Getting varied recommendations on treatment after surgery: Confused

Sorry to hear about your situation. Did the left iliac lymph node show up on a post op PET – PSMA scan?

Are you familiar with the decipher test? It’s a test that looks at 22 genetic markers to determine the aggressiveness of the cancer. I had to have salvage IRT after RALP due to a postop PSA level of 0.4. A postop PETPSMA scan clearly showed disease in a left pelvic lymph node that could not be reached during surgery. My oncologist recommended both first and second generation ADT along with the 31 sessions of IMRT and my high Decipher score of 0.95 confirm the need to throw the kitchen sink at the disease so that’s what we did.

Here’s a link to more information on the decipher test. https://www.veracyte.com/tests/decipher-prostate/

Hope things go well for you.

I am sorry you have to make more decisions. I recently had RARP & considered SBRT. My idea of treating prostate cancer is to hit it hard early & prevent metastasis. I would follow oncologist’s recommendation.

I am in a similar situation as you but my surgery was October 25.
My psa after was 0.045 which saw as good but doctor wanted no detection. I am going back may 5, 2026 for follow up. Hoping for the best but he said depending on psa number he may recommend radiation and maybe hormone therapy! I hope not! Would like to follow your success to prepare myself for my future treatment. Stay in touch!

After a prostatectomy, your PSA is supposed to become undetectable. The fact that yours never did means that there is some thing in your body producing PSA, and since your prostate’s been removed, it’s almost always a metastasis or micro metastasis that can’t be seen in a PSMA pet test.

The recommendation is to have salvage radiation and since your PSA never did become undetectable ADT is almost essential. Your oncologist is trained in this, a Urologist is not. I think if you were to go to a Genito urinary oncologist, The ones that specialize in prostate cancer, they would undoubtedly want you on ADT.

It took 3 1/2 years before my PSA started to rise to .2 after a prostatectomy. I was put on Lupron (ADT) And two months later, I Went through 8+ weeks of Salvage radiation. That’s pretty much the standard. It took me 3 1/2 years and I still put me on ADT.

Here’s the recommendation from the American Society of clinical oncology for what to do after a prostatectomy. While it doesn’t say you need ADT if you have a PSA lower than .5, They don’t cover the fact that you’re in PSA never went down to undetectable which is a real dangerous situation for overall long term survival.

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/
Prostate cancer has become a chronic disease, not a deadly disease for most people. If you are treated properly, you can live a long life if you skip essentials that is uncertain.

I’ve had prostate cancer for 16 years and I have had four reoccurrences. I have a genetic problem BRCA2, which makes my cancer much more aggressive, but the proper treatment over the years has kept me alive, and nobody would know I have prostate cancer. I’ve been undetectable for 29 months, a big reason is I’ve had a GU oncologist overlooking my treatment.

Ok de todas maneras tu caso es distinto porque ya estas en un nivel indetectable. Seguramente te mantengas ahi.
Saludos

@fabianrinaldi
There are some new guidelines about possible avoidance of ADT in adjuvant or very early salvage RT after RARP BUT with very precise "risk stratification". There is no universal agreement among doctors and institutions in that regard and one has to really educate oneself about pros and cons.

The fact that your post op PSA was never undetectable and was in the zone that actually requires immediate action is putting you in possibly higher risk and having cribriform (if large) is putting you in very high risk, so even though I am not a doctor, according to all that I read so far and according to what I was told by my husband's RO and MO, ADT would be really, really preferable.

If you were 3+4 intermediate favorable with no cribriform and you had BCR after a year with very slow doubling time, no ADT would possibly be something to consider or not, but with your clinical presentation it would be really risky : (.

ADT has multiple benefits - it downgrades vascular growth which leads to apoptosis (death of cells) and stops formation of new vascularisation (formation of new blood supply to cancer cells) and ADT also reduces required EBRT dose for control of 50% of the tumor !!!

People forget WHY ADT is used - yes it has side effects but short term ADT in salvage therapy definitely can do more good than harm in the long run IMHO.

Listen to your MO and I am wishing you complete eradication of PC in very near future .

same situation had surgery PSA increased started radiation and orgovgy PSA now .1

I put your data into the Memorial Sloan Kettering PSA Doubling Time Calculator. While it was not a lot of data, it did determine your doubling time at 4 months, which is considered fast. PSADT is a significant datapoint when determining the use of ADT. I also had a fast doubling time after my RP. In addition, I had a small positive margin. All of my drs recommended ADT (Urologist, 2 - RT, and my Ocologist - all in favor). I went on Orgovyx. It was generally ok but had some hot flashes, weight gain and tiredness/joint pain. After the 6 months of ADT and 39 radiation treatments, were over I am pleased to say I'm undetectable. Hope this helps and good luck with your decision.

Follow Jeff Marchi guidelines. And keep singing TURN ME LOOSE: from the 60s. Great song and you are a great singer too.

I would suggest salvage radiation protocol - treating the bed, and all the pelvic nodes; possible SBRT to that one pesky node as well.
I would also recommend ADT for 6 months at the very least since your cancer could be of the more aggressive type due to your Gleason/Cribriform status. Just my opinion based on my own experience - not medical advice. Best,
Phil