Knowing ASAP if with recurrence - Your Thoughts, Please!

I am one 4+3, one 3+3 (some cribiform atypia) , Decipher .84, PSMA PET confined to prostate. I did 5 SBRT and 6months Orgovyx for ADT.

Thanks for telling your treatment. Hopefully it works well for you! Unfortunately my husband’s told he doesn’t qualify for PSMA PET scan.

I'm not going to try to persuade you one way or the other, but, I don't believe there is a big difference in possibility of recurrence either way.

I had robotic prostatectomy and a recurrence in less than a year. I was also 3+4=7. Had salvage radiation since then and now still on ADT (doc wants me on it for 2 years.) Been undetectable for about 18 mos now.

The reason I chose this direction was that if there is a recurrence, it's much more difficult to do surgery after radiation as opposed to radiation after surgery. (or so I was told)

This is a complicated scenario to unpack.

Efficacy of early salvage radiotherapy post RP (PSA ~ 0.2) is higher than if the patient waits until higher PSA levels after BCR. Adjuvant RT (when RT is considered a pre-planned part of the primary treatment) is even more likely to kill off all cancer cells but is also more likely to cause injuries to the healing anastomosis where the bladder neck and external sphincter were joined during surgery.

Even if a patient has an aggressive BCR with a PSA doubling time < 9 months, then unless he has persistent PSA, meaning his PSA never becomes undetectable post RP, then there should be time to allow the anastomosis to properly heal before zapping it with early salvage RT without significantly increasing the chance of secondary BCR at 5 or 10 years post salvage RT.

Another factor that should be considered in a post RP BCR is that the ability of a radiologist to read a PSMA PET/CT scan and correctly call a positive lymph node (LN) or cancer in the prostate bed increases as PSA values increase. The more cancer present, the more likely for it show up on the scan.
So if you do adjuvant RT assuming (but not knowing) there will be a BCR, then you can't target positive nodes and give them a booster dose of radiation. OTOH if there is no or very low PSA at that point then it doesn't take as much radiation to kill any extra-prostatic cancer cells in the treatment field.

Likewise, reading a PSMA scan post RP at a PSA level of 0.2 may result in some growths being detected correctly but may also miss some. This is usually accounted for in the treatment plan by applying lower doses to broader fields to account for unseen extra-prostatic cancer cells where you aren't certain cancer is present and more concentrated doses where you can see cancer on the PSMA scan.

So the bottom line IMO with post RP BCR -- there are a lot of tradeoffs to consider about when to re-treat, but you do have a very precise biomarker to know immediately if there is extra-prostatic cancer and as you track it month over month, you glean insight on the aggressiveness of the localized BCR or metastasis, whichever is the case. That's not feasible when you have BCR after primary RT with a prostate gland still intact...at least not that quickly and precisely.

With high grade PCa, the combination of brachy and EBRT as primary treatment has been shown to provide a higher likelihood of avoiding BCR at 5 and 10 years compared to RP alone. That is why men with high risk PCa believed (but not known) to be confined to the prostate often think of RP and salvage RT as part of the same therapy.

I realize all of the above is a lot to digest but hope it might help you navigate your decision process just a little.

It is so complicated, isn't it?! If Jim chooses radiation, he favors HDR brachy, either as mono-therapy or adding 4 months of ADT to the HDR brachy. His radiation oncologist prefers this dual therapy instead of EMRT + brachy, saying the addition of ADT is preferable because it covers the entire body. There are so many varying recommendations, it seems.

Jim would, of course, like to decrease post-treatment side effects (knowing the incontinence post-surgery and the many side effects of ADT). But most important is to choose a treatment that is most likely to eliminate a cancer recurrence and need for further therapy.

Bottom line, we think we're back to choosing prostatectomy, primarily because it will alert us to any recurrence as soon as possible. (Worrywart that I am, not knowing if recurrence might be happening since the PSA interpretation isn't as black and white regarding cancer status post-radiation will be stressful!) It seems that the sooner we know of recurrence, the sooner it can be addressed, with our health providers' guidance. We also like the fact that after surgery, the entire prostate will be biopsied, so we better understand the degree of seriousness of cancer at that time. And, as we understand it, after initial treatment with prostatectomy, more options remain for treating a possible recurrence than if radiation is done initially.

I wish we felt more confident in our understanding so as to feel confident we're makeing a best choice. It's just hard to know if our rationales for leaning toward RP are right-thinking. You seem to be very knowledgeable, russ777! IF you have any other points of further clarification or thoughts that may make things more clear to us, I would welcome hearing back from you. Thanks a lot for what you have shared! (I'm pretty sure I understand most of what you've said!) 😉 All the best to you!

Thanks. I assume with a 3+4 his risk group was favorable intermediate, assuming no concerning staging issues found on biopsy. That would prevent you from getting a PSMA PET scan in most cases. With the high risk evaluation in his Decipher test, that might motivate your RO or urologist, whichever is doing the overall management, to order a PSMA PET scan that your insurance might approve. That could potentially confirm that he actually needs ADT and radiotherapy instead of surgery.

Your thoughts on the post surgery pathology are good. Keep in mind that not only will the gland be removed, but also the seminal vesicles and some number of pelvic lymph nodes will be biopsied for pathology. You should inquire about what fraction of pelvic nodes will be removed/biopsied, which ones (some are more prone to spread cancer out of the pelvis than others) and discuss unilateral or bilateral nerve bundle sparing versus cure rates with the surgeon for those with high risk cancer.

As far as the systemic aspect of ADT goes, just keep in mind it is not curative. It can suppress the cancer, potentially for a very long time, but it is not cytotoxic like radiation or chemo.

You might be overthinking this? When you thought/knew you had (at least) 3+4=7, you were still in the "intermediate favorable" category and you could consider radiation or other forms of ablation (using other ways to "zap" certain areas). But, like me, you got news that things are (likely) worse. In my case that was a second node of concern on a repeat MRI and two 4+3=7 on biopsy.
At that point, I no longer qualified for the (new form of) ablation clinical trial and I was advised that RP was a preferable next step for all the reasons that have been discussed. (The research urologist said he had treated a lot of post-brachy recurrence in his own practice and he felt I was not a good candidate for that with my diagnostic indicators.) This was confirmed when the RP revealed positive margins and some more advanced cancer cells in the prostate. I felt bad about losing options before the RP, but mostly bad knowing my cancer was more advanced than I had hoped.
Now I'm in the waiting for BCR stage not quite two years after RP. In this case, I'm glad I'm still waiting, but disappointed the latest uPSA was higher than previous ones. I prefer sober reflection to flights of optimism, but I can guarantee that others experiences will differ in that regard :-).

Recurrence treatment does not go on the standard PSA numbers. According to the PCF anything over .2 you should be seeing a Urologist as soon as possible. Personally I started out at .1, went to 1, then 1.31 and finally 1.6. Your Gleason score will tell the Radiation Oncologist just how aggressive your recurrent prostate cancer is. I had 39 external beam radiation treatments and a 6 month shot of Lupron. God Bless and good luck

Rose, I agree with the other comments, no two people are the same and each man will ultimately need to move forward with the treatment plan best from himself and his loved ones. For myself, I went with a robotic radical prostatectomy with nerve sparing at a center of excellence. I had my surgery in November 2022 and was 56, healthy, positive attitude with life, and was wanting another 30+ years of living with my wife. I did a significant amount of research before my first appointment to ensure I went into the the conversation with a baseline of knowledge. I decided on a robotic RP because of several reasons: (1) I wanted to fully understand the level of cancer that was in my body (post surgery pathology) and not rely on imperfect imaging tools and biopsies. (2) Cancer is so complicated and you never really know if the prostate cancer is completely gone - A RP does not guarantee all the cancer is removed, but in my opinion, gives you the best chance to address the known cancer. (3) A radical prostatectomy removes the prostate, seminal vesicles, and an assortment of pelvic lymph nodes versus radiating areas of concern or suppressing the cancer. (4) I did not want the possible side effects of radiation. I can handle the potential side effects of the RP (incontinence, impedance, infection), but I did not want to add in another variable like radiation.

Everyone is different when coming back from a radical prostatectomy. However, if you choose the best possibly doctor at a center of excellence (like Mayo-Rochester), your chances of recovery are very good. For myself, I am a bit over a year out from surgery. As far as I know, cancer has been removed (can never really know) and follow up PSA levels have been undetectable. Thankfully, incontinence and impedance were minimal post 3 months. As with others, I was methodical with my Kegels and getting plenty of sleep after the surgery. Also, stayed active during the recovery.

Please note - I am completely biased based on my experience with the RP. Each individual is different and treatment plans must align with life expectations.

Best of luck to you and your husband in making the treatment decision and moving forward.

Jim

All great comments here - showing just how difficult and variable this disease is. I had Gleason 4+3 unfavorable and two radiation oncolgists said they could treat it successfully. That word ‘unfavorable’ gnawed at me and against every fiber in my being I went for RP.
The reason was already mentioned: if PSA post op starts rising you can retreat with ADT and radiation - VERY difficult to do it the other way around. 4 1/2 yrs later PSA is rising, now at .14. Going to Sloan today for follow up with a second PSA.
Not looking forward to any of this, but the threat was always there so now I deal with it.
You never mentioned your husband’s age and that has a lot to do with treatment options. I was 64 at diagnosis but if I were 74 It would have been cyberknife all the way.
As one oncologist told me: whatever you decide will be the right decision. Yes, it leaves a lot to chance but that’s life, right? Best of luck!!