Anyone had salvage radiation therapy post-prostatectomy?

Unfortunately you never mentioned your Gleason score. You also didn’t talk about the other things found in your original biopsy and the biopsy of your prostate after surgery. Those are major factors in what you want to do.

The palpable nodule in the prostatic fossa Is something you need to treat?. Yes, you can wait for .2 but the fact is you have cancer already in that spot and you really want to treat it as soon as possible rather than let it spread. Of course, if you are on ADT, you have time before it can start spreading.

A palpable nodule in the prostatic fossa is a key sign of a potential biochemical recurrence, which is defined as a detectable and rising prostate-specific antigen (PSA) level after treatment. Your PSMA PET scan shows it is not potential. It is for sure cancer. Your PSA should stay undetectable after a prostatectomy if it does not then you definitely have something producing PSA and you know what it is.

Maybe this is the case where you need to get a second opinion from a center of excellence, Or even just a different center of excellence than you are at now, so you can get More educated decision.

I am not a doctor, So I can’t tell you what to do. I could only say what I would do in your case.. My PSA rose to .2 3 1/2 years after radiation. I had an ADT shot and two months later salvage radiation. It gave me another 2.5 years Before my PSA started rising again. I have BRCA2 so my cancer can never be controlled completely But I am still around 15 years later after four reoccurrences, Because I have continued to get treatment when it was necessary.

Have you had genetic testing? It might make sense to find out if there is a genetic issue, causing your cancer. If you have not had a test, I can tell you where you can get one for free.

Similar situation, undetectable for eight years, now 10 yrs post robotic removal and psa has crept up to .5. Two PSMA PET scans, nothing detected. Studies show PET scan detection rates were 38% (PSA 0.2-0.5 ng/mL), 57% (PSA 0.5-0.9 ng/mL), 84% (PSA 1.0-1.9 ng/mL), 86% (PSA 2.0-4.9 ng/mL), and 97% (PSA ≥ 5.0). JAMA Oncol. 2019;5(6):856-863. I agree with my uro's suggestion to hold off radiation with blood test every 6 months. He believes recurrence is likely in the prostate bed and a targeted approach is best vs radiating the entire bed and risking collateral damage. I believe (purely anecdotal) those of us "lucky" enough to experience BCR many years after surgery are in a different position than those who experience BCR < 3 yrs post surgery and that watchful waiting is a prudent course.

ASCO, which set some of the standards for handling prostate cancer doesn’t agree with your doctor at all. I think you should find a second opinion at a center of excellence because waiting is not to your benefit.

From Ascopubs about what PSA to do salvage radiation.
≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

This article discusses the above;
https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/

RP 3 years ago.
BCR @ 2 years with .22 PSA
Started ADT then 3 weeks later Radiation.
Sought a second opinion after radiation at a CCC research hospital and he stated that he would not take me on as a patient as he only treats stage 4's.
Gave me a 70-30% chance of never having to deal with this again.
Suggested if I went BCR again to wait until PSA was 2.0 and stated they could find it at that point. Will I do it? Not sure. Now that I am off private insurance more facilities open up for consultation and consideration.
No more EBRT as they torched my rectum and 6 months later bleeding everyday. I will travel for proton.
They wanted me in my RO office for PSA testing and whatever two days after finishing what we knew was a successful ADT based on being non detectable at 3 months. I view that as a money grab for a doctor's kid BMW.
My limited observation is most at .2 get a PSMA Pet and nothing shows up on the scan. Then the cycle of ADT and PETS for life start.
Somewhere in this, quality vs quantity of life has to be considered. I don't want to be dope sick the rest of my life. I am a fighter but I feel like I am fighting greed over cure at a private Urology practice that pretty much has a monopoly on the area.

If you mean, dope sick because of ADT or the ARSI drugs, that is not definite. You can learn to live with the drugs. I’ve been on ADT for nine years and an ARSI for 5. Yes, Zytiga did really did cause me issues, But I was able to do it for 2 1/2 years without becoming dope sick.

Since then, I’ve been on Darolutamide And it is pretty easy On the body.

I guess it’s a sort of case where you Take was available now and thenwait until they come out with the next drug that really can lick the things we all have.

I am so sorry that you have such terrible side effects from radiation : (((. What kind of radiation did you have ?
Thanks in advance for the info. 🌸

@squash05

You’re not wrong about BCR of 3+ years following surgery. The tables in Dr. Walsh’s book show that men whose recurrence is >3 years after surgery have much better odds of not dying from PCa at 10 and 15 years than those who have recurrence < 3 years after surgery, regardless of Gleason score and PSA doubling time. But if your Gleason score is < 8 and DT is greater than 3 months, your odds of survival improve even more, according to the tables.

I’ve said this before—from all my investigations and readings, it seems that if you are experiencing BCR and are in the intermediate risk category that there is no real physician consensus on when and how to treatment.

I agree with Jeff that second (and third opinions) are a very good idea. And in agreement with Jeff, there is a good body of literature that indicates that early salvage RT yields better outcomes. And that early salvage is the route I am taking.

But also, in the intermediate risk category, I think it is important to weigh one’s specific circumstances in any treatment decisions. The first RO that I consulting with wanted to treat with RT and short term ADT based on the SPPORT trial results. However, because I have a palpable, local lesion, I would have been disqualified from that trial. The SPPORT trial was valid, but how it applied to me was not clear. When I brought that up with the RO, he as much admitted that I had a valid point and that he was extrapolating the results of the SPPORT study to my specific case. I moved on to a different RO.

Lastly, to me, quality of life is an important factor, or at least shouldn’t be brushed aside/minimized, as seems to happen with many treatment recommendations, especially in the intermediate risk category.