Salvage radiation therapy after radical prostatectomy

Usual dose is 66Gray (Gy) when they give 35 sessions.

My Salvage Radiation after RP was 37 treatments 66.6 gy delivered at fractions of 1.8 to the pelvic region with 25 of those treatments including the pelvic lymph nodes.

Radiation Oncology in general has been delivering different fractions over different periods of time through the years.

Best wishes

I had radical prostatectomy in 2019 but now PSA is rising and currently at 0.4 so the radiation specialist has recommended salvage radiation to prostate bed. I am concerned with the potential after effects (morbidity) of the treatment. I'd like to know if there are those in the group that have decided to not go that direction for this reason and to follow obsevation and hormone thearapy using radiation for a more targeted approach as things may develop as well as the use of chemo. To risk quality of life in the early stages of the disease is a hard choice when there is a good chance the radiation may not have any positive effect. I'm not good at betting on the odds. I'm surprized that there aren't more disscussions on this. Any input??

Dear Fellow Journeyman...
You took words out of my mouth. I am in the same boat as you are and that's why I posted the question.

There are models that predict risk of distant metastases which includes
1. PSA - Double Time. If >12 months, low risk
2. Gleason score - 7 or below
3. If first rise after prostatectomy is after 18 -24 months.
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If person falls meets above criteria, they are considered low risk of distant metastases.
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There is normogram from Memorial Sloan Catering which one can do.

https://www.mskcc.org/nomograms/prostate/biochemical_recurrence
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We are in same boat. I would be curious to know what route to take.

Best wishes for your journey..Hugs..

It's looking like my doubling time will be under 12 months. We are still looking to establish that. My schedule PSA test next month will tell us more. My Gleason score is 7 and time to recurrance is approx 5 years so I'm on the edge except for doubling time which is looking maybe around 8 months. Time for recurrance of 5 years seems to be one factor possibly in my favor. My radiation oncologist tells me these cases don't follow a consistant path and that is one of the challenges in making these decisions. I'm 69 and fairly fit. I have been dealing with the typical incontinance issues of a couple pads a day and ED. The risk of total incontinence, rectal bleeding, bladder and those issues give me pause in wanting to take the salvage route even though I am considering any options. I know the cancer growth is relatively slow and with hormone therapy and chemo I could possibly have a number of years with basic systems still in working order and deal with those side effects later down the line. I'd like to think targeted radiation to metastases that could occur could be beneficial for at least a while. I wouldn't feel cheated if I don't reach the age of 90 but I'd be grateful for 8 to 10 more years.

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

Thanks for your responses. For the recommended salvage radiation the radiation oncologist was to include ADT which I didn't mention above. Also, I unfortunitely remembered the Gleason score of 7 was from my original biopsy. The adjusted Gleason score of 9 was given upon examining the removed prostate.

Gleason 9 is serious business. I know that from experience. I’m told that the typical standard of care now is RT to the prostate bed and perhaps lymph node basin and up to two years of first and second generation ADT. I am on first generation ADT, Orgovyx and second generation ADT, Zytiga. I went into this in excellent shape for being 69 years old and continue to exercise every day, including resistance training, which has helped minimize muscle loss and weight gain. My prostate bed was previously radiated when I got received low dose brachytherapy in 2020 so that can’t be repeated for me, but it might be part of our standard of care plan for you. I’m currently undergoing 33 sessions of VMAT format IMRT on the lymph node basin only. My PSA is currently undetectable.

Not sure where you live, but I strongly suggest that you consider making certain that you’re getting care at a center of excellence even if that requires travel. My initial care was not at the center of excellence and I underestimated just how important it was which is why I share these thoughts with you.

Best wishes for success on your journey.

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.

Thank you for your note. Your positive experience gives me a better insight to SR and its benefits.