What's Next After SBRT and ADT?

What’s next is getting PSA test every three months for a couple years and then every six months for the rest of your life.

With the 4+3 it may or may not come back? A decipher test will give you an idea if you are likely to have it come back.

I was a 4+3 and I’m still around after 16 years. I had surgery 16 years ago at 62 and radiation 12 years ago.

The drugs we have today keep me alive and better ones are being developed All the time. You have a long future to look forward to.

Not to be a downer, but the number one proven way of preventing prostate cancer recurrence is to die of something else before it happens. That counts as treatment success in all of the statistics and why long-term studies only count prostate cancer specific deaths. Since most prostate cancer occurs in elderly men there are more deaths from other causes than prostate cancer in the 15 to 20 year longitudinal studies.

You're in a very favourable bracket for non-recurrence. Your cancer was caught early, it was only Gleason 7, you had both SBRT and ADT, you're still relatively young, and your PSA dropped to undetectable quickly. Obviously, life doesn't come with guarantees, but IIRC your odds of surviving long enough to die of something else or old age are somewhere in the 95%+ range, unless you have some dangerous genetic mutations or the cancer is unusually aggressive (and even in those cases, there are excellent treatment options these days).

You're absolutely right that a healthy lifestyle -- good balanced eating and activity, managing metabolic health, etc -- is the best thing you can do for yourself right now. And, as @jeffmarc mentioned, frequent testing (every 3 months at first, then maybe drop to every 6 in a couple of years if all seems well).

We’re all in that same boat; some of us even on Round 2 and asking the same question: ‘What’s next?’ Well…
ADT, lutamides, SBRT, Pluvicto, Chemo…
All singly or in combination.
So don’t worry, Science has you covered!😉

The problem with recurrence is most is out of our control. The two largest factors are genetics (Decipher test mentioned can give you some insight on your situation) and how through your treatment was (positive margins on surgery, misses on radiation, or undetected micro-metastasis that PSMA PET could not detect). Read the Active Surveillance - Systematic Review post for information on lifestyle actions (the poster also has a website that covers many supplements, etc.). Exercise and diet seem to have the most impact and you have those covered. From a medical standpoint more ADT will reduce if not eliminate prostate cancer recurrence, but studies have shown that the increase in all causes of death from the ADT side effects out weights any population benefit from decreased prostate cancer death. Unfortunately, there are more snake oil cures or preventions for cancer than just about any other disease. People like to be in control, even if it is an illusion. If one of these cures gives you a sense of comfort and control than go for it. Just keep the PSA testing current with everything else you do.

For your current situation your PSA is still being suppressed by ADT and may be until early August. It is not unusual for PSA to become detectable again once testosterone returns after radiation and ADT. PSA remaining under 0.25 is predictive of a low recurrence rate while > .50 has significantly more recurrences.

There isn't a thing you can do that I am aware of. I am 4 years in and after removal went BCR after 2 years. Onto radiation and adt and 6 months post tx. undetectable. One year test coming up in July. It appears you are taking care of your body the best that you can. This is an unpredictable cancer that can lay dormant for years then pop back up out of the blue. While it is always somewhere in the back of my mind, I can usually deal with it by staying present in the moment and current day. Stay busy, live your best life and keep going is my suggestion.

@jim18

Yes, Jim you are right. Deaths from other causes do slant the statistics when claims are made that ADT's help. There are even studies that show ADT's harm all men and help a few, but the studies fail to show the price we pay due to heart, muscle, and bone damage. The studies typically ignore the down sides of ADT treatment. They always seem to only mention hot flashes as the primary side effect while ignoring the life-threatening side effects.

@pesquallie Researchers are aware of that issue, so trials typically look at "overall survival" (OS) rather than just death from cancer. They want to compare how long people in similar situations live not getting a treatment live compared to people getting the treatment. That way, if ADT reduces your risk of dying from prostate cancer, but increases your risk of dying from heart disease, it still shows up in the findings.

Other metrics are "progression-free survival" (how long people go without the disease getting any worse) and quality-of-life (QoL), but OS is the biggie.

You could research and/or ask about brachytherapy. Advocates of brachytherapy claim that external beam plus brachytherapy boost, and depending on your risk classification, more or less ADT, offers the longest freedom from recurrent disease, because the total radiation dose to the prostate is higher than any other therapy can safely produce. It may be that once the SBRT is planned and performed its too late for brachy but....

Otherwise, it seems very wise to keep up the "rigorous strength training" you are already doing.

Apologies if you are already quite familiar with this guy: the most prominent advocate of exercise as a first line treatment, or as a "what to do next" treatment is Dr. Rob Newton.

Newton published a short article with a good description of why exercise can be viewed as medicine, and what exercises to perform at different stages of a prostate cancer journey in 2022 "Prostate cancer treatment with exercise medicine" https://onlinelibrary.wiley.com/doi/epdf/10.1002/tre.884

One thing that was new to me as I read this article was this statement he made:

"As stated above, each training session causes a surge of exercise medicine, so it is preferable to spread the dosage across the week and even throughout the day. So rather than do a large volume of exercise on two or three days per week, it is preferable to perform shorter bouts over five, six or even seven days."

This is a modification to the general recommendation for exercise he cites i.e. "to accumulate 75 minutes of vigorous to 150 minutes of moderate aerobic exercise each week and two or more resistance training sessions".

I was doing 30 minutes of vigorous cardio Monday, Wednesday, and Friday, and 1 hr of resistance training Tuesday, Thursday, and Saturday, with Sundays off. I'll try this idea of spreading out the resistance training to 30 minutes every day. He suggests alternating muscle groups that are exercised, so that the same group of muscles is only subjected to resistance training every alternate day.

I wish I could see an exercise oncologist of Newton's caliber as part of my treatment to get what he is calling these days a "precision exercise" prescription.

I feel like what I'm doing with my exercise program is I can see that the field of exercise oncology has matured to the point that all oncologists are waking up to the idea that exercise is a "must have" as opposed to the idea that has prevailed i.e. "good to have", but I've been left to just guess as to what to do. Its as if I could see that advocates of ADT were starting to persuade the surgeons and radiation oncologists that ADT was a "must have" in many situations, but I was left to figure out what drug, what dosage, and what length of time I should take it for.

Newton presents much more detail in his 2025 book My Exercise Medicine for Cancer.

@climateguy

Exercise has always been important to me, but my side effects have been so painful to my bones, joints, and muscles that I have had to significantly reduce how hard I exercise. For instance, my 45-minute treadmill workout had to be reduced from 4 mph at 10% slope to 3.2 mph at 10% slope. My muscle pain level was so high that I felt that my legs had been beaten with a baseball bat.