Radiation with or without ADT

I was in a similar boat. My Gleason was lower, 4+3, but, when I went to the RO he told me that ADT increases the possibility of a cure by 2%-3%, that's it. My philosophy at the time was "give me all ya got doc"

The ADT isn't fun but my feeling was, I'm young(ish) and otherwise in fairly good health, let's whack this thing as hard as we can now.

I have read studies with slightly better numbers, but no more than 3%-5%. You have to decide if the side effects are worth it for you. Also, the numbers might look a little better at your gleason score.

There are also new(ish) studies that indicate more isn't necessarily better. My RO says 6 mos to a year is reasonable time to be on ADT, my surgeon wants me on it for 2 full years. We're about to have a conversation as to "why?" next week.

Not everyone gets all the side effects, and at 8+ mos now, the hot flashes are diminishing greatly, and I've got the "lupron belly" somewhat under control. (I'm on Orgovyx)

A couple other folks who have done a lot more research than I have posted some links regarding this, have a search for them, perhaps look at @kujhawk1978 's work here. He's posted a lot of helpful articles/studies and links to them.

Best of Luck to you whatever you decide!

Thanks for your reply @web265, I'm also a youngish 61 and otherwise also in good health, the problem is the conflicting reports I find,some recommend not starting adt until PSA higher than 0.6 others stating that high risk groups should start RT with ADT at the first rise in PSA .
The RO believes if I wait until 0.4 rescan then treat with proton radiotherapy I still have a possibility of being cured, but as I said with my risky pathology some studies say to attack aggressively that better outcomes are associated with intervention at lower PSA rates. There is so much ambiguity around the treatments and when to start in relation to bcr after RP it can be very overwhelming to make the decision on the treatment.
Good luck with your treatment.

Rad62: My non-medical understanding is that the rising PSA treatment range is 0.2 to 0.4/0.5 for BCR, and the trend is to treat at the lower number in the range (i.e., 0.2).
My 90 day postop PSA was a disappointing 0.19, and Radiation Oncologist prescribed 4 mos of ADT together with 38 radiation treatments. Gleason 9 w/ EPE final postop path report; 72 yrs old.
Honestly, I have not seen conflicting reports from current research.
Earlier treatment tends toward better results. And combination ADT and radiation have statistically better outcomes.
Best wishes to you in the challenging arena of PCa tx.

In February 2023, I finished 28 radiation treatments for BCR. I received a 6-month shot of Eligard in October 2022 so am still dealing with side effects, which I am tolerating pretty well. I was convinced of having radiation therapy with ADT after reading an article in the Lancet describing how the addition of ADT was associated with increased metatasis-free survival.

I had my RALP in March 2022. Final pathology report was 4+5 Gleason with clear margins. In June 2022, my PSA was undetectable but rose to 0.5 in Sept 2022. Had a PSMA scan in early October but no cancer was detectable. My oncologist decided to radiate the prostate fossa as well as the pelvic lymph nodes. Still dealing with urinary and bowel issues from the radiation but they are diminishing. Am hopeful for the future.

67 yo male, Gleason mostly 3+3, some 3+4. PSA under 10. Subsequent MRI showed no cancer spread outside the gland.

I don't think my options for ADT were discussed, possibly due to the extent of the cancer found and family history with this crap (my dad, his three brothers all had it, as did (we think) their father. I did Eligard in December, 2022. My effects, thankfully, have been minor. Gained a few pounds but nothing significant. A little tired at first (21 days of Casodex immediately after the Eligard), and my "dry January" started on Christmas and will probably go until at least Easter. Did brachytherapy about 2 weeks ago with a little urinary burning, but nothing else. I start low dose radiation tomorrow for 23 sessions. We will see how that affects me short and long term.

Its possible that my minimal effects could have something to do with my job, which has me lifting boxes from 2 to 40 pounds and walking about 5-6 miles a day. We shall see how it goes with the next step in therapy.

Well, hmmm. That may may meet the definition of BCR which is .2 followed by a 2nd reading such as yours, which if using a single decimal pint, would be rounded up to .3.

Would be useful to the group to know the pathology report - final staging, margins, seminal vesicles, ECE, % prostate involvement...

Still, it is BCR, so what to do... You have a variety of choices, some depending on your personal preferences, others based on any co-morbidities...

At that PSA, statistically, 30% chance or so a PSMA scan locates anything. If it did, great, you have more data to inform a treatment decision. If not, well, you're still trying to decide based on limited data.

You could choose to be aggressive, you have BCR. First, do some homework, find and read articles about doublet and triplet therapy.

If you image and it shows location of sites of recurrence, you could consider short term ADT combined with radiation to the prostate bed and the ENITIRE PLN system. The ADT is to deal with micro-metastatic PCA, too small to be seen on imaging. If there are locations in the PLN system, wider margins and higher doses to those sites.

What I would not do if you image and it comes back "negative" - Mono-therapy, either ADT or radiation to the prostate bed only.

You could also do nothing, continue to monitor your PSA and determine PSADT and PSAV. If that PSADT were 12 months or more, may consider doing nothing but continuing to actively monitor since with that kind of doubling time, could be awhile before treatment is needed.

Kevin

@kujhawk1978
Thank you for your input and your knowledge on the subject, you are helping me understand more about my situation.
Very important that you alerted me to the psa /uspsa point. I have been using wrongly the uspsa to determine treatment options. As generally accepted bcr is considered 3 subsequent psa tests >0.2 , so would this mean that my uspsa results of 0.11, 0.13, 0.16, would all be rounded up to 0.2 and signify bcr ?
In trying to calculate my risk of metastasis, according to Dr patrick walsh book surviving prostate cancer the time from RP to PSA rising and psa doubling and velocity can be a factor in survival rates and determining when to start additional treatment, using USPSA my post op psa rose from 0.02 to 0.03 one year later then rose to 0.1 almost 2 years later to determine PSADT and PSAV do we use USPSA or PSA to one decimal point? and at what point do we start psa doubling time? from the first increment using USPSA or PSA to one decimal, this will give two very different results, i dont have a clue as to my PSADT and velocity ,when ive mentioned it to the doctors they are very vague, if anyone is able to help me with this information it would be extremely appreciated i have attached a PDF below with psa results, all done in the same lab.

My pathology:
Specimen with cancer in both lobes, periprostatic and perineural infiltration, seminal vesicles on both sides free of cancer.
Pelvic lymph nodes with no evidence of metastastic disease.
Pre-prostatic tissue and frozen sections tumor-free
UICC-Classification pT3a pN0 (0/11) pMx L0 V0 PN1 R0
Gleason Grade 4+5 (10%)=9 tertiary 3 (15%)
ISUP 5
Tumor volume 2,67ml/8,08 %
Remaining Foreign Material - None

Here is an extract of the summary from the Pet/Psma scan from August 2022
Findings
The tomographic study shows a correct incorporation and renal elimination of the radiopharmaceutical with a good signal-background ratio.
The distribution of the radiopharmaceutical, both in the early and late study, does not show pathological deposits suggestive of local recurrence.
However, an infracentimetric nodal deposit of moderate capture intensity (SUVmax = 1.9) is observed, which persists without significant changes in the late study, located posterior to the right common iliac, at the height of L5. Above this, an area of diffuse capture of lower intensity is observed, which, like the previous one, does not clearly have an anatomical repercussion in the CT study. Nevertheless, tumor infiltration cannot be ruled out, so close follow-up is recommended.
Focal uptake in the lateral arch of the 5th right rib, which presents sclerosis in the radiological image, with moderate capture (SUVmax = 1.5), currently unspecific, to be monitored evolutionarily. The distribution of the radiopharmaceutical in the rest of the bone skeleton and studied structures is of physiological characteristics.
Diagnostic judgment. Focal deposit in the right common iliac chain, which recommends close follow-up. MAIN DIAGNOSIS Adenocarcinoma of the prostate Gleason 9 (4+5), pT2a, with biochemical recurrence. Focal deposit in the right common iliac chain. Recommend further PET/PSMA when psa reaches 0.4 and if findings confirmed the best dosimetric option in case of rescue radiotherapy is Proton therapy, but not together with ADT.

The RO who wrote the above report suggests the uptake in the rib is not so concerning due to the radiograph showing sclerosis in the rib which can account for the uptake and also says my psa would be much higher (20.0 +) if i had bone mets. I have found a lot of info about 68 GA-PSMA-11 showing false positives in the ribs.

Another RO from another clinic after seeing the PET/PSMA scan reached this conclusion.
Up to 3 deposits are appreciated (all of them doubtful given the low SUV of all of them) from greater certainty to lesser would be: 1. Subcm adenopathy (SUVmax: 1.9 and that is maintained in late) in the territory of the common iliac D (at the level of L5). 2. Cranial to this: "area diffuse uptake of lower intensity (SUVmax is not specified), which, like the previous one, does not present a clear anatomical repercussion in the CT study. However, it cannot be ruled out that they correspond to tumor infiltration”. 3. “Focal uptake in the lateral arc of the 5th rib D that presents sclerosis in the radiological image, with moderate uptake (SUVmax: 1.5), currently non-specific, to be controlled progressively”.
However, we also comment that, given the significance of the findings (it would be a stage IV oligorecurrence (due to cM1a -rcN in the common iliac- and rcM1b -costal-)
I indicate that we would recommend a mixed treatment consisting of a long Androgen Blockade (2 years: neoadjuvant, concomitant and adjuvant to RT) together with pelvic RT (pelvic bed and lymph nodes with concomitant boost in nodes affected by the PSMA) using the IMRT/VMAT technique (35 fractions) and SBRT (radiosurgery: 3 fractions) at the level of the rib injury.
I apologize for this post becoming rather long.
With time (and the help of the experienced people on this forum) i am learning more about my situation and i now think radiotherapy and 2 years of ADT may be my best option.
Thank you to everyone taking the time to read and comment on my posts and my best wishes to all fellow patients.

Again, my thoughts...

You said - "As generally accepted bcr is considered 3 subsequent psa tests >0.2 , so would this mean that my uspsa results of 0.11, 0.13, 0.16, would all be rounded up to 0.2 and signify bcr ?

My answer would be the first two would be reported as

@kujhawk1978
Do you have any thoughts to offer on my psadt & psav with regards to the pdf PSA list I attached?

Here's your PSADT using the MSKCC Nomogram.

The 9.2 months would indicate the area where you have time to decide but may likely need to decide.

So, it's another piece of the clinical data puzzle which may confirm your pending decision - treat, radiation and ADT for a defined period, 6-24 months, assess, stop and actively monitor or continue.