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When to begin Salvage Radiation when BCR occurs?

Posted by Tom @tom86, Oct 7 12:27pm

Is Salvage Radiation done prior to .2 PSA to get ahead of the BCR? I know some radiologists do this. Some MDs still want to wait until it can be seen on a scan. Any experiences that can be shared? TYIA

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wheel1 | @wheel1 | Oct 8 6:25pm
In reply to @optimistic "@jeffmarc I'm a bit puzzled by the recommendation to consider adjuvant RT over salvage RT when..." + (show)
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@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.

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@optimistic
You are absolutely right. Everyone can make their own decisions what is right for them but need the information to make that decision. All you will hear is OS was better and higher, you won’t hear however when it comes to the 8 year mark one has a higher incontinence and fecal incontinence level. Factor that in and well explained to the patient it could make changes in their decision.

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Jeff Marchi | @jeffmarc | Oct 8 9:59pm
In reply to @tom86 "I am a bit too late for Adjuvant therapy. Post prostatectomy 6 years. At this point,..." + (show)
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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.

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@tom86
The American Society of clinical oncology (ASCO) Recommends having salvage radiation following A prostatectomy as follows.

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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heavyphil | @heavyphil | Oct 9 6:24am
In reply to @optimistic "@jeffmarc I'm a bit puzzled by the recommendation to consider adjuvant RT over salvage RT when..." + (show)
Profile picture for optimistic @optimistic

@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.

Jump to this post

@optimistic What you say makes total sense; I guess adjuvant radiation makes the most sense when your surgical pathology shows distinct negative findings: positive margins, seminal vesicle invasion, etc.
You totally know that some cancer was left behind; waiting for the magical PSA of 0.2 to begin SRT might give those cells a jump start to be off and running.
Bad enough the surgeon couldn’t get it all, but distant metastasis is much worse. Best,
Phil

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bikeman1 | @bikeman1 | Oct 10 7:34am
In reply to @surftohealth88 "@tom86 I would kindly suggest that you do all of your research and be ready for..." + (show)
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@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.

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@surftohealth88
Yet again, I agree with Mrs Surf; her husband and I have very similar stories.
When my uPSA started creeping up post-RALP, I wanted to get on ADT right away, based on the information presented above by jeffmarc. Unfortunately, Orgyvx conflicted with my heart medication and it took a while to sort things out with my cardiologist. By the time I was put on bicalutamide (as a stopgap measure), I hit .215--not bad, but not great. Even though I think my RO is really good, I had to push things along to make things more quickly. So, getting as much as possible arranged in advance is a very good idea, especially for aggressive cancers that don't fit the "slow growth" model of most cancers.

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dhasper | @dhasper | Oct 10 10:07am
In reply to @surftohealth88 "@tom86 I would kindly suggest that you do all of your research and be ready for..." + (show)
Profile picture for surftohealth88 @surftohealth88

@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.

Jump to this post

@surftohealth88 I agree with Surf. Time to be a bit of a pain with your Dr's office. Narrow the window on the PSA timing, emphasize you want to go salvage early and tell them you understand radiation has risks but you personally want an agressive approach. There is a trend now to wait but make clear that is not the approach you prefer. That is just my feeling but having just been through this that is the approach I took. Do you have a sense for how fast it is rising? That may make a difference also. I did not have much time to act.

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jamie1957 | @jamie1957 | Oct 10 10:34am

I just finished Early Salvage Radiation with currently very few side effects. I had 20 treatments at a Center of Excellence so I guess time will tell if it was the right decision or not? I feel very comfortable with my decision!

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