...the one variable, OS, is hardest to determine.

I don't know that you'll find consensus in the medical community about SRT vs ASRT. Ultimately, it may be your decision in conjunction with your medical team based on your clinical data, the guidelines such as NCCN, AUA and your willingness to accept and manage the side effects associated with your treatment decision.

I have seen some literature that points to a number of years before metastases "appear," ergo, you can wait until then to treat. Again, I think those "findings" are in the context of conventional imaging, not USPA and PSMA PET .

I am high risk, so since the epic failure of SRT (long story, I've explained why in other posts), I've chosen to be aggressive in my approach to managing my PCa. Has that approach improved my OS, we'll never know since we can't run a controlled clinical trail with my clone...

The plethora of choices can lead to paralysis by analysis as we sift through the literature. I am not sure there is a "right" decision, I am comfortable with there are good decisions. My radiologist told me that when she sits on the tumor review boards, oncologists are all over the map on why they chose which ADT, which ARI and the length of those treatments. So heck, if someone who is trained, educated, board certified has "difficulty" in defending their decision, what about us "laymen!?"

Kevin
https://www.urotoday.com/conference-highlights/sociedad-colombiana-de-urologia-scu-colombia-2025/162647-scu-2025-evaluation-and-management-of-biochemical-recurrence-in-prostate-cancer.html?utm_source=newsletter_14559&utm_medium=email&utm_campaign=highlights-from-cartagena-2025-colombian-urological-society-meeting

I went on Orgovyx and Erleada very very soon after diagnosis, then 10 weeks later surgery and then I could decide when I had radiation. The medication stops it from spreading so timing of radiation is not as critical
I was a Gleason 9 Grade 5

You may find this review paper (Shore and others, 2023) on treatment for BCR following either prostatectomy or radiation. It lists a range of approaches but clearly shows that risk stratification is a key factor, across the board. From all my readings, the various approaches seem rooted in trying to balance the risks of under-treatment against the risks of over-treatment.

My story: Robotic radical prostatectomy in 2015. Margins were positive, Gleason 3+4, Prolaris score of 1.7 with a 10-year risk of BCR at 53%. pT2c, Gleason Group 2, unfavorable intermediate. For ten years, my PSA was undetectable (< 0.1). In June 2025, my PSA was 0.11 and 0.12 on closely consecutive tests (lab error ruled out). A DRE detected a small nodule in my prostatic fossa. This was followed with a PET PSMA scan that showed high specific activity of the nodule, but no evidence of metastatic disease. A pelvic MRI with contrast further confirmed the lesion in the fossa and yielded no evidence of pelvic lymph node invasion, consistent with the PET scan. After conferring with two ROs, I will begin EBRT in a couple of weeks. No ADT at this point. Will also test PSA one more time just before beginning RT. So, my PSA is below 0.2 but because of the confirmed presence of a local recurrence, RT was recommended by both ROs. Surveillance was off the table. This seems consistent with most the treatment guidelines listed in the attached paper, including NCCN guidelines.

Best wishes for getting the treatment that you believe you need and that fits with your goals and values.

Melvin, sounds like a plan. Are you scheduled for radiation to the pelvic nodes?
Even if PSMA or MRI does not show presence or detection of lesions, the newest thinking is to treat the nodes as well.
There is a greater than 30% failure rate in SRT and it has been attributed to failure to treat the nodes.
I am sure your RO knows this but doublecheck to be sure…Best,
Phil

Yes, absolutely will be hitting the pelvic lymph nodes, prophylactically. Good mention that you brought this up. I’ve come across the same info that you have mentioned.

M

I’m in the planning stage (dosimeter, mapping) for my proton therapy. This is at Mayo, highly respected. Twice I’ve asked whether he will treat the lymph nodes. He says no, he only treats what he thinks is there. That is in keeping with my philosophy, so I’m okay, as long as nothing in the recent imaging changes that. That raises the risk, maybe, but my gut tells me over-treating might affect me worse. They’re doing a genomic trial and that might change things.

Robert, “he only treats what he thinks is there.” If you take that statement completely out of context and apply it to anything else -
Car repair, leaky roof, plumbing issue, etc., would you accept that? I certainly wouldn’t. I would want to know how he/she comes to that conclusion.
Who the heck REALLY KNOWS where these miserable cells are?? He doesn’t, and neither did my RO or anyone else’s - that’s for sure.
Treatment of the pelvic nodes in salvage radiation is not an opinion any longer, but an established norm.
If you are talking about primary treatment - no prior surgery - that’s still debatable. Many RO’s still favor IMRT vs SBRT in cases where either Gleason score or MRI/PSMA findings indicate possible spread from the gland.
But you’re at Mayo, one of the best, so I guess you have to take him at his word. We’re all kind of in the same boat - we can ask, we can pester and we can push, but in the end the Drs do what they want anyway. Best on your treatment!
Phil

My husband has been treated and monitored since January 2011 by Dr. Kwon at Mayo Rochester, and by several radiation oncologists there as well. Every single one of them repeats the statement "We can't treat what we can't see." I know it is frustrating to wait for something to show up, but it's probably better than taking a shot in the dark that might cause harm and do not good. Hang in there!