Is hormone therapy necessary with radiation?

I haven't posted for awhile; my story is many posts back in this thread. In short, I have aggressive cancer that has returned after RALP in 9/25 and I am beginning treatment this week.
I started radiation therapy for my pelvic region and lymph nodes today--smooth start.
I met my medical oncologist yesterday for the first time (Dr Paller at J. Hopkins) and really liked her. She agreed to my request for the Estradiol patch (which I started today) and then we discussed Nubeqa v Zytiga (with prednisone). I ultimately decided on Zytiga because: 1) The study (NRG-GU006 / BALANCE) showing significant benefit of using a second drug in addition to ADT for patients in the Luminal B subgroup (like me), used Zytiga as the second drug; 2) She preferred to keep the Nubeqa in reserve for later recurrences (consistent with the NCCN guidelines); 3) There are mixed thoughts about which drug has worse side effects (including in this thread).
I will start these drugs tomorrow.
I still am on bicalutamide; it dropped my PSA from 0.215 to 0.133 in one week--not bad. I will stop the bical when I switch to Zytiga. I had hoped to start treatment before reaching 0.2, as that leads to better outcomes, but 0.215 is not that bad.
Thanks to all of you for your encouragement and interest.

I am trying to get feedback from others who have been through salvage radiation plus ADT, especially regarding how long to stay on ADT. Here is my prostate cancer history:

I was originally diagnosed with prostate adenocarcinoma, clinical stage cT1c, with a PSA of 14.97. My biopsy Gleason score was 4+4. I had a robot assisted laparoscopic radical prostatectomy in January 2025.
Final pathology after surgery confirmed prostate adenocarcinoma, Gleason score 4+3, Grade Group 3, pT3aN0M0, AJCC Stage IIIB. Margins were negative, lymph nodes were negative, and there was no seminal vesicle involvement.

However, there were several adverse features, including lymphovascular invasion, perineural invasion, and focal extraprostatic extension in the right posterior dominant nodule. My Decipher score was high, around 0.84 to 0.85. After surgery, my PSA did not become undetectable. My post prostatectomy PSA readings were:

Before surgery PSA: 14.97
April 2025: 0.11
June 2025: 0.15
Later readings gradually rose to around 0.17 to 0.18 before salvage treatment.

Because the PSA persisted after surgery and gradually rose, my doctors treated it as likely residual microscopic prostate cancer, even though imaging did not show visible metastatic disease.

I started Orgovyx, on October 14, 2025. I started salvage radiation on November 20, 2025, after about five weeks on Orgovyx. I completed 39 radiation treatments after surgery.

My current bloodwork after radiation and while on Orgovyx shows my PSA is less than 0.01. My testosterone on April 6, 2026 was 9.2, so Orgovyx is clearly suppressing testosterone.

My doctor would prefer I stay on Orgovyx for at least 18 months. He even mentioned 24 months. I am trying to understand whether extending closer to 18 months provides a meaningful benefit in a case like mine, given the high Decipher score, persistent PSA after surgery, and adverse pathology, versus the side effects and quality of life impact of longer ADT.

Because my PSA is currently being measured while my testosterone is extremely low, I understand that I may not know my true post radiation PSA behavior until testosterone starts to recover after stopping Orgovyx.

I would be interested in hearing from others with similar pathology, persistent PSA after prostatectomy, salvage radiation, and ADT. How long did you stay on ADT, and what factors helped you decide between 6, 12, 18, or more months?

I am only 58 years old so I worry the damage Orgovyx is doing internally. I am active, healthy, 6' 174 lbs. Side effects really are minimal. I see a little loose weight gain around my stomach, lost some muscle tone and get the hot flashes when I sleep. I would prefer to stop taking Orgovyx if it doesn't improve my survival outcome by much.

@tj1967
I have run into a lot of people with equivalent issues to what you have. I do attend nine advanced prostate cancer meetings every month So I hear a variety of cases.

You have a very aggressive case of prostate cancer. There is just no doctor that would recommend you’d be on ADT for less than 18 months.

You have a high Gleason score. You have a pT3a, EPE, A PSA that never became undetectable after surgery, Which is a major issue. You can stop Orgovyx sooner than 18 months, But your PFS (progression free survival) is probably going to be very short.

It would make a lot of sense for you to attend an ancan.org Advance prostate cancer weekly online meeting. They’ve been helping people 15 years with prostate cancer treatment questions. They’re very experienced with working with people with your level of cancer. I know what they would say, 18 to 24 months for sure. They have been seeing people with your level of prostate cancer after treatment and those that survive the longest stay on ADT.

I got prostate cancer at 62 and had surgery, 3 1/2 years later, it came back and I had salvage radiation. 2 1/2 years after that, it came back and I went on ADT. I’ve been on it for eight years now. Yeah, it gave me a little bit of a belly, but I’m 6‘4“ tall and weigh about 189. I walk on the track a mile twice a day (I was running, but my Orthopedics said stop because of my new hip), And I go to the gym three times a week and work on my muscles, So I don’t lose any more muscle strength. I also take a bone strengthener, Though I just finished and what I took will last a year or more. I am 78 and You would never guess I had prostate cancer and was on ADT for so long.

If you’re keeping good shape and exercise, ADT won’t have a major effect on you long term.

If it continue to have a problem with hot flashes at night, there are a lot of solutions, Come back and ask for help.

I am trying to get feedback from others who have been through salvage radiation plus ADT, especially regarding how long to stay on ADT. Here is my prostate cancer history:

I was originally diagnosed with prostate adenocarcinoma, clinical stage cT1c, with a PSA of 14.97. My biopsy Gleason score was 4+4. I had a robot assisted laparoscopic radical prostatectomy in January 2025.
Final pathology after surgery confirmed prostate adenocarcinoma, Gleason score 4+3, Grade Group 3, pT3aN0M0, AJCC Stage IIIB. Margins were negative, lymph nodes were negative, and there was no seminal vesicle involvement.

However, there were several adverse features, including lymphovascular invasion, perineural invasion, and focal extraprostatic extension in the right posterior dominant nodule. My Decipher score was high, around 0.84 to 0.85. After surgery, my PSA did not become undetectable. My post prostatectomy PSA readings were:

Before surgery PSA: 14.97
April 2025: 0.11
June 2025: 0.15
Later readings gradually rose to around 0.17 to 0.18 before salvage treatment.

Because the PSA persisted after surgery and gradually rose, my doctors treated it as likely residual microscopic prostate cancer, even though imaging did not show visible metastatic disease.

I started Orgovyx, on October 14, 2025. I started salvage radiation on November 20, 2025, after about five weeks on Orgovyx. I completed 39 radiation treatments after surgery.

My current bloodwork after radiation and while on Orgovyx shows my PSA is less than 0.01. My testosterone on April 6, 2026 was 9.2, so Orgovyx is clearly suppressing testosterone.

My doctor would prefer I stay on Orgovyx for at least 18 months. He even mentioned 24 months. I am trying to understand whether extending closer to 18 months provides a meaningful benefit in a case like mine, given the high Decipher score, persistent PSA after surgery, and adverse pathology, versus the side effects and quality of life impact of longer ADT.

Because my PSA is currently being measured while my testosterone is extremely low, I understand that I may not know my true post radiation PSA behavior until testosterone starts to recover after stopping Orgovyx.

I would be interested in hearing from others with similar pathology, persistent PSA after prostatectomy, salvage radiation, and ADT. How long did you stay on ADT, and what factors helped you decide between 6, 12, 18, or more months?

I am only 58 years old so I worry the damage Orgovyx is doing internally. I am active, healthy, 6' 174 lbs. Side effects really are minimal. I see a little loose weight gain around my stomach, lost some muscle tone and get the hot flashes when I sleep. I would prefer to stop taking Orgovyx if it doesn't improve my survival outcome by much.

I haven't posted for awhile; my story is many posts back in this thread. In short, I have aggressive cancer that has returned after RALP in 9/25 and I am beginning treatment this week.
I started radiation therapy for my pelvic region and lymph nodes today--smooth start.
I met my medical oncologist yesterday for the first time (Dr Paller at J. Hopkins) and really liked her. She agreed to my request for the Estradiol patch (which I started today) and then we discussed Nubeqa v Zytiga (with prednisone). I ultimately decided on Zytiga because: 1) The study (NRG-GU006 / BALANCE) showing significant benefit of using a second drug in addition to ADT for patients in the Luminal B subgroup (like me), used Zytiga as the second drug; 2) She preferred to keep the Nubeqa in reserve for later recurrences (consistent with the NCCN guidelines); 3) There are mixed thoughts about which drug has worse side effects (including in this thread).
I will start these drugs tomorrow.
I still am on bicalutamide; it dropped my PSA from 0.215 to 0.133 in one week--not bad. I will stop the bical when I switch to Zytiga. I had hoped to start treatment before reaching 0.2, as that leads to better outcomes, but 0.215 is not that bad.
Thanks to all of you for your encouragement and interest.

I haven't posted for awhile; my story is many posts back in this thread. In short, I have aggressive cancer that has returned after RALP in 9/25 and I am beginning treatment this week.
I started radiation therapy for my pelvic region and lymph nodes today--smooth start.
I met my medical oncologist yesterday for the first time (Dr Paller at J. Hopkins) and really liked her. She agreed to my request for the Estradiol patch (which I started today) and then we discussed Nubeqa v Zytiga (with prednisone). I ultimately decided on Zytiga because: 1) The study (NRG-GU006 / BALANCE) showing significant benefit of using a second drug in addition to ADT for patients in the Luminal B subgroup (like me), used Zytiga as the second drug; 2) She preferred to keep the Nubeqa in reserve for later recurrences (consistent with the NCCN guidelines); 3) There are mixed thoughts about which drug has worse side effects (including in this thread).
I will start these drugs tomorrow.
I still am on bicalutamide; it dropped my PSA from 0.215 to 0.133 in one week--not bad. I will stop the bical when I switch to Zytiga. I had hoped to start treatment before reaching 0.2, as that leads to better outcomes, but 0.215 is not that bad.
Thanks to all of you for your encouragement and interest.

I haven't posted for awhile; my story is many posts back in this thread. In short, I have aggressive cancer that has returned after RALP in 9/25 and I am beginning treatment this week.
I started radiation therapy for my pelvic region and lymph nodes today--smooth start.
I met my medical oncologist yesterday for the first time (Dr Paller at J. Hopkins) and really liked her. She agreed to my request for the Estradiol patch (which I started today) and then we discussed Nubeqa v Zytiga (with prednisone). I ultimately decided on Zytiga because: 1) The study (NRG-GU006 / BALANCE) showing significant benefit of using a second drug in addition to ADT for patients in the Luminal B subgroup (like me), used Zytiga as the second drug; 2) She preferred to keep the Nubeqa in reserve for later recurrences (consistent with the NCCN guidelines); 3) There are mixed thoughts about which drug has worse side effects (including in this thread).
I will start these drugs tomorrow.
I still am on bicalutamide; it dropped my PSA from 0.215 to 0.133 in one week--not bad. I will stop the bical when I switch to Zytiga. I had hoped to start treatment before reaching 0.2, as that leads to better outcomes, but 0.215 is not that bad.
Thanks to all of you for your encouragement and interest.

@tj1967 ADT has the greatest effect the first 6 months after radiation. Additional benefit declines as months increase. Some studies have shown that except for stage 4 disease ADT is negative for all-cause mortality by 24 months (you have referenced a few). I doubt your doctor will agree to reduce ADT below the guidelines due to litigation risk. Better to say the patient stopped ADT against advice. You will need to decide if any reduced recurrence risk is worth the impacts additional ADT has on your life. It would be easier if you had positive margins since that would be the obvious cause of the PSA increase.

@jim18
That is exactly what I am struggling with. My PSA was low when I started treatment, so I keep wondering how much benefit there really is after 12 months. At the same time, I know my pathology and Decipher score were high risk, so I understand why my doctors are recommending longer.
I am not trying to ignore the guidelines or pretend I know more than the doctors. I am just trying to figure out whether the possible added reduction in recurrence risk from going beyond 12 months is worth the impact ADT has on my quality of life.

@bikeman1 How did you get set up with Dr. Paller? That seems like someone I would like to consult with.