Salvage radiation therapy after radical prostatectomy

My MO at Johns Hopkins uses regular PSA test (Labcorp undetectable is < 0.1). When I asked him why he didn't use the ultra sensitive test he said, 1) the ultra sensitive tends not to be accurate a low numbers and the results can fluctuate, 2) the PSA would have to rise above 0.1 before it would trigger possible additional testing i.e. another PSMA PET. Makes sense to me. I've had enough anxiety without watching an ultra sensitive test yoyo and not do anything about it.

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

uPSA = ultrasensitive prostate-specific antigen (assay or test), the two most common are probably the one used by Labcorp (minimum sensitivity .006) and the one used by Quest diagnostics (minimum sensitivity .02).
SE= side effect

Dear Fellow: Your post is most comprehensive and filled with empathy! I truly appreciate it...
1.As far as opinions, I have spoken with 3 rad-oncs and reviewed guidelines. They all recommend salvage RT to prostatic bed but no ADT. As far as side effects, the forum may not have posts from fellows who don't have side effects. I think I have a good rad-onc, knowledgeable and easy to reach and communicate with. He is trying to balance timely treatment and not over-treatment.
2. I love exercise and so hopefully I will continue.
3. Your point about doing what makes one happy and surround with people with positive people and live one life is so crucial...
Thank You dear...

RP in 2013. Positive PSMA PET in 2023 at PSA 0.23. Just completing 6 months ADT and prostate bed salvage radiation (X36). Here are my thoughts. DON'T PANIC. You have time to sit back, do your research and make the correct decision FOR YOU. If you read all the comments about negative side effects you will be paralyzed with fear. (I know I was.) There is no way to predict what YOUR journey will look like. My guess is the vast majority of patients have manageable side effects and don't bother to write comments or posts. 1: You have time to get multiple second opinions from top doctors at major teaching hospitals and center's of excellence. This is SO important. (I had six different opinions!) In the end I travelled 1200 miles to Mayo in Rochester, MN to receive treatment. 2: Exercise! Movement is medicine!. You don't have to run a marathon but you do have to get off the couch. 3: Figure out what makes you happy and DO IT! 4: Surround yourself with positive people and smile. You have one life, one journey. You're in charge! Sending positive thoughts your way.

there are regular PSA tests which generally measure PSA to .1 and anything less is reported as < .1

And < .1 is the goal post surgery

And there are ultrasensitive PSA tests (uPSA) which have lower levels of detection: Quest Labs limit of accurate sensitivity is < .02

Johns Hopkins is, or was, < .03

I have seen reports into the 3 digits, such as < .008

Honestly, not sure why there are different tests to such low levels. 🤔

I infer that allows a patient to follow any rise in PSA post treatment, even at extremely low levels.

If my PSA rose for example to .04 from < .02, I would "lose my mind", but I do not think that it would trigger any treatment; certainly would trigger closer monitoring.

One friend post surgery and post salvage treatment is being tested to < .1 level.

I believe that some MDs feel it reduces anxiety w/o impacting negatively on care and treatment to test to < .1

SE is shorthand for Side Effects (sorry)

What is uPSA? What is SE?

PSMA Pet scan didn't reveal distant spread. Thank you...

I had Salvage Treatment: 37 IMRT radiation txs over 8 weeks to whole pelvic floor and pelvic lymph nodes together with a 4 mos short term of ADT.

See SPPORT trial info.

This was shortly after my Prostatectomy. My PSA was "persistent"; 1st 90 day PSA .19 (did not return undetectable).

Referred immediately to Radiation Oncologist.

Bowel/bladder: 1st 4 wks no particular issues. 2d 4 weeks, increasing diarrhea and some pain/ stinging upon defacation. Resolved 2 - 3 wks after radiation completed.

Same experience for a salvage treatment friend.

Sexual function: I am not a good resource to respond; the ADT eliminated any libido and I was only a few months out from surgery and erectile function return was in its infancy.

On the happier side, my uPSA 1 year post salvage treatment has been undetectable at < .02 (limit of testing accuracy at Quest Labs).

Also, started ADT a month prior to radiation and that "no fun ride" made I difficult to distinguish between SEs from ADT and/or radiation.

Best wishes for a successful treatment.

Have they done a PSMA PET scan yet to determine where exactly the recurrence is? What (& where) were the SUVmax scores from the scan?