ADT started before SRT or concurrently?

3 1/2 years after my prostatectomy, my PSA started rising. At .2 they gave me a 6 Month Lupron shot And two months later I had eight weeks of SRT. Because I Had less radiation each session compared to what they give today with 20 sessions, I had no side effects at all. Six years later, I started having some incontinence, but I’d had radiation and surgery and who knows what caused it.

The SRT lasted me 2 1/2 years before my PSA started rising again and I had to go on ADT full-time.. I have BRCA2 which explains why it keeps coming back. It has been 12 years since I had salvage radiation.

Here are the recommendations from the American Society of clinical oncology on when to get salvage radiation after having a prostatectomy

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/

We had consult with RO about 2 weeks ago even though last uPSA was about 0.057 since we are almost sure that BCR is in making.

He told us that my husband would start Orgovyx 6-8 weeks before RT starts.

There have been studies looking into whether it’s preferable to front-load ADT as part of radiation treatment or to backload it.

This is a paper titled - “In Prostate Cancer, ADT After RT Better Than Before RT” - that was presented at the American Society for Radiation Oncology (ASTRO) 2020 Annual Meeting —> http://www.medscape.com/viewarticle/940049)

It discusses whether (and why) ADT with (and after) RT leads to better outcomes than ADT well before RT (which is how it is usually given).

The study’s conclusion favors an adjuvant-based rather than neoadjuvant-based approach, and it has to do with ADT’s continued suppressive effects after radiotherapy to help radiation kill prostate cancer cells.
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We had read similar papers prior to beginning my proton radiation treatments (during April-May-2021), indicating (as this paper states) “… starting ADT with radiotherapy significantly improved meaningful outcomes for patients, compared to starting ADT months before radiotherapy.”

So we didn’t start my ADT many months ahead of radiation treatments as some do. We started Casodex, then 6 days later started Eligard, then 5 days later started proton radiation. With two 3-month injections, the ADT remained in my system for 8 additional months after radiation treatments ended, so that the majority of my ADT was back-loaded to occur after radiation treatments.

Today, we’re 5 years past those proton radiation treatments. Things have gone very well (just as planned and expected). So far, so good!

@brianjarvis
Thanks Brian for this info. I tried to find studies done for salvage RT and could not find any. The closest that I found was this on UCLA site :

"Researchers observed a significant interaction between ADT sequencing and RT field size for all study endpoints except overall survival. For patients receiving prostate-only RT, ADT occurring during and after radiation was associated with improved metastasis-free survival compared with neoadjuvant/concurrent ADT.

However, with patients receiving whole-pelvis RT, no significant difference was observed with ADT sequencing, except greater distant metastasis occurrence among those who had concurrent/adjuvant ADT. "

This statement is also referring to initial whole prostate RT (primary RT) , but the last sentence refers to the "whole pelvis" RT which is actually more similar to salvage RT, I guess ?

I you happen to have any papers that refer specifically to salvage RT and initiation of ADT timing, please post them here (when you find time) - thanks so much in advance 🙏.

@surftohealth88 Dr. Kwon (of Mayo Clinic) has a 2019 PCRI presentation addressing Mayo’s protocol for salvage treatment of recurrence (following surgery and radiation). At various places in his presentation he covers what you’re asking about.

See Dr. Kwon’s presentation about recurrence at: https://youtu.be/Q2joD360_pI)

Hey bud, My Orgovyx was started 10 weeks before SRT, continuing during SRT, and then continued for 10 weeks after - 6 months total.
Phil

The cancer cells will be weakened with ADT either before or after. Unless you are using SBRT (8 Gys doses, etc.) the radiation causes DNA damage, but death takes months to years to complete. Studies have shown ADT is more effective concurrent and after, although these were done with primary treatment. Studies also show sRT is more effective if started at lower PSA (disease) levels. If PSA is rapidly increasing it is probably better to start ADT right away to arrest the peak PSA at a lower level (no studies on this). With your schedule for a quick start to treatment, it probably does not matter.

@jeffmarc
Thank you for sharing your experience and for the additional info on the recommendations for salvage radiation. I see in your case that ADT was started 2 months before starting the radiations.

@surftohealth88
Thank you for sharing your experience. I see that in your case the recommendation will be to start 6-8 weeks before radiations begin. All my Best to your husband and you.

@brianjarvis
Thank you for sharing your experience and for the interesting article. Besides the Casodex and the Eligard, at what point was your first ADT injection administered? Was this before starting your radiations or at the same time?

Good to hear that things are going well for you and my Best wishes that they stay that way.