Adjuvant radiation and ADT after radical prostectomy: Thoughts?

Hi @nishamunst :

My PSA in Nov was "undetectible" (aka: < .02). My surgeon recommended no treatment at this time, but I am not going to just leave at that. I self-referred myself to a top UCLA RO Dr. Amar Kishan and will see him in January to discuss my treatment options. Conceptually, I believe my choices are Adjuvant RT (ART) relatively soon, or Early Salvage RT (eSRT) if and when my PSA is still low but detectible (ie. greater than or equal to .02), or Regular Salvage RT (SRT) if and when my PSA is higher (e.g. greater than or equal to 0.2). Treatment guidelines for high risk patients like me are evolving and not all doctors are on the same page about recommending ART or eSRT or regular SRT. As you would expect, these are very complicated decisions since there are pros and cons for each approach regarding cure rate, quality of life, possibility of overtreatment (since BCR is likely but not guaranteed in every high risk case), potentially losing the "window of cure ", or the ability or inability to use imaging to see where the BCR has occurred.

I could change my mind after consulting with Dr. Kishan, but based on what I have learned so far,I am not in favor of ART soon given its negative impact on my quality of life (e.g worsening incontinence, ADT side effects etc), and the possibilty of over-treatment. However, given my high risk profile, I am leaning towards eSRT if and when my PSA is still low but detectible.

Will keep you posted.

I’m in the same place as several of you in this sub. My RALP was 9/22/25. Recovery has been great. Postop Pathology was not so great -Gleason 4+3 in most of the prostate; I was “upgraded” to Stage pT3b,R1. I had 4 positive margins - both seminal vesicles, and bladder neck and one spot on the prostate where there was extra prostatic extension. I also have Intraductal Carcinoma, Cribriform, PNI all positive/indicated. My pre-op PSA was 17.8 and my biopsy Decipher Score was 0.89. So just about every high-risk feature you can list, I’ve got. My first PSA (ultrasensitive) was 10/29/25 and result was 0.03 ng/mL. (uPSA Detection Limit of 0.006 ng/mL). I am getting my second post op uPSA next Monday 12/12/25. Needless to say, I’m just a little anxious about it… I’ve been researching all the guidelines on secondary (adjuvant, early-salvage or standard salvage) treatments, and I agree with the respondent above that said there are varied opinions with treating oncologists, and it’s continuously evolving - The consensus seems to be that the the higher your “risk profile” (my term here), the earlier you should consider salvage treatments.
For me, if this next uPSA is above the first, I will retest again in another 4 weeks (mid-Jan26), and if the third PSA confirms the same or a higher value, or at any point my PSA reaches >=0.1, I plan to get with my medical oncologist and start ADT and then meet with radiation oncologist to schedule the 6.5 weeks of M-F EBRT treatments to the prostate bed. I’ve already spoken with both of them about this, and they have concurred it’s a prudent approach given my GS (4+3), Stage pT3b, Decipher 0.89 and all the other high risk features of my cancer. Wishing everyone the best and strength to carry on the fight.

@esperling
I like your PSA result. It wasn’t the normal length people wait before getting it, but it was still really low at .03.

I can imagine you are anxious with the high decipher and all the other issues that makes it more aggressive as well as the margins not being cleared.

Don’t start the ADT until you get your next PSA because it will really reduce the results and they already look pretty good. It may not result in your Delaying radiation, but the number is really good. You’ve Gleason score is a positive thing too, It means that it probably is going to grow slower so getting on ADT can stop it completely. My Gleason store is 4+3 and I’ve got BRCA2, which makes my cancer much more aggressive, I’ve had four reoccurrences and I’m still around after 16 years. With good treatment, you could live decades.

One thing I don’t see you mentioned is a PSMA Pet test. That should’ve been done when your PSA was higher so they could tell whether or not the cancer has spread anywhere else. Did that test get done?

If you go on ADT, try to get Orgovyx. It’s a pill you take once a day and it has fewer side effects for many people.

Were you able to find out if the cribriform was large or small? That does make a difference, Though with the other issues, I’m not sure it actually matters.

Not sure you saw these recommendations for adjunct radiation. You have to have two of these in order for them to consider that Adjunct radiation makes sense. You have all four,

Adjunct radiation
Dr. Efstathiou concluded as follows:
* 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