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Salvage radiation decision: with or without hormone therapy?

Posted by chuckbies @chuckbies, Jun 10, 2025

I had a prostatectomy in 2021. PSA was undetectable for 2 years. Then PSA went to 0.1 in 2023, and then 0.2 in 2024. I saw an Oncologist last month who recommends salvage radiation to the prostate bed. I will do that soon, but first need to make a decision on whether I should do hormone therapy with the radiation therapy. I have a family history of prostate cancer, and my PSA was fairly low (5.0) when I had the initial biopsy and diagnosis, which showed prostate cancer existed in all samples. The Gleason score was the bad 7. I had a PET scan and bone scan before surgery which did not show any signs of metastatic prostate cancer. So my question to the group is: should I do hormone therapy at this time? Or just do radiation and see if that works? I'm 64 and in good health.

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

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philipsnowdon | @philipsnowdon | Dec 28, 2025
In reply to @brianjarvis "The duration of ADT depends on the aggressiveness of the disease and any other risk factors...." + (show)
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The duration of ADT depends on the aggressiveness of the disease and any other risk factors. NCCN Guidelines call for ADT duration of:
> Unfavorable intermediate: 4-6 months
> High or Very-High Risk: 12-36 months
Adding hormone therapy lowers testosterone, which removes the “food” prostate cancers need. This starves/weakens the prostate cancer cells, making them more susceptible to DNA damage from radiation (and also weakens their repair mechanisms),

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@brianjarvis

Hello fellow men with PC in one degree or another. Pre or post treatment options considered or completed.

As I was already on “TRT,” TESTOSTERONE REPLACEMENT THERAPY FOR 12 years before my RALP, I had to stop my “TRT” a month prior to my surgery and 5?months following. Due to other debilitating health conditions, ADT would never be a practical or workable solution for me. Every patient is different and generates specific treatment options based on his medical history and preferences for the future.
If I don’t utilize “TRT,” my Testosterone goes down between 20-90, essentially making me medically castrated without the treatment for it.

More men need to do a lot more research on Testosterone and post PC surgery. The more recent and current research is much more informative and accurate about this issue.

Firstly, all men have Testosterone. Secondly, not every man develops PC.
It’s true that while you have PC, you should not feed your cancer with Testosterone. However, assuming they removed all of the detectable cancer, there isn’t any more cancer cells to feed. In other words, by removing your PSA FACTORY, your Prostate, you are essentially like a Nan who never had PC.
Many men utilize “TRT” and never develop PC. After a successful removal of your Prostate and all of the detectable cancer, you are able to utilize “ TRT!”
Of course, you monitor your PSA and Testosterone with along with all of the other essential markers and indicators to make sure you have not incurred a Biological Reoccurrence of your PC. Between 30%-40% of the time within the first 5-10 years following a successful Prostatectomy, PC returns for men.

Obviously, the huge majority of men in this category are not utilizing “TRT!”
Every individual has to do their own research. ( I am continually surprised how many men do not or do nothing more than a cursory review etc).
The reason I took the surgical route initially is so I could use the Salvage procedure if need be at sometime in the future.
There is no right or wrong way to treat PC. Their is what you and your physician and other advisors determine to be the most appropriate way to treat your PC and.how to continue with whatever post PC treatments everybody finds to be in their best interest.

In short, there are absolutely “NO GUARANTEES” about what your individual case of PC will or will not do after your initial treatment protocol.
The best thing you can do is to stay on top of it and monitor your situation so you can act accordingly if need be at some time in the future.
Thankfully, I had my RALP performed in October of 2022 and remain in remission. My PSA has remained steady at < 0.014 since my surgery and continues to do so through December of 2025.
Again, depending on what you believe. Some people hold the view that regardless of whatever kind of cancer you have had and it currently have. You are either in a state of remission or you are not. There is really no such thing as a “Cancer Cure!” Once you have cancer you deal with it for the rest of your life in one way or another or in repetitive ways over time.
This not a negative statement but one of fact.
I hope I remain in remission the rest of my life with PC and I certainly hope I don’t develop any other form of Cancer. Just as I wish for any man or woman dealing with whatever type of Cancer(s) they are dealing with now.

Hope for best but always be prepared for any other developments.
GODSPEED

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icorps | @icorps | Dec 29, 2025

My bet would be to take the hormone therapy. You can look up the issue in terms of it "radiosenstizing" the tumor or lesion which as I understand it assists the radiotherapy by making it harder for the cancer to repair its DNA which the radiotherapy has whacked. Also there's the possibility of micrometasis in some of the nearby lymphe nodes that PSMA PET can't detect
Look on it as an insurance policy. But talk to your Doc, bearing in the Doc's done a lot of this and it may be more of an art than a science

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chuckbies | @chuckbies | Dec 30, 2025
In reply to @melvinw "Chuck, I completed 38 fractions of salvage IMRT on November 18 (no ADT). Hit the prostate..." + (show)
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Chuck, I completed 38 fractions of salvage IMRT on November 18 (no ADT). Hit the prostate bed as well as the pelvic lymph nodes, prophylactically. First follow up PSA will be in mid February 2026.

I had a RARP in 2015. Gleason 3+4, one positive margin, Prolaris score 1.7 with a 53% chance on BCR at ten years.

I went ten years with undetectable (< 0.1) PSA. Then in June 2025 my PSA hit 0.11 (Quest). A repeat test a few days later yielded the same result, ruling out lab error. Then, a DRE detected a palpable nodule in the prostate bed. That precipitated a PSMA PET scan and MRI with contrast, both confirming that the nodule was cancerous. No scanning evidence for pelvic lymph node involvement, nor distant mets.

Two oncologists recommended short-term ADT with the IMRT, one did not. I weighed the pros and cons for my case. The barely detectable PSA and ten years to recurrence were strongly in my favor. Three months after my PSA hit 0.11, it remained unchanged, and actually an usPSA test from Labcorp yielded 0.094. Curious to think that if I had that test back in June, I likely would have been told to come back in a year, rather than getting scanned and diagnosed with recurrent PCa.

Anyway, I decided against the ADT, concluding that the benefits did not outweigh the risks for me. Gray area decision. Someone else with different concerns/priorities may taken a different path.

Another oddity of my case was that despite the low PSA, the nodule lit up on the PSMA PET scan with a max SUV of 13.3. Data don’t always align, and sometimes they defy conventional wisdom, but I think the important result was that the nodule lit up and nothing else did. My urologist concurred.

I posted a long summary of my IMRT experience if you haven’t seen it: https://connect.mayoclinic.org/interaction/discussion/68361/reactions/listview/

I will add that post-RT, I have had a bunch of rashes and skin irritations in different parts of my body. Bothersome and unsightly, but my dermatologist saw nothing serious. Probably opportunistic fungal or viral flare ups because my immune system was whacked out. They seem to be resolving now. I didn’t think that my RT fatigue was real bad, but now in late December, I am feeling pretty much back to normal energy levels (am 73 now). Looking back, I was more wiped out by the RT than I realized. Getting back to full energy capacity took more than a couple weeks. Feels good to just be living a normal life again, including not being on the “full bladder/empty rectum” diet.

Hope your RT goes well.

Here’s to a better 2026 with ultra low PSA! I’m sure we will be comparing and sharing PSA scores and progress in the new year.

Mel

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@melvinw Mel - thank you for reaching out to me and sharing your IMRT experience. I read your other post too, and your comments are very helpful and fill me with hope! I know I'm taking on additional risk by choosing no ADT, but like you, I believe the benefits outweigh the risks in my situation. I wish it wasn't such a grey area, and I know I need to get more comfortable with my decision, but at times I still have second thoughts about whether or not ADT would have been a better course.

When do you get your first PSA test after IMRT? It seems like that will be the key indicator of success. Since you are not on ADT, does your Oncologist still expect your PSA be < 0.1 after finishing IMRT, or will it take time for the PSA to drop?

Also - I printed the article you sent from the VA on the "full bladder/empty rectum diet" and I think it will be a very helpful resource as well. I just finished day 5 of 38. No issues so far. Fingers crossed!

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melvinw | @melvinw | Dec 30, 2025
In reply to @chuckbies "@melvinw Mel - thank you for reaching out to me and sharing your IMRT experience. I..." + (show)
Profile picture for chuckbies @chuckbies

@melvinw Mel - thank you for reaching out to me and sharing your IMRT experience. I read your other post too, and your comments are very helpful and fill me with hope! I know I'm taking on additional risk by choosing no ADT, but like you, I believe the benefits outweigh the risks in my situation. I wish it wasn't such a grey area, and I know I need to get more comfortable with my decision, but at times I still have second thoughts about whether or not ADT would have been a better course.

When do you get your first PSA test after IMRT? It seems like that will be the key indicator of success. Since you are not on ADT, does your Oncologist still expect your PSA be < 0.1 after finishing IMRT, or will it take time for the PSA to drop?

Also - I printed the article you sent from the VA on the "full bladder/empty rectum diet" and I think it will be a very helpful resource as well. I just finished day 5 of 38. No issues so far. Fingers crossed!

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@chuckbies

My first post-RT PSA test will be around February 13. My RO said she would be satisfied if it is below 0.1 and stays there. And yes, it might take many months to bottom out. PSA testing will continue every three months for the foreseeable future. Should there be a sustained rise above 0.1, I will get a PSMA PET scan.

The ADT decision for cases like ours is a tough one. Here are a couple discussions that weighed into my decision to pass on the ADT that might also ease your mind a bit.

Dr. Adam Kibel, a renowned urologist at Harvard, recommends against adding ADT to RT in men with BCR and a PSA < 0.5, citing evidence that the ADT can actually cause harm when PSA is low. Listen to his talk:


Dr Mark Scholz discusses ADT for men with intermediate risk PCa. This doesn’t apply specifically to relapses, but is still thought provoking in terms of when ADT is beneficial and when it is not.

Lastly, studies have linked ADT to increased risk for dementia and Alzheimer’s. The risk increase is not huge, but I have a family history of dementia and am concerned about anything that increases my risk of cognitive decline. Similarly, heart disease runs in my family, and ADT is known to increase the risk of cardiovascular disease. And I do not have a family history of PCa. So, my family history factored in to my decision to treatment relapse with just IMRT.

Should things change for the worse down the line, I will revisit all options on the table.

Stay the course. You’re off to a good start!

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chuckbies | @chuckbies | Feb 22 3:16pm
In reply to @melvinw "@chuckbies My first post-RT PSA test will be around February 13. My RO said she would..." + (show)
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@chuckbies

My first post-RT PSA test will be around February 13. My RO said she would be satisfied if it is below 0.1 and stays there. And yes, it might take many months to bottom out. PSA testing will continue every three months for the foreseeable future. Should there be a sustained rise above 0.1, I will get a PSMA PET scan.

The ADT decision for cases like ours is a tough one. Here are a couple discussions that weighed into my decision to pass on the ADT that might also ease your mind a bit.

Dr. Adam Kibel, a renowned urologist at Harvard, recommends against adding ADT to RT in men with BCR and a PSA < 0.5, citing evidence that the ADT can actually cause harm when PSA is low. Listen to his talk:


Dr Mark Scholz discusses ADT for men with intermediate risk PCa. This doesn’t apply specifically to relapses, but is still thought provoking in terms of when ADT is beneficial and when it is not.

Lastly, studies have linked ADT to increased risk for dementia and Alzheimer’s. The risk increase is not huge, but I have a family history of dementia and am concerned about anything that increases my risk of cognitive decline. Similarly, heart disease runs in my family, and ADT is known to increase the risk of cardiovascular disease. And I do not have a family history of PCa. So, my family history factored in to my decision to treatment relapse with just IMRT.

Should things change for the worse down the line, I will revisit all options on the table.

Stay the course. You’re off to a good start!

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@melvinw
Did you get your first post-RT PSA test and was it below 0.1?

I finished RT last week. I’m feeling good and will have my first post-RT PSA test the middle of May. Fingers crossed!

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melvinw | @melvinw | Feb 22 5:36pm

Yup, PSA tested (Labcorp ultra sensitive) on Feb 13, right on schedule. Result came back the next day—0.086. Going into RT, I was at 0.094. So, that was a big sigh of relief. Met with my RO last Thursday who was satisfied as well. Good chance it will keep going down for a while, but if it just hovered where it is until the end of days, I would be just fine with that.

Glad to hear you finished with RT!

I really haven’t suffered any serious ill effects after 3 months. My urge to go has increased a bit, especially with BMs, but not to the point of having accidents or anything. Totally recovered from the fatigue in about a month. Of course, I felt some anxiety as the date for the first PSA test approached, but now it’s pretty much back to life as usual.

Best wishes going forward! Keep us posted.

M

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