Prostatectomy and Radiation - Now what?

If I were you, I would want a new PSMA PET scan prior to any treatment beginning. It may be just a spot or 2 that can be zapped with SBRT but you have to find it first. Any other treatment decisions would be based on where it is and how much. Have you had any genetic testing of previous tumors or blood? That may provide further insight. Sorry you had to jump back in the fray.

I did IMRT as primary treatment because I was already metastatic when diagnosed. ADT/ARSI since June 2025. Lowest PSA was 0.19 but became castrate resistant about 6 months later. SBRT to spinal bone met in May 2026. Started chemo (Taxotere) a couple weeks ago. Somatic testing showed a TP53 mutation so if chemo doesn't work, Pluvicto is not in my toolbox but may be in yours. Hope that gives you some idea of what's out there. Best wishes! 👍

@mjp0512
I did have a decipher score of 6.1 which was just in the .1 in the high range. I suspect I be asked to do the PSMA PET scan again. I am 63 years old and hoping a small spot is all that is found. The SBRT just shot the prostate bed as nothing showed up in PSMA PET scan. I obviously worked as my PSA score was down to .04 for almost a year. I wasn't sure what options were available after both treatments completed. I have not had genetic testing. Thanks for your comments and yes.... not thrilled to be back in the fray!

@rjnoonan - Short of finding a specific lesion to zap, I would think that ADT/ARSI would be a next step, although, you don't mention if you've already had them.

@mjp0512 I have been on Orgovyx for 16 months with Testosterone of 13 as of 4 days ago. I am not sure I know ARSI but I will chatGPT it.
Thanks

I believe ARPI is the correct acronym for Androgen Receptor Pathway Inhibitor?

Just read arsi and arpi are the same thing. I'll never get all these acronyms remembered.

@rjnoonan ARPI/ARSI = Nubeqa, Erleada, Xtandi. Abiraterone and Prednisone (for side effects) has slightly different method of action but is included with the 3 above and is often first since it is generic. The other 3 are over $10K per month in USA. Will probably be prescribed one of these 4 even if it is just a few spots that can be zapped with SBRT radiation. Want the PSMA PET since if spots can be identified the Chemo will probably be held for later.

@rjnoonan - I too have been on Orgovyx since June 2025. Along with that, I was on Nubeqa over the same period. It became obvious that since my PSA kept going up, this ADT/ARSI combo became ineffective. Scans confirmed extensive bone metastasis. Next step for me was Taxotere (Docetaxel). Carboplatin / Cabazitaxel would be a next step should docetaxel fail.

Please stay in touch after you meet with your Dr. I'm hoping that if you are recurrent, they find a small spot or 2 that can be zapped and you can avoid systemic treatment.

I had a prostatectomy in 2010 and in 2014 my PSA started rising again so I had salvage radiation. 2 1/2 years later, my PSA started rising again, so I went on ADT. These days you could also go on estradiol, which Has a lot fewer side effects.

Have you had hereditary genetic testing? Is there cancer in your family? It could be you have a genetic problem like I do and that’s why it keeps coming back. There are treatments for some genetic issues.

ADT (Lupron) kept my PSA low for 2 1/2 years, but then I became castrate resistant and had to go on an ARPI, In my case, it was Zytiga. After 2 1/2 years on Zytiga, I switched to Orgovyx And Darolutamide. That has kept me undetectable for the last 35 months.

There are treatments for what you have, My case I’m 12 years past salvage radiation. A rising PSA is not a death sentence with the drugs we have available today.

"What treatments will be available to me...?"

The answer...

It depends!

On what?

Your clinical data...

You have some of it:

Prior treatment.

Pathology report from surgery.

GS
GG
PSA results...

I assume your SRT was to the prostate bed only?

If so, question is where is the PCa activity now that is causing an uptick in my PSA?

The only way to know that is through imaging, PSMA PET.

The question, when do we image and with what?

That's a discussion and decision between you and your medical team, depending on your insurance, that may factor in the discussion. Intuitively, the higher one's PSA, the greater the likelihood imaging shows something actionable.

Depending on your risk category as defined by your clinical data such as GS, Grade Group, PSADT, PSAV and imaging you'll have decisions to make:

Do nothing, continue to monitor.

MDT only to site(s) identified in the scan.

Doublet or triplet therapy though the latter generally reserved for high volume, bone, organ...cases.

SBRT could be added to the doublet therapy of imaging shows where recurrence is.

How long and which agents for doublet therapy? Generally 6-36 months with low risk on the left, high on the right. Which agent, Lupron vs Orgovyx, which ARI...discuss side effect profiles with your medical team and any insurance issues.

Think of it this way, you don't have the clinical data to discuss treatment options. So, the better question may be:

What clinical data do I have now?
What clinical data do I need to determine if I need treatment, how do I gather it?

Once you've done that then discuss treatment options with your medical team, include:

Which agents in systemic therapy.
How long?
Radiation?
De-intensification criteria?

Start with the guidelines such as NCCN, AUA, look for pertinent clinical trials, discuss outcomes you are seeking, PFS, RPFS...

Balance treatment side effect profiles with impacts on outcomes.

In my last two treatments, triple and doublet, that's the model I've used.

In triplet therapy we planned 24 months of Lupron, stopped at 18 given my response, did not add the ARI.

Similar for doublet, did 12 vice 24 months systemic therapy, did not add the ARI.

Kevin