Should I add ADT to Salvage Radiation at age 76?

You need to think of ADT as a radiation helper. If you were having radiation as a primary treatment with a prostate still in place there are a lot of factors that affect whether radiation needs help or not. These would be your Gleason score, Decipher score, intraductal, cribriform, seminal vesicle invasion, EPE or ECE. (extraprostatic extensions or extra capsular extensions). All of these come into play about whether ADT would be beneficial or not.

When your prostate is gone and you need salvage radiation, you still want to look back at whether these factors were present or not and also factor in your Gleason score and ideally a Decipher score. The more factors you had and still have that indicate aggressive cancer, the more likely ADT will be beneficial for you.

Even at age 76, you still want to minimize your chances of a recurrence and if that means that 6 months of ADT would be helpful then that is not the end of the world. Most people can tolerate ADT and the use of ADT is often life saving. See my bio for more info.

One problem is that you’ve waited a little too long before doing radiation. As a result, the American Society of clinical oncology (ASCO) recommends that you have ADT. You could Put it off until you come back from your trip. It may allow the cancer to grow a little bit, But it is an option. One thing is you do not have a higher risk case since you are a 3+4.

When I have my first ADT shot after my cancer came back, following a prostatectomy, I didn’t even notice the side effects And two months later, I had Eight weeks of salvage radiation. It was a six month shot. 2 1/2 years later when I had to go on ADT full-time then I noticed the side effects.

I’m 78 and I’ve been on it for eight years. I have no fatigue at all nothing that would prevent me from really getting out there and doing whatever I want. I walk a mile at high speed twice a day and I go to the gym three days a week to get weight exercises.

Check out the recommendations from ASCO

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/

@jeffmarc Looking at the ASCO recommendations, it appears that the need for ADT with salvage radiation is driven primarily from PSA levels at the time of treatment. Whereas the need for ADT with radiation as a primary treatment is affected by numerous factors like Gleason score, Decipher score, intraductal, cribriform, seminal vesicle invasion, EPE or ECE (extraprostatic extensions or extra capsular extensions). The ASCO approach seems a bit simplistic to me to look only at the PSA level of a salvage radiation patient because if such a patient with many previous risk factors (high Gleason, high Decipher, intraductal, etc.) decides early to get salvage radiation treatment while with a low PSA value, ADT would automatically not be prescribed even though it might well be beneficial.

@wwsmith
It’s the PSA level after treatment. When you have a prostatectomy your PSA is supposed to be undetectable Six or eight weeks after surgery. That’s different from radiation where they have set the bar at two points above your minimum PSA, Before additional treatment. Of course, if you have radiation, you may Need to have ADT as well, depending on your extent of aggressiveness.

After a prostatectomy, if the PSA rises, then they know that salvage radiation may eliminate the cancer again. Of course, if you get a PSMA pet test and it shows you have a metastasis somewhere then you want that zapped as well.

If someone starts off with a very aggressive cancer that spread, then they are probably not gonna be getting a prostatectomy. More likely chemo and not even trading the prostate.

There are so many variations.

@jeffmarc We frequently hear of guys that have a biopsy with 3+4 and then an RP later shows them to have 4+5. So then a year later the 4+5 guy starts to show rising PSA values. He could wait until the traditional 0.2 level to start salvage radiation or he could act early and start radiation treatment maybe at 0.1 PSA. But whatever PSA level he and his doctors decide to start salvage radiation, they know that he had an aggressive 4+5 case, so wouldn't most RO's recommend ADT for that salvage radiation case no matter what PSA level they began the salvage treatment?

@wwsmith
As @surftohealth88 Has said her husband’s Doctor said he would probably start treating him when his PSA hits .1 because his cancer is so aggressive.

I would not be surprised if a doctor would put somebody on both an ADT and an ARPI If they had a very aggressive case of prostate cancer, and it came back after a prostatectomy. Many combinations are possible, but that is very likely.

@jeffmarc

Yes, you remembered well Jeff : ).
And yes, my husband will need ADT at least for 6 mos (we were told), regardless of how low PSA is. Even if we decided to have adjuvant immediately post op with uPSA undetectable, my husband was advised to have ADT since he is a high risk patient.

“Activity limited to the prostate bed only”…this is a very sore point for me.
You have recurrent PCa and even though it took many years to rear its ugly head, it is back; is it the same cancer you had years ago? Who knows, but it certainly appears to be more aggressive this time around. And it had had a LOT of time to wander around, right?
Even if it doesn’t show on a scan You MUST target the pelvic lymph nodes as well; there is a documented 30% failure rate in SRT when the nodes are not included.
They radiate them along with the bed at the same time so no extra sessions are necessary. I had both done in 25 sessions at Sloan.
ADT has different side effects in different people; my 6 months on Orgovyx (that’s what you want - not Lupron) was nothing terrible - very minor SE’s and I recovered very quickly. If you are truly in good health it should pose no problem and leave you with no regrets later on. Just my opinion…Best,
Phil

Very helpful conversations about all this stuff. I'm looking at treatment options after my second biopsy last month indicated 4+3 in a couple areas (see my profile for deets). Meetings with the RO and urologist in April after I have the PSMA-PET on April 7. I'm also considering TULSA-PRO pending the PET results. Like @jablakely I'm not enthusiastic about ADT. @jeffmarch comments on ADT are encouraging but others have not had so good an experience. JAblakely: have you looked into TULSA?

Do you know when your PSA was first detectable (>0.1), what that value was, and how long it took to double that value. The very long time (15 years) to recurrence is in your favor, but the PSA doubling time is important data for making a decision of ADT/no ADT.

Given that you are intermediate risk (3+4) and given your age, I think you are right to explore the question about ADT along with RT. This is a big gray area and your personal life priorities should factor into any final decision along with medical best practices. Find an oncologist that will work with you in that regard. Many oncologists will almost reflexively recommend the ADT+RT route without considering patient priorities (I speak from experience). There are several studies that support that approach, so it is not unreasonable. But there are also docs who will not recommend ADT as part of a salvage therapy until PSA is greater than 0.5. Unfortunately, your PSA has exceeded that threshold, a complicating factor that weighs in favor of ADT.

I do completely agree with heavyphil—when you do RT, hit the pelvic lymph nodes prophylactically.

Last year I had a local recurrence, ten years after a RARP. I was also Gleason 3+4. In my case, a small nodule was detected during a DRE, and my PSA had risen to 0.11 after ten years of being undetectable (< 0.1). PSMA PET scan confirmed that the nodule was cancerous and found no evidence of distant mets. I got opinions from three oncologists. Two recommended IMRT plus at least 6 months ADT, and one (an RO) was fine with just RT. I scoured the medical literature and listened to many video presentations by top docs. In the end, I decided that the risks outweighed the benefits of ADT in my case and did 38 sessions of IMRT without ADT (I turned 73 during treatment). But, I will say that if my PSA would have been 0.7 instead of 0.11, I might have made a different decision. I would have put a lot of thought and questioning into it, all the same.

When I made my decision to forgo ADT, I strongly considered that I have a family history of heart disease, diabetes and dementia. ADT is a documented risk factor for all three of those things. On the other hand, I do not have a family history of PCa. And yes, studies clearly show that ADT works synergistically with RT, and can achieve better outcomes at five years, but when it comes to overall survival, studies are less clear about that. This includes the much heralded SPPORT trial which found no overall survival benefit of adding ADT to RT.

Best wishes moving forward.