Salvage surgery or salvage radiation?

@prettypass2000
I have nothing constructive to add, but as a wife I just want to welcome you here and tell you that I understand your anguish and all worry and work that is involved in coordination of care. I am wishing your husband very successful next treatment, whatever it might be < 3

Thanks also for sharing information about this novel approach - it is almost unheard of here in the USA : (((.

@prettypass2000 WOW - that’s incredible! My RX was $2800/month here in the US.
With insurance, it was ‘only’ around $650😫…
Phil

@prettypass2000 Yes, absolutely - NOTHING is going to detect a clump of cells. In fact, someone here on the forum once presented evidence that it has to be a few thousand or so before they will take up adequate tracer and show anything.
Also, this lymph gland dissection is not error free; who can say that more PCa cells won’t be released during retrieval and go elsewhere? Just my point of view, not disparaging your surgeon or his good intentions.
Phil

@heavyphil I totally agreed with you. Even though he's one of the excellent surgeons, I know they can miss those microscopic cells that they can't visibly see. It happened during his first surgery that the pathologist confirmed there was tiny trace of cancer in one of the seminal vesicles that didn't show up on the scan. It creeped me out when I heard the word "another surgery."

@heavyphil But other medications, such as Xtandi, Neubequa, Abiterone, and such are more expensive. They're between 1800 and 3500 euros ( price before insurance's reimburse). However, my husband has hypertension and a family history of Alzheimer's (his mom and grandma and great-grandma), so only Orgovyx or Firmagan seem to be the only best options

@surftohealth88 Thank you so much! Best wishes to you and your husband too. I was anguish because the chief urologist pressured my husband into saying yes to surgery without offering him a chance to meet with their radiation oncologist on Thursday. I then found out yesterday that they scheduled his surgery on next week. I kindly asked them to cancel the surgery appointment because I am not going to pay anything up front unless my insurance approved this procedure. Thankfully, I was able to schedule a consultation with radiation oncologist after showing up there and convincing them that my husband has the right to see the whole circle of treatments before making his own decision. I feel like had I not advocate fiercely, my husband will not be able to get all information he needs in order to make his decision.

P.S. Lymph node dissection has been used for a long time, but it's not popular. There aren't many studies about it. All studies show high chance of relapse (40%-60%). I don't think it's a good idea to go on this route when higher chance of relapse is possible.

@jeffmarc I was able to get the PSMA PET/CT scan report. There is not evidence of any metastasis on other parts of body. Only one lymph node on the right pelvic is infected (SUV mean 25.3). Could you please explain what SUV mean 25.3 is? I have no clue.

@jsh327 I was able to schedule an appointment with radiation oncologist on this coming Friday.

@heavyphil

Here you go

@prettypass2000

I've posted these before...

If even today's most sensitive imaging cannot see micro -metastatic disease, not sure what a surgeon can do to outdo imaging...

As I said, my urologist, who was very experienced and skilled, was opposed to surgery to remove lymph nodes when I had BCR.

I was thinking I had responded to this post but scrolling through didn't see it.

So, he's high risk given the clinical data you describe minus one perhaps critical piece, his PSADT and PSAV.

I don't think his medical team has laid out all his options:

Do nothing, continue to monitor. It could be some time before treatment is "necessary..."

MDT mono therapy which may delay the need for systemic therapy.

Doublet or triplet systemic therapy though in low volume cases the latter is generally of marginal value.

ARI mono therapy, EMBARK

There is the PATCH trial with the use of Estrogen.

I think the outcomes of treatment that drive the decision are:

PFS
RPFS
Patient preferences:

Desire to delay systemic therapy

Concerns with radiation side effects.

What would I do were I he?

MDT + short term systemic therapy, 6 months. I would likely use Orgovyx. I would hold on the ARI and add only if PSA did not drop to undetectable. Of course if you have to do that you are likely pushing systemic to 18-24 months...

If his PSA drops to undetectable in the first 3-6 months then that is a favorable sign for longer PFS and RPFS..

From my foxhole he is now managing this as a chronic disease, I'm in the "advanced PCa is incurable"...camp, rather it is manageable.

I think the group discussion provides a great degree of information to inform your discussions both you and your husband as well as his medical team.

Try not to go down the Alice in Wonderland rabbit hole with the horror stories about treatment surfaces. They are statistical, population based and historical, often not reflecting changes brought about by medical research and consequent advances. Where will your husband fall in the side effects impacts, unknown.

There are mitigating strategies, diet, exercise, managing stress, his medical team has options too.

The other thing I throw out because of the difficulty of measuring OS impacts of treatment is change the thinking from day 10-15 years to say 3-5, will this work for the next 3-5 years? Yes, great, we likely have more choices by then.

The good news, he had choices, the bad news, he had choices. I am also in the camp that says with a plethora of choices there are many good ones, there is no black and white checklist that says if that then this. "Plethora" can also lead to "paralysis by analysis."

After surgery and SRT failed using SOC from the NCCN guidelines my subsequent treatment decisions have been "hybrid" combining the guidelines with changes from CTs entering mainstream clinical practice and my preferences.

Like I've said about radiation, 69 treatments, SRT, WPLN and SRT, 155 Gya, side effects, none. I didn't lose my libido during ADT, still could achieve erections and orgasms. So, I may not be the one to ask...as I'm one or more standard deviations outside the "mean!"

Kevin