IMRT Radiation/ADT after surgery?

This is discussed in a few different places, I'm not sure what heading they'd be under. My progression was somewhat similar. I was sent in to radiation about 9 mos after surgery.

My numbers went like this...
10/22/21 PSA Result of < 0.1 (After surgery)
01/26/22 PSA Result of 0.039
04/26/22 PSA Result of 0.091

I guess the first test wasn't ultra sensitive, so hard to use that one..Once we had the confirmation that the PSA was rising, we started the salvage radiation and ADT. This is considered by some to be a bit aggressive. Some might consider waiting for one more test, I'm okay with the aggressive approach.

I've been testing < 0.006 since 11/28/22. (knocks wood)

Too early. 0.02 is within the tolerance of accuracy relative 0.01. BCR is at 0.20 and it is not unusual to begin salvage radiation below 0.20, when it is clear that the PSA level is rising and especially if the PAA doubling rate is less than 3 months.

Take a look at the PCF webinar dated Jan 17 2023. It's titled rising PSA after treatment. I'm sure treatment options also depends on Pathology report. At least you can reference this webinar and ask your Urologist his opinion on it. Maybe you can test monthly for awhile to see if trend keeps rising or fluctuates?

Thank you all for the prompt replies. This cancer has so many ifs ands and buts it helps to have real life experiences to comfort and educate,

Well, your PSA data may indicate BCR...too soon, depends...!

First question is, what are your doctors recommending, is the IMRT to the prostate bed only or do they plan in extending the treatment field to the pelvic lymph nodes (the latter being a significant decision)? How long are they saying saying will you be on ADT, when will you start it, simultaneously, shortly before you start IMRT, what ADT agent do they plan on you using, will they add an ARI, if so, why, when...

Second question is, do you want to wait until your PSA rises to a level where you and your medical team are comfortable that one of the PSMA scans could reasonably locate the recurrence and thus inform your decision? Would waiting for that change your treatment decision, would it entail any risk to the outcome...?

How aggressive do you want to be in your treatment. Including the PLNs is one example, Adding an ARI is another, do you add it from the start or wait to see if the ADT drops your PSA to undetectable in the first three months or so, if not, add the ARI, A third is how long you want to be on ADT, 6, 12, 18, 24, 36 months..., want to be super aggressive, chemotherapy?

Waiting until your PSa reaches say .5-1 which is where the statistical probability of locating a recurrence increases greatly may also give you sufficient PSA results to calculate PSADT and PSAV, more clinical data informing your treatment decision.

These are questions and discussions you may want to have with your medical team before pulling the trigger and treating.

If your PCa has escaped the prostate and is advanced, generally, the medical community says it is not curative though that may be based on past therapies. With newer drugs, better imaging, improved radiation planning software and delivery hardware, maybe. More likely, managing with the outcomes of treatment being control and progression free survival vice say overall survival though that too can be allowing an end from something else. My medical team knows their mission is "something else", so far, they are successful over the ten years.

Kevin

Kevin thanks for your reply. I have read many of your posts/comments on this site and you seem to have done your homework. Suggested radiation to prostate bed, and pelvic bed due to one of 12 lymph nodes removed was cancerous. ADT to be determined on 4/2/24 appointment.

I should add that my treatment is at Loma Linda University, Loma Linda, CA.

In my post I was hoping to find someone with my numbers to see what treatments were used, if any and the outcome.

Thanks again Kevin for taking the time to comment, informative and appreciated.

ok, one part of your treatment decision is decided based on clinical data, IMRT to the prostate bed and WPLN.

In both my ADT stints, Kwon in 17-18 and my current oncologist in 23-24, they decided not to add the ARI since treatment dropped my PSA to undetectable and it stayed there while on treatment. While aggressive in their approaches, they did not want to overtreat.

Things have changed (imagine that...) since my diagnosis and GS has morphed in groups:

Grade group 1: Gleason score of 6 or lower, which is low-grade cancer
Grade group 2: Gleason score of 3 + 4 = 7, which is medium-grade cancer
Grade group 3: Gleason score of 4 + 3 = 7, which is medium-grade cancer
Grade group 4: Gleason score of 8, which is high-grade cancer
Grade group 5: Gleason score of 9 to 10, which is high-grade cancer

You're a 3, so, intermediate risk...the infamous gray zone, do I, do I not... I'm a four, made my decisions easier, particularly with that PSADT

Early in 2019, my PSA jumped to .36. That was my first USPSA with the new urologist, I was ready to hit the treat button, ASAP...! I took a deep breath, asked him to repeat after two weeks, then .124, and .06. Then you see it rise and fall again until 2022 when it began its continuous rise. I could have treated, he would have done what I asked, but with the variability I set some ground rules:
three or more continuous and significant rises spaced 2-4 months apart.
same labe, same time, same pre-draw routine
we would not image until PSA was between .5-1.

In March 2023, had criteria was met. Had I reacted to the increase in 2019, I would have started treatment four years earlier than maybe needed.

The other interesting thing is my testosterone.

Mine recovered quickly and higher than my baseline (287) going into triplet therapy. Oct 18 135, Feb 19 432 and by Apr 23, 610. So, if T is the fuel for PCa, should I not have had recurrence around Oct 18, certainly Feb 19 when T hit 432...or shortly after!

You can find arguments either way, treat early as you and your medical team are contemplating, or not necessarily now, later. Questions you may never know, if we treat now, does that change the outcome, cure, progression free survival, overall survival...? If we treat later, same questions but you will have enjoyed longer time off treatment and the outcomes still the same...

We want a checklist to follow, unfortunately with the plethora of treatment options comes an equivalent plethora of decisions with unknown variables in terms of outcomes. Medicine, part science, part art...

I don't think you can necessarily make a "wrong" decision. You make the best choice based on the clinical data you have, your priorities, financial toxicity,...and go from there when you see the results. In business case studies, they call the past "sunk costs" or irrelevant to the decision today!

Let the forum know what you decide and your progress on treatment and after you come off.

Kevin

0.02 is a very low PSA level to treat with radiation after RP. Literally 1/10th of the standard for occurrence of BCR. If you watch or listen to talks by ROs from 10 years ago they will say treat as soon as there's a reliable increase in PSA. That's because there was no PSMA PET scans back then and they knew the lower the PSA, the easier it is to eradicate the disease in a BCR scenario. The downside is you don't know exactly where the cancer is so you have to assume it's everywhere in the pelvic region. That means a lower dose wherever the cancer is.

With PSMA scans, if you let the PSA get high enough for any small tumors to show up on the PSMA scan, the RO can plan a booster dose to the locations that light up in the scan and hit the wider pelvic region with a lower dose, same as if you had proceeded with early salvage RT.

I'm not aware of any clinical trials or retrospective studies tat have been done that have identified one approach or the other as being superior.

My input is continue testing PSA. If continued significant rise after 1 - 3 additional tests then initiate treatment.
.2 or even lower would be cause to begin to treat.
Now you are into the "art" of medical treatment.

My case:
1st postop PSA @ 3 mos was .19

Considered BCR. Therefore, Salvage Radiation protocol.

PSMA PET Scan did not identify any definitive area of recurrence. Note low accuracy at that level of PSA.
Therefore, belief is that cells remain in the prostate bed and pelvic area.

SPPORT trial supports whole pelvic radiation WPRT together with treatment to the pelvic lymph nodes.

I received 37 txs IMRT to those areas together with short term ADT 4 - 6 mos (my Rad Onc recommended 4 mos).

6 mos and 9 mos following Salvage tx, PSA undetectable at less than .02

Layman summary: I would treat upon continued rise in PSA and by or before .2
And after the trend in PSA is established.

However I would want to treat sooner than later with a positive lymph node.

Best wishes.

Thanks for the informative replies and experiences. This type of info helps to weigh in a more educated decision.