What is best next treatment after 20 years of active surveillance?

At 87y - and 20 years post-treatment - you’ve done well.

Have they assessed how aggressive this recurrence is?
> In the PSMA PET scan report, what were the SUVmax scores of your blood, liver, and parotid glands?

Is the recurrence hormone sensitive?

In 2016 when our PSA hit .24 you should’ve had salvage radiation. That would’ve probably killed all the remaining cancer cells and left you without a problem today. In 2014 when my PSA hit .2, 3 1/2 years after a prostatectomy I was immediately given salvage radiation.

You could talk to a radiation oncologist and find out if it’s possible to zap the active metastasis you have.

You could just let it go, but dying of prostate cancer is extremely painful. My father died of it at 88 and the last few weeks he was unable to communicate with anybody because the amount of morphine he was on was too much to be able to talk. When I was younger, he had his teeth ground down and crowned without Novacaine!

Since your cancer has spread to multiple places, you could have chemo or Pluvicto. That’s something you have to discuss with an oncologist. Another option, which might work for you is to get on Nubeqa. It is able to keep your PSA down and keep your cancer from growing with testosterone present. They can also stop the existing cancer from growing and spreading. Another thing you could speak to your doctor about. You could do that instead of getting on ADT, which could be a problem because of the side effects especially at 87. Nubeqa Has very few side effects, I know a lot of people in their 80s using it alone. I’m 77 and it has kept me undetectable for the last 23 months, eight of which I didn’t use ADT. I’ve had PC for 15 years and started with a 4+3. I do have BRCA2, which is why it keeps coming back.

Well, there are A number of options to speak with doctors about

Adding that depending upon where you are presently being treated, you now want the best prostate oncology medical expertise possible. If not already being treated at Prostate Cancer center of excellence, consider going to one now.

This also applies to the types of treatment options. For example, if you chose radiation therapy, I recommend soliciting input from this group on the specific available options and the specific treatment centers nearest you.

Why? It is unusual not to have treatment when your PSA was greater than 0.20 in 2016. In order for you to have the best possible information for decision making, it helps to have the input from an expert that is updated on all of the options, including those mentioned by @jeffmarc.

Only you can make the best decision for yourself and you deserve the best information on the most updated available treatments for your specific condition.

Hello Quincy, First of all, congrats on being 87 and still so physically active; I am sure that the two go hand in hand!
The short answer is ADT and salvage radiation…that’s pretty standard for recurrence.
You can also go the total hormone route, using meds to keep your PSA low and your cancer from spreading. But those meds over time exact a cost and your quality of life could be impacted adversely. Your 87 years could suddenly feel like a lot more!
Your age is the SINGLE factor that most doctors are going to focus on; do they treat you ‘palliatively’ with hormones, fearing that radiation may be seen as being too aggressive for a man your age? It IS something that goes through a practitioner’s mind and something you should be aware of when you have your consults.
You really have to know what YOU want, and not what your doctor wants. So many times, well meaning docs do what they think is ‘best’ for us; in reality, they do what’s best for them. Just throwing a bunch of pills at you is the path of least resistance, IMO…
With your level of fitness, I don’t see why you should be treated any differently than I was, completing SRT and 6 months of ADT at age 70. Your physiological age is probably a lot closer to my chronological one…Best of luck in your decision.
Phil

Layman here:

What do your Drs say? Clearly you have followed your cancer and been followed for many years. Do they have a plan for you or suggestions?

Not in any order of suggestion:

1 - Continue to watch PSA
2 - Radiate whole prostate region including pelvic lymph nodes w/o ADT. My salvage treatment included short term ADT and other than transitory radiation proctitis, I felt that the ADT resulted in the most significant side effects and impact on QOL.
3 - WPRT radiation w/ short term 4 - 6 mos ADT. Orgovyx if not too expensive and you can reliably take a daily pill.
4 - Medication only, which probably means both ADT and an ARSI.
5 - ? Are you consulting with a Center of Excellence?

Personally, I think that radiation only would be the least disruptive to you physically and mentally. Adding short term ADT might be more aggressive and effective. I felt pretty much "normal" at 73 about 6 - 9 mos after completing Radiation Treatment with short term ADT. However, I cannot say that the 6 - 9 mos ADT impact was not significant.

It seems like a challenging balance between treatment and QOL, and I wish you well.

@heavyphil
Salvage radiation is used to radiate the prostate bed when somebody’s PSA is around .2. His is 1.1.

His PSA is too high, and his cancer is in more places than the prostate bed. As a result, salvage radiation doesn’t really make sense. Targeted SBRT would make more sense, But even that may be inadequate.

Thanks for all your thoughtful replies. My medical center is a center of excellence that is a member of NCCN. When my PSA started rising after prostate cancer surgery, the center’s policy was to respond with salvage therapy when the PSA >=0.5. Since my prostate cancer was growing slowly (PSADT>36 months), I decided instead to continue active surveillance.

My 20 years of active surveillance was so side-effects free that I am hesitant to start radiation of the wide pelvic area that includes the prostate bed plus the pelvic lymph node group with the high probability of QOL side effects.

I am reviewing with advice to first radiate the lymph node area with SBRT. This lymph node procedure has a history of only minor side effects. If advised, this procedure could also include short term ADT or ADT +. This would at least reduce the probability of distant metastases and increase probability of longer overall survival.

I would still have the cancerous area in the prostate bed. If my PSADT remains > 36 months, could I delay for a while? Is there a systemic option? I would be interested in the experience of anyone that had radiation of the prostate bed area after recurrence: Success? Side effects?
Thanks again.

@jeffmarc Seemed like the disease was confined to the prostate bed (along the rectum and at an anastomosis) -
And a single iliac node.
My thought was that ADT could shrink this even more, followed by radiation to the bed and pelvic nodes - with possible SBRT to anything outside the range of standard SRT.
Also, are you saying that anyone with a PSA of 1.1 can’t have SRT? I would think that while a PSA of 0.2 or less is ideal, the term SRT is not PSA specific; but more descriptive of a lower dosage multi treatment regimen targeting the bed and nodes; anything outside of that area would be treated focally with high dose SBRT to avoid damage to surrounding structures. Is this incorrect? Thanks,
Phil

@qldodge I must say, that was a gutsy call on your part when your PSA hit 0.5…and you’ve been doing great so far, so keep doing what you think is best.
What you propose is certainly doable radiation-wise. Most systemics involve some form of ADT, which again can affect your QoL possibly even more than pelvic radiation.
But no one can know this except with 20/20 hindsight and by then it’s too late to remake your decision. Best,
Phil

@heavyphil
Because the metastasis they saw were outside the prostate bed. It’s very unlikely they would even consider doing salvage radiation. It’s too late.