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Thoughts on treatment options?
A quick rundown of my situation:
57 yo, 188 lbs 5’10”, active, good overall health and diet, working out, no booze, smoking or drugs, good relationship, Buddhist meditator, etc
2020s - elevated PSA
Nov 2024 - biopsy, two spots that 3+3 = 6, Group 1, active surveillance
Nov 2025 - biopsy, spots are now 3+3 = 6 and 3+4 = 7 with only 10% in the 4 range, Group 2, treatment recommended.
Feb 2026 - MRI, I don’t have the details of what this showed yet
It took a few months to get back in to see urologist, the combo of the biopsy and MRI has him recommending treatment: surgery, radiation or HIFU.
I’m leaning towards radiation just to minimize potential side effects and cost for now, kicking the ED and incontinence can down the road so I can take steps to mitigate over the next few years or so. The time commitment for treatments is acceptable for me, I work from home and have a fairly light schedule.
Curious to see what others think before I contact my urologist and get started on one of the options?
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@wheel1 A quicker recovery for continence is a bonus for sure.
The article discussed how tumor location can play a factor in Retzius which uses the more complex posterior pathway and can therefore limit anterior access. So what’s your thoughts when MRI shows tumor to be anterior lateral?
God help me if my new search now involves finding a surgeon who utilizes the “Hood technique”
The hood technique, developed by Tewari et al., reinforces this perspective.9 By preserving the detrusor apron, puboprostatic ligaments, and arcus tendineus using an anterior approach, the technique replicates the structural advantages of Retzius-sparing surgery while avoiding the technical complexity of a posterior dissection. In their single-surgeon series, 88% of patients were pad-free by 6 weeks, with a low (6%) positive margin.9 These results support the notion that targeted anatomical preservation, rather than the route of access alone, drives improved continence.
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1 Reaction77 year old male...overall fit and good health...prostatectomy 2 years ago....(gleason 3 + 4). PSA now 0.29.....goes up slightly with each 3 month check....unsure about doing "salvage radiation". PSMA 3 months ago showed no cancer evident.
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1 Reaction@ireland1964
I did not know all the details at the time but now know my Surgeon’s Retzius sparing technique was the Bocciardi approach. I really never realized the difference’s. I guess you likely want to choose one and find the Doctor. I don’t know if you try googling Retzius sparing surgeons in michigan if that might help. I mentioned I also would try for a surgeon that sends off the margins for inking while you are in surgery. I know it seems like a lot to find one that does it all. If you want i could try and send my Surgeon an email and ask if he is aware of any surgeon’s in Michigan
@ken726
You may be unsure, but you should get a PSMA PET scan first. With a PSA that high, they might actually find something. If nothing is found, then you should probably follow the recommendations of the American Society of clinical oncology. Here’s an article so you can read about it
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/
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1 Reaction@ken726
If it is just going up slightly and is not in a doubling pattern I suppose you could continue with frequent PSA’s which at some point another PSMA should hopefully show where it is. .29 is definitely beyond BCR territory and many would have started salvage radiation. It almost is how comfortable you are possibly waiting for a target to appear in the PSMA for the radiation since you have not started anything yet. Your Doctor must have given you some recommendation at this point. Regardless I would not wait around long at this point getting monthly PSA’s and picking some number in your head that you and your Doctor are ready for another PSMA Pet and if that still did not show anything and your PSA is still rising, have to bite the bullet.
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1 ReactionI'm currently in need of some recommendations on potential treatment(s) for a recurring cancer myself, which was (is) much more aggressive than yours (albeit based solely upon Gleason score), so I may post much of this in a new posting here soon, in hopes of getting some experienced opinions, but here's my story . . . I hope it's helpful in some way . . .
I was diagnosed in early 2018 following a biopsy, with a Gleason score of 9 and a PSA of 90. I subsequently underwent what was called a treatment "triple-play", which was 1) ADT (Casodex + Lupron), 2) Low-Dose Brachytherapy, and 3) Seven-weeks of daily IMRT Beam Radiation. I have been cancer-free (PSA = non-detect) for eight-years ever since, until January of this year, when my 'rebounding' PSA was first detected to be 4.5.
Over those eight-months since, my PSA has slowly risen from 4.5 to its current level of 13.4, and a recent PSMA-PET scan shows recurrent 'localized' cancer, restricted to the gland itself and the right seminal vesicle. The potential for post-radiation surgery (partial or holistic prostatectomy), is unlikely, and I am actively seeking future treatment recommendations from several oncologists, including my original (treating) oncologist, the latter of whom (I'm told), is likely to call for Orgovyx, plus Abiraterone. There may in-fact be, no other treatment options available to me (focal?, etc.?), and of course, I have no real idea what my newly projected life expectancy might be (could be months or years)!
Anyway, I'll hope that some of this information (surrounding my own journey), might be of help to you in your decisions going forward, but I'll close by noting two key things . . . 1) I would strongly recommend more specific diagnostic imaging to map specifically where the cancer is located (i.e., PSMA-PET scan), and 2) Any radiation treatment(s) MAY preclude you from future surgical options, should recurrence take place thereafter.
Best of luck to you!
@toomany If confined to the prostate you can get Cyro or other ablation therapy that will eliminate the lesion. Current Cyro is MRI guided so more accurate than in the past. There are failures with all treatments, including surgery followed on by salvage radiation.
@toomany
It might be possible to use proton radiation to radiate those spots that are in the prostate area.
Here are some other options
Recurrence after radiation - focal therapy or surgery
People who have radiation as their primary treatment have been told by doctors that surgery isn’t really an option if there’s a reoccurrence. Other options are not really mentioned..
This study shows that both salvage focal therapy (HIFU and cryotherapy) and salvage surgery were equally effective at extending the life of a patient that started off with radiation.
Those that had focal therapy had fewer perioperative complications.
https://jamanetwork.com/journals/jamaoncology/article-abstract/2844900
@wheel1 I guess in a perfect world I’d simply find a facility experienced in Retzuis Ralp and they would evaluate my MRI, tumor location and biopsy etc to determine if an anterior approach using the Hood-sparing technique or the posterior approach with the Boccardi was best option.
My gut tells me it’s not gonna work that way
@ireland1964
All one can do is hopefully reach a level of confidence in the surgeon one finally selects. All of your research at least helps you in having questions for the Doctor’s and you can also evaluate them on their knowledge regarding these other techniques and see their responses to your concerns and how they address them.
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