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Salvage Radiation Therapy with or without ADT added?
I am the point where I need to get Salvage Radiation Therapy. I had RALP in November 2025 and now, 6 months later, my PSA has presented an increasing tendency, 0.18, 0.19, 0.21 in the last test results, over the past 2 months.
In my recent consultation appointment with my Oncologist, the plan is that I do need to get SRT. At that time, he ordered a PET PSMA CT scan and leaned strongly about adding 6 months of ADT, regardless of the results of the scan. He explained that the scan would be just to define if the target is only the prostate bed, or anything beyond that also.
I just got my PET PSMA scan results and these came out perfectly clean. Nothing showed up, fortunately.
I have researched about the need or benefit of adding ADT in my particular case and it seems like I am right at the gray line, where it might or might not be of significant benefit.
I am 56, my Adverse Factors are : 3mm Positive surgical margin post-RALP (pattern 4), Gleason 4+3 (high proportion of pattern 4), Low tumor volume (5%), Early PSA rise (< 6 months); my Favorable Factors are: pT2 (no extracapsular extension), pN0 (clean lymph nodes), Negative PSMA PET. Side effects from RALP: zero incontinence, ED gradually recovering.
My big dilemma at this point is trying to ponder the tradeoff between possible added benefit vs side effects of ADT. ADT might not add any significant benefit in my case, but it might not be as bad as to not accept the marginal benefit that it could provide for me. On the other hand, the marginal added benefit might not be worth the possible side effects. Without being completely certain of making the right decision, I am leaning more towards avoiding it.
I have my next appointment with my Oncologist scheduled, where we will review my PET PSMA scan and define the final plan. I would greatly appreciate any comments and shared experiences regarding this big decision, that will help me be better prepared, with good supporting arguments, when discussing my treatment plan with my Specialist.
Thank you.
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As far as I am reading lately, newer recommendations are different than what was previous protocol. It is tough decision indeed.
https://www.urotoday.com/video-lectures/asco-gu-2026/video/5413-poseidon-meta-analysis-re-examines-the-role-of-adt-with-salvage-radiation-for-prostate-cancer-amar-kishan.html
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6 ReactionsNote that at such low PSAs, PSMA PET scans are highly ineffective at detecting prostate cancer and will miss most of them. This is why many centers wait until PSA exceeds 0.4 before trusting a PSMA PET scan not to deliver a false negative. Also note that about 15% of prostate cancers are PSMA-negative, and would never show up anyway. (You should have this discussion with your doctor.)
> Have you previously had a PSMA PET scan?
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Ok, back on topic —> If it were me, and ADT would lessen risk at all, I’d use it.
In your situation, you originally had a 4+3, which (if you had gone the route of primary radiation) would’ve warranted the use of ADT for 6 months (due to the risk of metastasis); you also had a high proportion of pattern 4, which would’ve warranted the use of ADT possibly for a few more months (due to the increased risk of metastasis). And now that you need salvage treatment for biochemical recurrence, that same “ADT warning” is knocking on your door once again - trying to help you, not hurt you. If it were me, this would be an easy call.
If it were me (and if I were seriously considering not using ADT), I would first get the ArteraAI prostate biomarker test. The ArteraAI test assesses your biopsy tissue to predict whether you will benefit from hormone therapy and also estimate long-term outcomes.
If it indicates a benefit, I’d use it; if it indicates marginal or no benefit, then it’s a toss-up call. (But, have a logical treatment-related reason not to use it.)
Having been on 6+ months of Eligard myself in conjunction with my 28 proton radiation treatments (during April-May 2021), I can tell you that the side-effects of ADT are easy to minimize, if you’re willing/able to put in the effort. There’s been much reported on this. Here are a few informative resources:
> Drs. Sholz and Moyad talking about exercise and hormone therapy:
> A paper on The Benefits of Exercise During Hormone Therapy: https://static1.squarespace.com/static/54c68ac6e4b06d2e36a4b8c9/t/55cb7275e4b0d97ae7ff60af/1439396469154/The+Benefits+of+Exercise+During+Hormone+Therapy_Insights+August+2015_PCRI.pdf
> A study about the benefits of exercise to counteract the adverse effects of ADT: (They describe a good resistance-training program): https://journals.lww.com/acsm-msse/fulltext/2023/04000/resistance_exercise_training_increases_muscle_mass.2.aspx
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6 ReactionsHi,
You could try one of the newer ADT drugs in pill form rather than going with an older drug like Lupron. The ADT drugs before and after radiation weaken the cancer so the radiation is more effective. Orgovyx is a daily pill so if reactions due become to severe you can stop where Lupron is a shot lasting many months.
Dave 3+4
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3 ReactionsHaving been in your shoes - but 5 years to BCR, not 6 months - I would strongly suggest ADT. 6 months of Orgovyx is not a life changer; annoying at times, yes, but it’s all temporary…
Also, you ABSOLUTELY need radiation to your pelvic lymph nodes - not just the bed - regardless of PET scans. See the SSPORT trial and do some research.
You gotta try to kill this fu**er now!
Phil
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4 ReactionsI had surgery at 62 and 3 1/2 years later had SRT when my PSA hit .2. They gave me a six month Lupron shot two months before the radiation and I had no side effects that I can recall from that shot. Radiation was 12 years ago And I have BRCA2, which makes my cancer much more aggressive. I’m still here and people have no idea I have cancer that keeps coming back.
My brother at 77 had six months of Lupron just before his five sessions of SBRT radiation as his primary treatment. The only side effect that bothered him was hot flashes, And they weren’t severe.
Six months of ADT is really not causing major side effects for most people. If you can get Orgovyx Instead of other ADT drugs, you will have your testosterone come back much quicker when you stop and most people say there are fewer side effects from it. I definitely have many fewer hot flashes, But I’ve been on ADT for eight years. Even though I’ve been on it that long it’s really not a detriment for me. Yes, I have to go to the gym three times a week and I walk a mile twice a day on a track and I have taken bone strengtheners, All things that you really need not sweat about with six months of ADT. For the first five years, I was on it the only thing I did was take Fosamax to keep my bones strong.
Good luck with the SRT resolving your problem long-term.
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3 Reactions@surftohealth88
Thank you very much for the link. Very interesting interview discussing exactly my current concern. It apparently favors my case, with a PSA lower than 0.5, to avoid the need to get ADT.
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1 Reaction@brianjarvis
Thank you for you response. I did get a PSMA scan 2 months before my RALP procedure and it only showed the lesion in my prostate at the time, nothing else.
My Doctor explained that the purpose of this last PSMA scan was just to rule out the possibility of anything showing beyond the prostate area., which would change the Radiology plan.
I see your point of ADT being an apparent benefit for my case. I agree that ADT is supposed to help me but my understanding is that it can also hurt me, which is what I would want to avoid, to the extent that it is reasonably possible.
I was not aware of this ArteraAI prostate biomarker test, but I will look into it. Thank you.
Were your radiation treatments your primary treatment or were these to treat a biochemical recurrence? Were you able to fully recover from these or not completely?
Your comment on the ADT side-effects being easy to minimize are certainly encouraging. Thank you for the helpful links on the benefits of exercising, I will check them thoroughly.
@clevelandguy
Thank you for your response. I have read about the Orgovyx pill being not as aggressive as the Lupron shots and that recovery is faster bit apparently this pill is not available in my region, from what I have researched. I will be confirming this with my Oncologist on my next appointment when we define my treatment plan.
@heavyphil
Thank you for your response. I do see your point about suggesting to go with the 6 months of ADT. You mention that it is temporary but I have read that some of the effects are not fully reversible and that some permanent damage might occur. The cardiovascular damage is one of my biggest concerns.
My Oncologist did suggest that radiation to the pelvic lymph nodes would be required, besides the prostate bed. Thank you for pointing that out.
I just checked the SSPORT trial that you mention. Very interesting study that does confirm the substantial benefit of adding treatment to the lymph nodes. Thank you and thank you for the encouragement!
@jeffmarc
Hi Jeff, thank you for your response. Your experience and your brother's are very encouraging, with all that you have gone through, even more so if I am currently, possibly, only looking at 6 months of ADT.
As I mentioned in another response, apparently Orgovyx is not available in my region. I still need to confirm this with my Oncologist but if that is the case, I would be stuck with Lupron treatment, which you also have gone through.
It's great that you have been able to find your way to make the best of living with this. I admire your positive attitude. Thank you for your kind wishes.