When to begin Salvage Radiation when BCR occurs?

I had salvage radiation last year (IMRT, 38 sessions) for a local recurrence. My PSA at the time was 0.11 on a regular test and 0.094 on an ultrasensitive test.

Now, the kicker was that it was a bit more than a BCR. I had a radical prostatectomy in 2015, and my PSA thereafter stayed below detection (<0.1) until June of 2025. However, in 2023, my urologist, during a DRE, noted a small nodule in my prostatic fossa. My PSA was still undetectable at the time, so there was no further action other then continued PSA testing. When I crossed over into detecatble territory in June 2025, things took off.

A PSMA PET scan, followed by a pelvic MRI was ordered. Both strongly indicated that the nodule was a cancerous lesion. On the PET scan, the nodule showed intense activity with a maximum SUV of 13.3. Neither scan showed evidence of distant mets. Interesting to note that PSMA PET scans usually do not pick up anything at such a low PSA, but then I had a palpable, cm-sized nodule, not just some mircomets. Although DREs seem to be on the outs theses days, it was a crucial/critical part of my relapse diagnosis. Saved by the finger!

Anyway, radiation therapy was the recommended route, and sooner than later. None of my docs thought that waiting was a good idea. I was in the gray zone when it came to adding ADT. In the final analysis, I decided against it.

Almost a year after finishing radiation therapy, my PSA is still hovering around 0.1. Only time will tell if it goes up or down. For now, in the words of my urologist, my PSA is "low and stable".

I still think that moving forward with treatment at such a low PSA was the right decision. No second guessing there.

That's my story, and I'm stuck with it.

Mel

@melvinw
Thank you for taking the time to share. I am interested in situations such as yours' as my doctor has stated they will not begin ANY type of treatment until I reach .2 uPSA. Won't even consider it even if it should get there quickly. Also, haven't found the MD yet that will do a DRE post prostatectomy. I like the sound of what your doctor is doing. Best going forward. Thanks again, Tom

All studies show big advantage of having even "blind" RT before uPSA goes over 0.2 .
My husband has very aggressive cancer (gleason 9 with cribriform and IDC) so we had an agreement with RO and MO that RT will start possibly even at 0.1 .

BUT, when uPSA started rising nobody showed any "urgency" which drove me nuts ! Well, I made sure that my husband has PSMA scan at 0.14 and it showed 4 glands glowing and ADT was implemented immediately and than RT followed. He is now 4 weeks post RT , uPSA less than 0.006 and he will be on ADT (doublet) for 18 mos per current recommendations.

Wishing you the best of luck 🍀.

My RO said if I get to .1 we need to start radiation and ADT after PSMA, also something about radiation of lymph nodes. Not sure why lymph nodes as during RP they removed 10 and all were negative. Did have <3mm positive margin and SVI along with cribriform. I posted all this pathology and recommendations under my journey. This plan was from KUMC a center of excellence.
Now local old RO wanted to start radiation in April of 2027 after I get over the incontinence. But that is not what current thinking is , he wanted to do adjuvant treatment while KUMC say salvage treatment is just as good and delays side affects.
So far local Urologist that did RP agrees with KUMC and so does local Oncologist. But nobody seems to want to do a DRE.

I tripped .2 at 2 years with negative psma pet and 25 sessions of radiation with 6 months of ADT. 1 year later undetectable.

@chippydoo
Here is the recommendation from a well renowned oncologist.

Adjuvant radiation
Dr. Efstathiou concluded as follows:b
* Early salvage radiotherapy is favored over adjuvant radiotherapy in most patients
* Consider adjuvant radiotherapy in otherwise fit, motivated, very high-risk patients with ≥2 of the following risk factors:
* pT3b-4
* Gleason score 8-10
* pN+ Lymph node Metz
* Decipher score >0.6
* In high-risk patients, use lower thresholds to initiate ‘ultra-early salvage or adjuvant-plus’ radiotherapy
* If giving adjuvant radiotherapy, it implies high-risk disease. Thus, Dr. Efstathiou would recommend treating the prostate bed and pelvic lymph nodes, in addition to short-term versus long-term ADT, depending on risk factors
* May consider genomic classifiers or artificial intelligence tools to help with informed decision-making
* The goal is to avoid (or delay) radiotherapy in those who we can, without missing a window to cure patients who are guaranteed to recur

Here is a link to the article supplied by @surftohealth88 originally
https://www.urotoday.com/conference-highlights/apccc-2024/151546-apccc-2024-debate-how-to-best-manage-a-fit-patient-with-high-risk-localised-and-locally-advanced-prostate-cancer-how-to-select-patients-for-adjuvant-therapy-after-radical-prostatectomy-and-how-to-treat-them.html

I am a bit too late for Adjuvant therapy. Post prostatectomy 6 years. At this point, the MD is saying they will not even consider a BCR of any type until .2 uPSA is reached. I have very high risk scorings and think perhaps I should look to start any Salvage treatment before the .2 mark. Thanks.

@jeffmarc I'm a bit puzzled by the recommendation to consider adjuvant RT over salvage RT when to quote from the presentation: "An updated report of the RADICALS-RT trial of adjuvant versus early salvage radiotherapy was recently published in the Annals of Oncology. At a median follow-up of 7.8 years, there were no significant differences in freedom from distant metastases (93% versus 90%) and overall survival (HR: 0.98, p=0.92). However, patients receiving adjuvant radiotherapy had worse urinary and fecal incontinence one year after randomization (p=0.001), with fecal incontinence remaining significant after ten years (p=0.017).6"

If adjuvant RT is no better than salvage in freedom from distant mets or in overall survival and is worse as far as urinary and fecal incontinence, why would one want to undergo that?

In my own case, as a high-risk patient (Gleason 8, pT3b, but LN-negative) who would consider myself fit and motivated, no doctor I have consulted has proposed doing anything as long as PSA remains undetectable (<0.02 at the lab I've been using). In fact, I recently contacted a renowned cancer center in NYC asking about a consultation and was told to come back when/if my PSA hits 0.1.

I'm happy with following PSA and dealing with a BCR if or when it happens and otherwise getting on with life.

@optimistic

Yes, there is very small advantage but some patients would like to have that small advantage . We were advised to wait so we did not press for adjuvant even though it was available for us if we wanted it.

As with everything PC, there are many options and decisions are very individual and often subjective which is OK .

There is no full proof treatment for any stage or gleason so at the end one can only make a choice by personal preference in regard to longevity or SAs.

@tom86

I would kindly suggest that you do all of your research and be ready for BCR since there is always a lot of time needed to organize everything - from PSMA to MRI to getting approvals and deciding on a treatment and having appointments with RO and MO and having simulation done etc etc.

If we relied on DRs who went with their very relaxed pace, my husband who had fast doubling time would have started his RT much later than 0.2 which is a cut off PSA for achieving the best possible results.

So, you preferably need to have everything lined up and ready to START with RT at 0.2.