Salvage radiation therapy after radical prostatectomy

Well, as others have said, those who have not experienced side effects from SRT, may not post on this or other forums.

I did SRT after a very successful surgery in March 2014, PSA was undetectable using standard PSA to a single decimal point until 15 months out (roughly September 2015) when it came back as .2, then 90 days later, was .3.

At the time, data was emerging from clinical trials as well as Mayo that in high risk PCA with BCR, there was often spread outside of the prostate bed to the PLNs and recommended treatment was SRT to the prostate bed, extend to the WPLN and include short term (six months) ADT.

I brought this data to my medical team who dismissed it saying there was no long term data to support it and the SOC was SRT to the prostate bed only.

Ninety days after completing the 39 IMRT, 70.2 GYa to the prostate bed only, epic failure.

So, understand your decision as it is from your radiologist, it is the "SOC" though as I have said before on this forum, are population based and historical, question, do you have an oncologist on your medical team, if so, what did that individual say, if not, consider consulting one.

The NCCN Guidelines, #13 for PSA persistence or recurrence after surgery suggest that if no other signs of cancer, radiation with or without hormone therapy or monitoring (see, choices, no definitive answer...!). So, your PSMA tests says "no cancer sign of cancer...yet, we intuitively know there is, otherwise your PSA would not be rising. At that PSA, low probability, rough 1/3, of finding any recurrence. There may be other data to aid in your decision making, the pathology report from your surgery which would indicate GS, GG, PSA tests which would give your PSADT and PSAV...

Question is, how aggressive do you want to be? In part, that depends on how aggressive your PCa is. The fact that it has returned may answer that question. As I said, so will your pathology report and PSA tests over time.

But, to answer your question since I haven't yet. I did not experience any SEs from my SRT. Why, who knows. I'm going to go with a highly skilled radiologist and her team.

Kevin

The short answer...the fatigue is likely the Orgovx and Zytiga, the nausea more likely the radiation.

Zytiga definitely causes fatigue even if taken with prednisone. My husband has taken it since January 2020 and the fatigue doesn't decrease with time. The nausea is probably the radiation as it is likely close enough to the stomach to cause it. See if your doctor will prescribe oral Zofran, anti-nausea dissolving tablets. Those helped when taken just before radiation and also after nausea starts.

Quick question: I’m currently going through 33 sessions of salvage radiation to the lymph node basin for Gleason 9 with EPE If that sounds familiar. Three weeks down and I’m experiencing substantial fatigue and mild to moderate nausea. I’ve also been on Orgovyx and Zytiga for three months. Did you experience any of this?

I am being treated at the Dan L Duncan Comprehensive Cancer Center in Houston. It is on the NCI list, but is it a Center of Excellence?

Quick question: I’m currently going through 33 sessions of salvage radiation to the lymph node basin for Gleason 9 with EPE If that sounds familiar. Three weeks down and I’m experiencing substantial fatigue and mild to moderate nausea. I’ve also been on Orgovyx and Zytiga for three months. Did you experience any of this?

What an awesome question! The National Cancer Institute recognizes centers around the country that meet rigorous standards for transdisciplinary, state-of-the-art research focused on developing new and better approaches to preventing, diagnosing, and treating cancer. Arguably there likely are several centers of excellence in the United States that don’t meet NCI criteria because they’re not doing research qualifying research, but nonetheless have the most state of the art equipment, qualified staff and interdisciplinary treatment. When I started my journey with PCA, I had zero appreciation for the difference between just any health system and a center of excellence. I was under diagnosed and under-treated and now being treated for Gleason 9 PCa and my life has changed forever. I hope that doesn’t happen to you.

Here is a link to all the NCI approved cancer centers in the US sorted by State: https://www.cancer.gov/research/infrastructure/cancer-centers

Best wishes for success on your journey with PCa.

Kevin, I know you are very knowledgeable but just wanted to point out one fact. There is a difference between a radiologist and a radiation oncologist. They are 2 separate specialties. I practiced Radiology and was a radiologist for over 40 years. In our large group we also had 3 radiation oncologists. Totally different training and practice.

Salvage Treatment of radiation to the whole pelvic region and pelvic lymph nodes (WPRT) together with a short term 4 - 6 mos of ADT has not left me with any significant side effects (SEs). See SPPORT trial.
If you have had a PSMA pet scan w/o definitive identification of metastases, the expectation is that cancer cells remain in the pelvic region.
RP @ 72 in Aug 2022
Persistent PSA of .19 postop.
Salvage tx at 73 Feb - June 2023
PSA undetectable at < .02 6, 9 & 12 mos post treatment.
Feel very fortunate so far and hoping/praying to never hear from my G 9 w/ EPE again.
Highly unlikely.
Maybe I can get a few years into the future and tx will continue to evolve in favor of all of us. Taking it one 90 day PSA test at a time.
My experience and point being, that for now my BCR is treated and PSA is undetectable.
Any radiation side effects disappeared 2 - 3 weeks following completion of radiation. And yes, the 4 mos of ADT Orgovyx was not pleasant, and the hormone SEs took an equal amount of time to disapate.
Best wishes to you and all in your treatment decisions and results.

What your radiologist is recommending is somewhat "old school...!" I mean that's what my urologist and radiologist recommended in 2015-2016 when I had BCR, I argued for including the WPLN and six months ADT based on data from Mayo about BCR for high risk more likely already in the PLNs, they pushed back, I acquiesced, the SRT failed, I was right. Remember, the sensitive imaging we have today was't then.

As samadhi has said, there are other pieces of the clinical data set that may aid in your decision making:

Gleason Score
Grade Group
PSADT
PSAV
Time to BCR

Those still don't say where the recurrence may be, just the likelihood.

A PSMA PET scan may be the critical piece of clinical data you're looking for to aid in your decision making discussions with your medical team. Speaking of that, I would expect a radiologist to say "SRT to the prostate bed...!" Well, not really, mine wouldn't, we discuss multi-disciplinary treatment to manage my PCa. What does your oncologist say? If you are still seeing a urologist, what does he or she say?

For most intermediate and high risk patients, doublet or triplet therapy is more mainstream, at least in terms of NCCN guidelines. There are still challenges and issues with clinical practices adapting those into their clinical practice.

As I say, the questions you have to ask about imaging are:

"Will it inform and change the treatment decision.?
"Will waiting for the imaging (scheduling) or for the PSA to increase to a level, say .5-1 where statistically it increases the chances from roughly 1/3 to 2/3 of locating the recurrence, change the outcome of treatment?

The later is less likely, the former is the critical question.

So, my answer, ask an oncologist, get a PSMA scan, talk with your medical team, radiologis, oncologist and if you feel so inclined, urologist, review the NCCN guidelines, then make your decision.

From the data you describe, I am not sure you are ready to make that treatment decision your radiologist recommends. For myself, blindly radiating the prostate bed and ignoring the likelihood of micro-metastatic PCa would not be my choice, I would want to know where the recurrence is for any decision on radiation and my treatment decision would include systemic therapy for a defined period to account for micro-metastatic PCa.

As to the SEs of radiation, well, I've done SRT, WPLN and SBRT, zero SEs, then again, I'm a study of one, others on this forum are not so fortunate. Why, who knows but I've had the same radiologist for all three, she's damn good as is her team. The sophistication of the planning software and delivery systems is amazing and each team, her treatment plan was subject a peer review board for "approval."

Kevin