The right time to start radiation post RP with an increasing PSA?

@jeffmarc thank you Jeff. I will read the link you sent and thank you for pointing out the important information on your reply.

I guess we’ll be starting this journey of more treatments.

Thank you

I’m a firm believer in do nothing until the PSMA/PET shows exactly where the recurrence is located.

Hi Crustand,

This has been a great thread and Jeff touched on the topic of PSA doubling time (PSADT) that might be worth an additional comment as medical professionals may treat aspects of PSADT differently. It is safe to say that there is on ongoing effort to figure out how best to determine the aggressiveness of an individuals PC in order to decide if intervention is in order. That applies to pre-treatment and post-treatment such as the case in BCR following surgery or RT. That effort is something of a holy grail in cancer research as I see it. While we obviously use rising PSA (the check engine light of PC) as one of the factors to diagnose PC, it can also be used to help determine cancer aggressiveness and or the need for additional therapy. PSA doubling time (PSADT) plays a role in the treatment decision process.
The reason for this discussion is that I am enrolled in a University of California Irvine Medical Center longitudinal PC study conducted by UCI Medical Center under the guidance of former Director of Urology Dr Ahlering. When I selected Dr Ahlering as my surgeon 14 months ago, I had to agree be a research subject in his surgical technique during the robotic prostatectomy and be a part of a 20 year follow up study. I asked him last month at my 1 year post surgery follow-up tele-med call ....what happens if my PSA rises? He said based on the PSADT, he would likely recommend active surveillance. I said what happens when it hits .2 ng/ml ... the normal trigger for additional treatment? Dr Ahlering said ..."well, prior to hitting that number we would look at the PSADT and if your doubling time was 12 months or greater...the PC producing the PSA is likely "indolent" and additional treatment may not ever be necessary". He said if the PSADT was under 12 months, we will look at additional treatments.

I mentioned to Dr Ahlering that my original PSA doubling time was under the 12 months (.8 to 1.8 psa). He said "that is because you had a prostate that was incubating Gleason 7 cancer and that "mothership" is now gone". Anyway without going into the weeds here, the "mothership" theory is explained in Dr David Walsh's book "Surviving Prostate Cancer". Dr Ahlering supports Dr Kwon's research that not all BCR is in the prostate bed so "salvage radiation" to the prostate bed may be unnecessary.

Crustand, with your Jan 2024 PSA of .04 and "Fall 2024" PSA of .11, your doubling rate is around 8 months and would probably fall under the guidelines of rapid PSADT ; the time frame of < 3-9 months PSADT suggests a more aggressive PC. I would expect your medical team to propose additional treatment. This is a tough decision as pointed out by other posters cause if it is in the prostate bed early treatment provides better outcomes. None of this is medical advice as I am only sharing my story of the PC train ride and that different practitioners prioritize medical information differently. It is always good to get second opinion whenever possible.

@robertehughes And what if the PSA rise is not a single cluster of cells but a more diffuse seeding of the prostate bed and pelvic lymph nodes and maybe even other areas in the body?
To wait for ‘something’ to show may turn into many, many things showing; either all at once or sequentially. You could play whack a mole with SBRT - if you are lucky - or might need Pluvicto if the cancer has metastasized.
I will grant you that SRT or ART can only address those areas in the pelvic proper, but at least you’ll treat those areas and if any cells manage to get out of that general area, you can then hit them selectively with SBRT. Just my point of view and we can agree to disagree…I hope!!🫣. Best,
Phil

From my experience you have received standard treatment advice. Is it the best advice? I'm not sure but suspect you will get standard prostate bed radiation and ADT depending on other scores as the Pet didn't point them to anything specific. I finished 6 months ago and my blood work last week points to undetectable PSA which is the hopeful outcome. I found the radiation/ADT a difficult process. The questions I would focus on in how they will protect your rectum, bowels and bladder. Do not let them slide if they minimize negative outcomes. You want specific answers. They hit my rectum and the result is radiation proctitis which comes with bowel incontinence. It's a bloody inconvenient mess. Was totally minimized during my appointment. They never mentioned bladder spasms and urinary incontinence and would never address it until I blew up on the table twice in one session after 20 sessions. I had to demand treatment threatening to not get back on the table until they prescribed meds for it. Even the techs knew of it and would allow me to hop off of the table before it was fully lowered due to undealt with urgency. I would suggest getting something like oxybutynin before you start. These are real issues that many of us experience. If I had to do it over again I would require firm answers from them prior to signing up with that doctor. There are other radiation guys out there if this one is evasive. Best wishes on a successful treatment.

I had a similar experience. It was about 2 years post RP that I had PSA that went from undetectable to .78 in 9 months. It was at .42 when they did a PSMA PET scan and found lymph node metastasis. I was told by the oncology and those involved in the PSMA scan that I was lucky the cancer showed at a PSA level of .42. Quoting Dr. Robert Reiter in an article where he speaks of the PSMA- PET Scan likelihood of detecting cancer based on the PSA level, "Generally speaking, below 0.2, the detection rate is very, very low". It's about 40% accuracy, the level I was at. You can view the article here:
https://www.urologytimes.com/view/dr-reiter-discusses-accuracy-of-psma-pet-scans
In my case, they started Lupron and waited for the radiation until they were clear on where to target, because some lymph nodes were questionable, others were obvious. At any rate, a lot to think about, but you are asking valid questions.

I too asked "when" I would have a PET Scan if my PSA ever started to rise? So far, I have had three consecutive PSA's at 3, 6, and 9 months, all < 0.1 ng/ml, and one ultra sensitive PSA of < 0.006 ng/ml that was done at 9 months, and was ordered during the consult with a radiation oncologist. He wants at least two data points for an Ultrasensitive PSA before he decides if/when I start on radiation therapy for what was/is my pT3b classification of cancer. This form of prostate cancer that included EPE, surgical margins, Cribriform glands, and left seminal vesicle invasion, results in a cancer that has a 25-50% chance of recurring "within" five years post-op, despite the prostate, seminal vesicles, and vas deferens all being removed. So...when I asked about a PET Scan if/when my PSA starts to elevate, my physician said that there are usually so few cells producing the PSA that they can't be detected on a PET Scan...the sensitivity to detect ultra-low level radiation signal from the Gallium-68 isotope just is not good enough. You could have a cancer that is growing again, but it just can't be seen on a PET Scan. That would be ideal, so the radiation oncologist could fine-focus and direct radiation only to that area, instead of frying your entire prostate bed, including your urethra and bladder, and possibly rectum. As advanced as the technologies are, the PET Scan is not advanced enough to be sensitive down to the level that a PSA or Ultrasensitive PSA test can detect cellular production of PSA.
Also, when I asked the official time line of when radiation is considered "Adjuvant" (immediate) vs "Salvage" (later), my radiation oncologist said, generally speaking Adjuvant is within the first six months post-op, and Salvage thereafter, but...BUT...he never does radiation before six months because he said that the man's body is still actually healing from the prostatectomy surgery at 6 months. He wants the man's body to be as recovered/healed as much as possible before beginning radiation therapy, and it barely is at 6-months, despite our return to our normal lives within ~3 months post-op. While he may start radiation after 6 months to a year, he still refers to it as "Adjuvant" vs "Salvage", the later of which he would term for radiation therapy after one year.