Deciding what to do when providers have such different protocols?

12 years ago 3 1/2 years after I had a prostatectomy my PSA hit .2 and I was put on salvage radiation. It’s interesting that you are going to have 7 1/2 weeks of radiation. That’s what I had 12 years ago. These days they’re talking about doing this is in 20 visits. This may be due to where you are going, not being up-to-date.

Having salvage radiation gave me another 2 1/2 years before it came back again.

The problem is, some doctor say don’t get salvage radiation because it doesn’t work out in many cases, Just get PET scans regularly and zap the metastasis. If only this answer really worked all the time, It doesn’t.

Here’s what the medical community says about getting treated with salvage radiation. As you can see from this information, waiting to have treatment can be very damaging to your future.

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.

Thank you for your reply - very helpful!
Still curious though....
We live in Green Bay - prostatectomy was at Mayo 2-1/2 years ago.
Current local providers know we would seek second opinion from Mayo.
We can't even get an appointment unless PSA is at least .4 - and considering the studies you cited, that is even more confusing that we can't be seen. Would be so nice if they all had the same protocol.

Is it Possible that the Mayo Clinic does not know that you’ve had a prostatectomy and that your PSA is hitting .2. As you can see ASCO considers that The point at which treatment should begin. Contact Mayo again and emphasize the fact that you are having recurrence after a prostatectomy, .4 should not be a limiting factor for treatment.

It sure did work that way for me, The moment my PSA hit .2 after my prostatectomy (I did take 3 1/2 years) I was set up for salvage radiation. This is extremely common to do it at .2.

lovinghim, Mayo won't see you, but you have to get a few more opinions. I wouldn't wait for .4.

Options —> There are a few questions you need answers to before you can answer those questions;

> What were your PSMA PET scan SUVmax scores prior to surgery?

> When you say “PET scan last week isn't very conclusive,” what does that mean? What were your post-treatment MRI SUVmax scores and where were the lesions? (Where will they know to target the radiation if they don’t know where the cancer is?)

The discrepancy in protocols is because PSMA PET scans aren’t very sensitive at lower PSAs. (See attached chart.) At a PSA if 0.2, PSMA PET will miss cancers about 66% of the time; at a PSA of 0.4, PSMA PET will miss cancers about 50% of the time. So some centers want to wait until there’s at least a 50/50 chance of there not being a false negative.

Dr. Kwon (of Mayo Clinic) indicates that only 1/3 of men who have recurrence following prostatectomy have recurrence only in the prostate bed, and that they should not get salvage radiation there unless they’re absolutely certain of the location of recurrence. He says to first confirm where the recurrence is. (See Dr. Kwon’s presentation about recurrence: https://youtu.be/Q2joD360_pI)

It’s not about only watching and waiting for the next PSA test:

> what was your pre-surgery biomarker (genomic) test result?

> what was your genetic (germline) test result?

> what was your post-surgery MRI result?

All of those (and maybe more) factor into your next treatment decision.

My PSA was .19 after RP in 2022.
Began Salvage Radiation Treatment protocol at COE.
37 radiation sessions over almost 8 weeks together with ADT.
See SPORRT trial.
Lower does of radiation (1.8 gys) over the longer period of time. Total 66.6 gys.
I believe that the trend is to begin to treat earlier in the .2 - .5 range, following hopefully negative PSMA PET scan.
Thankfully my PSA has been undetectable < . O2 almost 2 years since salvage treatment.
Facing the next 3 month prostate anxiety test end of August.
Northwestern U and U of Chicago near you, if you are uncomfortable with more local medical choices.
You asked for personal, not medical, opinions: Mine would be to treat sooner rather than later with low dose radiation protocol over the longer period of time. I had short term 4 - 6 mos ADT and while I would prefer not to have taken it, I would do so again.

Best wishes; it is an emotionally challenging period.

Thank you - very helpful - have now watched several Dr. Kwon videos.

JUST FOR CLARIFICATION: I'm the wife, writing on behalf of my husband's situation. This forum is not something he would look at. I'm just 'lovinghim', and trying to get him the best possible outcome.

I had a prostatectomy in July 2008 w/ divinci robot. Checking PSA every 6 months, last checkup a month ago was .12, up .01 from 6 months ago. Should I be concerned?

Yes, it is a concern but PSAs can sometimes jump around. Your next tests should be 3 months apart and you need to look for a consistent rise - and the velocity of it - in order to determine if salvage therapy is warranted.