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Salvage Radiation Therapy with or without ADT added?

Posted by animate @animate, May 2 8:13pm

I am the point where I need to get Salvage Radiation Therapy. I had RALP in November 2025 and now, 6 months later, my PSA has presented an increasing tendency, 0.18, 0.19, 0.21 in the last test results, over the past 2 months.

In my recent consultation appointment with my Oncologist, the plan is that I do need to get SRT. At that time, he ordered a PET PSMA CT scan and leaned strongly about adding 6 months of ADT, regardless of the results of the scan. He explained that the scan would be just to define if the target is only the prostate bed, or anything beyond that also.

I just got my PET PSMA scan results and these came out perfectly clean. Nothing showed up, fortunately.

I have researched about the need or benefit of adding ADT in my particular case and it seems like I am right at the gray line, where it might or might not be of significant benefit.

I am 56, my Adverse Factors are : 3mm Positive surgical margin post-RALP (pattern 4), Gleason 4+3 (high proportion of pattern 4), Low tumor volume (5%), Early PSA rise (< 6 months); my Favorable Factors are: pT2 (no extracapsular extension), pN0 (clean lymph nodes), Negative PSMA PET. Side effects from RALP: zero incontinence, ED gradually recovering.

My big dilemma at this point is trying to ponder the tradeoff between possible added benefit vs side effects of ADT. ADT might not add any significant benefit in my case, but it might not be as bad as to not accept the marginal benefit that it could provide for me. On the other hand, the marginal added benefit might not be worth the possible side effects. Without being completely certain of making the right decision, I am leaning more towards avoiding it.

I have my next appointment with my Oncologist scheduled, where we will review my PET PSMA scan and define the final plan. I would greatly appreciate any comments and shared experiences regarding this big decision, that will help me be better prepared, with good supporting arguments, when discussing my treatment plan with my Specialist.

Thank you.

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icorps | @icorps | May 6 10:28am

Animate
You might check this out to help in your decision

ADT with SBRT versus SBRT alone for hormone-sensitive oligorecurrent prostate cancer (RADIOSA): a randomised, open-label, phase 2 clinical trial

Giulia Marvaso et al. Lancet Oncol. 2025 Mar.

"To our knowledge, the RADIOSA trial represents the first randomised trial in the metachronous oligometastatic hormone-sensitive prostate cancer setting to report improved clinical progression-free survival with the combination of SBRT and a short course of ADT, although carefully selected patients might still benefit from SBRT alone. By demonstrating improved clinical progression-free survival, the RADIOSA trial reinforces the role of metastasis-directed therapy in delaying systemic treatment escalation. Additionally, it underscores the need for further studies to determine the optimal duration of ADT and identify biomarkers predicting response to SBRT alone."

Good luck!!

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michaelcharles | @michaelcharles | May 9 1:33pm
In reply to @animate "@heavyphil Thank you for your response. I do see your point about suggesting to go with..." + (show)
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@heavyphil
Thank you for your response. I do see your point about suggesting to go with the 6 months of ADT. You mention that it is temporary but I have read that some of the effects are not fully reversible and that some permanent damage might occur. The cardiovascular damage is one of my biggest concerns.

My Oncologist did suggest that radiation to the pelvic lymph nodes would be required, besides the prostate bed. Thank you for pointing that out.

I just checked the SSPORT trial that you mention. Very interesting study that does confirm the substantial benefit of adding treatment to the lymph nodes. Thank you and thank you for the encouragement!

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@animate
I had SRT w/ short term ADT after persistent PSA of .19 post RP consistent with the SPORTT trial.
Didn't like it but at the end of radiation, I was glad that I had agreed to the ADT as part of my salvage treatment. I only had 1 chance to have effective SRT and went with my ROs recommendation.
No permanent effects that I have noticed since ADT wore off, which was 4 - 6 mos after completion.
Best wishes

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animate | @animate | May 11 4:13pm
In reply to @michaelcharles "@animate I had SRT w/ short term ADT after persistent PSA of .19 post RP consistent..." + (show)
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@animate
I had SRT w/ short term ADT after persistent PSA of .19 post RP consistent with the SPORTT trial.
Didn't like it but at the end of radiation, I was glad that I had agreed to the ADT as part of my salvage treatment. I only had 1 chance to have effective SRT and went with my ROs recommendation.
No permanent effects that I have noticed since ADT wore off, which was 4 - 6 mos after completion.
Best wishes

Jump to this post

@michaelcharles

Thank you very much for sharing your experience. Good to hear that ADT did not leave any noticeable effects on you.

May I ask how soon after your RP your PSA started climbing and at what rate? Mine has steadily increased from .18 to .22 over the past 2.5 months, being now at 6 months post RP. I am not sure to what extent this is considered to be a moderate or fast PSA increase.

How long after your RP did you get your SRT + ADT and how long has it been since you finished the treatment? I assume that you are glad to have agreed to get ADT as your PSA has remained favorable?

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michaelcharles | @michaelcharles | 6 days ago

Animate:
RP at age 72 in Aug 2022. My 1st PSA test 90 days post-op in Nov reported .19 (confirmed 30 days later at .18).
So my post-op PSA never was undetectable and it was called "persistent".
FYI: My lymph nodes, seminal vesicles and margins were clear; and nonfocal EPE was reported on the surgical path report.
My surgeon referred me to a RO, who saw me in December.
I began ADT Orgovyx in Feb 2023, radiation Mar - May and ended ADT June.
My 1st post SRT uPSA was taken 6 mos after radiation ended in Nov 2023 and reported undetectable < .02 thru Quest Diagnostics.
And I have continued undetectable on all of my quarterly uPSA tests.
I couldn't be happier with the results of my treatment.
Also, I want to note that my radiation treatments were to the pelvic floor and the pelvic lymph nodes (WPRT), also consistent with the SPORTT trial.
And all of my treatment was by Johns Hopkins and it's Physicians.
Best wishes to you in your decision making.

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animate | @animate | 6 days ago
In reply to @michaelcharles "Animate: RP at age 72 in Aug 2022. My 1st PSA test 90 days post-op in..." + (show)
Profile picture for michaelcharles @michaelcharles

Animate:
RP at age 72 in Aug 2022. My 1st PSA test 90 days post-op in Nov reported .19 (confirmed 30 days later at .18).
So my post-op PSA never was undetectable and it was called "persistent".
FYI: My lymph nodes, seminal vesicles and margins were clear; and nonfocal EPE was reported on the surgical path report.
My surgeon referred me to a RO, who saw me in December.
I began ADT Orgovyx in Feb 2023, radiation Mar - May and ended ADT June.
My 1st post SRT uPSA was taken 6 mos after radiation ended in Nov 2023 and reported undetectable < .02 thru Quest Diagnostics.
And I have continued undetectable on all of my quarterly uPSA tests.
I couldn't be happier with the results of my treatment.
Also, I want to note that my radiation treatments were to the pelvic floor and the pelvic lymph nodes (WPRT), also consistent with the SPORTT trial.
And all of my treatment was by Johns Hopkins and it's Physicians.
Best wishes to you in your decision making.

Jump to this post

@michaelcharles
Thank you for your detailed clinical history. It seems like my case is similar to yours. I hope that I turn out as well as you have, regardless of whether I end up with ADT or not, which will be decided later this week with my Oncologist.
Much appreciated!

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michaelcharles | @michaelcharles | 6 days ago

Ye, I thought so also.
Best wishes

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bikeman1 | @bikeman1 | 1 day ago

I already posted the following in another thread, but I will add it here too, since it is relevant:
On the question of "who benefits from ADT and is it worth the side effects"? I just had an appointment with my RO at Johns Hopkins where he considered whether to add ADT to SRT. (Short story: I had RALP in 9/25; PSA still low but rising; aggressive cancer (IDC, Cribriform, EPE, Decipher .89, but clean margins on pre-surgery PET). The determining factor for him to add ADT was the detailed report that accompanied the Decipher one page summary. It showed I had Luminal B, an aggressive subgroup. The trial (which has not yet been peer reviewed) NRG GU006 (BALANCE) showed a clear benefit of adding apalutamide to SRT. If you have a high Decipher score, ask your doctor to get the detailed report that accompanies the one page summary. You can also google "NRG GU006 (BALANCE) and Luminal B" to see a discussion of the study.

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