Xtandi or Xtandi + Hormone Shots? I am trying to make a decision.

The prostate bed is radiated because that is where the cancer usually is. PSMA scans have not been around that long so if a bone scan did not pick up a metastasis the prostate bed was treated blindly. Still doing that if PSMA does not pick up anything. PSMA misses a lot with low PSA. It may be high enough by October to pick up something. By then the suggested treatment will probably be radiation plus short-term hormones.

The other option is to treat systematically with hormone therapy for life. At 79, if you go on ADT there is a good chance that your testosterone will never recover. More likely the lower your testosterone is prior to ADT. If not in excellent health this may be easier.

It is highly recommended to get Salvage radiation when your PSA hits .2 after a prostatectomy. You’ve gone way beyond that and as a result, it is recommended that you get ADT + an ARPI (like Xtandi) As long as you have an aggressive case of prostate cancer. If it’s not aggressive, you can avoid the ADT.

If it were me, I would ask the doctor for Nubeqa (Darolutamide) Instead of Xtandi (Enzalutamide). Nubeqa has no side effects for most people while Xtandi does have noticeable side effects for most people.

The American Society of clinical oncology has recommendations for what to do after your PSA has risen following a prostatectomy. Here are those recommendations. As you can see, you are beyond the point where you should’ve had treatment. The reason they treat the prostate bed is because that is the most likely place where cancer has started to appear and is in a state that is too small to be seen by tests.

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/

I think prostate cancer treatments should be directed by an oncologist. The Urologists are surgeons and are knowledgeable about the plumbing issues of the urinary system, but cancer is not their specialty. You should seek out an oncologist that specializes in prostate cancer, preferably at a center of excellence.

Jeff Marchi has given you good advice. I would add one item, if you are placed on ADT ask for ORGOVYX. It is a pill that you take every day. It suppresses the testosterone quickly and the recovery of testosterone when you stop taking it is much faster than the other ADT choices. Also it is easier on the heart. In trials it had less cardiovascular adverse events that other ADT medications. In the event that Orgovyx is not approved ask for Firmagon. It is similar in its effect on the heart. It is monthly injection, that causes a bit of pain for a couple of days right after the injection. I am on Firmagon.

ADT even with Xtandi or Nubeqa is not curative. It suppresses the cancer and delays its progression. Eventually it stops working and you have to progress to other treatments. Salvage radiation is potentially curative.

Perhaps you are concerned about the effects of radiation. Every man is different, but I considered the radiation of my prostate last year with 28 sessions of IMRT to be a “walk in the park”. I had only mild adverse effects that were quickly resolved without treatments. I went to the gym right after the radiations session 3 days a week. I was 91 then.

Embark Phase III trial has robust results for XTANDI and ADT. I opted to go with monotherapy using just XTANDI and 4 months into it and PSA is 0.05. As compared to Eligard & Zytiga, the side effects are very minor, a bit of nipple sensitivity (which is confirmed via the studies) and I experience very intense dreams (but that might be related to other factors, who knows!).

I would concur with other input that the best management practices for BCR PCA should be performed by an oncologist, but in all cases, the patient surely has a role to advocate and educate themselves.

(By way of reference, I'm 55 and 14 years into this prostate cancer journey)

Onward!

Well, there are various possibilities...

First thing, PAs are nice, I had a consult with my oncologist's APRN when he was called off for hospital rounds. That went well, she was an active listener, supported my decision.

Yet, if, when, it comes time to make a treatment decision, I want my oncologist.

So, two things to start:

See an oncologist.

Consult with a radiologist.

If you stay with the urologist, you're making a treatment decision, that should move you to the front of the appointment line.

As to a treatment decision...

In part, that could be a function of co-morbidities, life expectancy and your tolerance for side affects.

You could wait to see if imaging shows where, what, your recurrence is.

That might open up the possibility of MDT, kicking the can down the road for systemic therapy. From my foxhole, the risk of one's PCa getting out of control while waiting for PSMA to locate activity is not undue.

That's a long time from surgery to BCR but the GS and PSADT and PSAV indicate high risk.

Still, the flash to bang time before serious metastases could be awhile so continuing to monitor and decide later is a possibility.

You could shoot blind, SRT to the prostate bed only but given the clinical data, likely an epic failure.

You could do SRT to the prostate bed, include the pelvic lymph nodes, add short term systemic therapy, 6-24 months, Orgovyx...

You could do ARI monotherapy as others have pointed out was done in the EMBARK trial.

What would I do were I you?

See an oncologist.
Consult with a radiologist.
Wait until a scan showed what you are dealing with. There are other scans your medical team can and should discuss with you that may better locate activity.

Decide.

Kevin