Many years since radical prostectomy: PSA values rising

Consult with a Radiation Oncologist.

Salvage Radiation Treatment to whole pelvic floor and pelvic lymph nodes; WPRT

See SPPORT trial.

ADT - none or short term probably options; I would defer to RO.

I think that it is actually good news that you have gone 13+ yrs post-op with G 8.

May want to consider a Center of Excellence for consultation and creation/mapping of radiation treatment.

Best wishes.

I had a local recurrence last year, ten years after a prostatectomy (age 72 at time of recurrence). I did 38 sessions of IMRT without ADT. My PSA going into radiation was 0.1 and six months later it is still 0.1. My recurrence was first detected as a small nodule in my prostate bed, and a PSMA PET scan showed the nodule to be highly active.

Some thoughts regarding your situation:

- before considering ADT, get your testosterone tested. Testosterone tends to drop with age.

- if you do IMRT, hit the pelvic lymph nodes as well as the prostate bed. Research studies have shown that this yields better outcomes.

- IMRT alone can cause pronounced fatigue (resolves a few weeks after therapy). Adding ADT can turn that into extreme fatigue. Vigorous exercise can help with the ADT induced fatigue. I don’t know what your physical condition is, but I would have a serious conversation with your docs about the impact on your quality of life from the treatments. On the flip side, the side effects of ADT often diminish with age, mostly because testoterone is lower. Only you can decide if it either of the therapies are worth it or not.

- oncologists especially can get focused on curing disease over treating patients. If you have a trusted PCP, perhaps have a frank and open discussion conversation with him/her about your treatment options and quality of life. They tend to have a more patient centered view.

- get a second opinion. I actually got opinions from three oncologists before initiating radiation therapy.

- folks often focus on the immediate side effects of ADT like hot flashes, fatty weight gain, breast enlargement, penis shrinkage, etc. But there are also metabolic side effects such as increased risk of cardiovascular disease (including death from stroke and/or heart attack) and cognitive decline. Gather information on these risks relative to your health and medical conditions before finalizing any decisions. Many folks here are as knowledgeable as your docs, and often are more forthcoming.

- not all hormone therapies (ADT and ARPI drugs) are created equal in terms of side effects. As Jeff noted, Nubeqa (darolutamide, ARPI in pill form) is often well tolerated. In contrast, Lupron (leuprolide, ADT given as an injection) often has some brutal side effects. Learn everything you can about hormone therapies before agreeing to any doctor’s recommendation. Again, the brain trust in this group can really help you with that.

- radiation therapy will require “full bladder and empty rectum” to be most effective and to mitigate radiating healthy tissues. This can be achieved by proper dietary adjustments but it can be a daily stressor during treatment as well. Best to make necessary dietary adjustments at least a couple weeks before initiating radiation therapy. As with hormone therapy, get well informed about what to expect before starting treatment.

- the fact that 25 years have passed until your PSA rose above detection is in your favor (suggests non-aggressive cancer), but on the other hand, a PSA of 5.2 is concerning. For post-prostatecomy men, a PSA of 0.2 is usually considered evidence of a biochemical recurrence.

Best wishes with however you decide to go,
Mel

Layman comment: WPRT to entire pelvic floor and pelvic lymph nodes; see SPPORT trial.

Personally, I would think hard about ADT at 87: None or short course.

At 73, I had short term ADT w/ SRT post RP. And the ADT had an impact that I found "unpleasant". Tx has been effective for almost 3 yrs; undetectable PSA so far.

As heavyphil noted, ADT usage seems to be moving toward less or none in older, longer to recurrence patients.

Consider a 2d opinion from a Center of Excellence.

Best wishes.

This blows me away: "25 years" without issue, and the cancer STILL reared its ugly head again. Unreal. I just pray that I never have to cross this bridge, but if I do have BCR at some point, and I am presented with the recommendation for ADT, I will decline....ADT is my "line in the sand." You are literally messing with your brain...the hormonal control of your body...when on ADT. I've even hated the handful of times that I was on Prednisone in my life.
Jeff Marchi is well-respected here on this blog...I would go with his recommendation...with the approval of your physician of course, who has to write the Rx for the Nubeqa.
May last thought is that being 87 years of age, has your physician told you how long you might survive if you don't take any meds or do anything else? What is the history of longevity in your family? If you could hit 95 - 100 years of age with a good quality of life "without" medicine, and a slowly growing return of your cancer, then I wouldn't do a thing. Good luck to you.

@heavyphil
I went in at 7 AM yesterday for the procedure. It was started at 9 AM and by 1230. I was heading home. The nurse in recovery said I woke up quicker than most people.

I have some pain from it, but I’ve been taking Tylenol since the first time I took one 5mg oxycodin yesterday afternoon. Slept pretty good last night, though I did have to get up to pee, which I don’t normally have to do. That is difficult, a little painful. This morning, I’m not feeling bad at all. Biggest problem is sitting down. They open you up in the perinium and stomach. The 2” stomach opening doesn’t bother me at all, The perinium opening makes it really hard to sit down without it hurting and burning, But it’s not very painful laying down. I may have a high threshold for pain, I don’t know how to compare it to other people.

The doctor running the ancan.org Speaking freely Meeting last night was impressed that I wasn’t in more pain. He said when he was done, he felt like he had razor blades in his body that were just cutting him up. The pain went on for weeks. I know the doctor I had do it was real experienced at it. My oncologist said she was a real artist. My results seem to be among the better results I’ve heard from people..

@melvinw
Dear Mel,
thanks for the extensive replies. I also think that I shall consult different people before deciding what to do. Actually, my PSA was never close to zero over the years: well below 1.0 from the beginning and rather static for about 20 years. I noticed a linear increase in the last four years: four units in four years. I have read that exponential growth is dangerous, so in my case I do not have it. The PET activity identified also linphonode activity in the pelvic region, so perhaps something has metastasised. I also feel that ADT is really too heavy with SE so it may be useful in more aggressive cancer cases, while focussed, rotating photon beams may be less damaging in the long term. However, since all data indicate slow growth of this type of tumours and I am 87 years old, should I not let sleeping dogs lie? Something else will keep me within life expectation in the actuarial sense!
FAG

@fag
The problem is, Prostate cancer tends to go to the bone. It then become becomes quite painful. You Don’t want to be in that position.

My father died of prostate cancer at 88. I remember when he told me Lupron stopped working, but I didn’t know what it really meant at the time. There was no other solution. He had his teeth ground down and crowned without Novacaine When I was a teenager. He came home at night after he had it done and ate dinner with us. An incredible pain tolerance. In the last few weeks before he died, he was on so much morphine he couldn’t communicate. The pain was just that severe.

There are options, Do you really want your last year to go like that?.

@chippydoo
The Axumin and Choline scans Can sometime find prostate cancer. The PSMA PET scan is the industry standard Because it can specifically find PSMA In the body, which is produced by prostate cancer, though other parts of the body produce it as well.

The FDG PET scan is not designed for finding prostate cancer because it looks for glucose. That is consumed by neuroendocrine prostate cancer so that test can be used for those advanced cases.

Dear Jeff,
Of course you are right: prostate cancer is slow but can go somewhere else where it will be faster indeed.
I will consult with various oncologists and make a decision: it is all very recent and mental processing usually takes time! My hunch is that ADT has worse consequences than IMRT: the first oncological group was pondering to use only radiation and not hormonal depressing therapy..
I shall certainly keep fighting since I am still busy working with my head: that is why memory losses and un-focussing worry me a lot..
Thanks for sharing your thoughts
FAG

Your PSA is growing so slow - it needed years to come to 5 and also you had such a long cancer free period. It all points to the fact that your cancer is very indolent (slow growing) and there is no rush for any treatment. Take your time and perhaps ask for a second opinion. There is now even new approach of not treating indolent cancer even in metastatic stage if it does not effect quality of life, but it is still very novel idea.

According to new studies no ADT is needed for low risk cancer. However, your PSA is about 5 , so short term ADT might be beneficial (here they mention 4 months to 6 months) .
https://www.urotoday.com/video-lectures/advanced-prostate-cancer/video/5413-poseidon-meta-analysis-re-examines-the-role-of-adt-with-salvage-radiation-for-prostate-cancer-amar-kishan.html
But again, considering your age, you do have very valid point of questioning using ADT. As @jeffmarc suggested, you could ask for Nubeqa - it has very little side effects.

Wishing you super successful RT treatment and zero side effects 🍀🌺.