The right time to start radiation post RP with an increasing PSA?

After a prostatectomy, they usually want to do Salvage radiation when the PSA hits .2.

That is exactly what happened to me And many other people I know of. I had the RP at 62. When My PSA hit .2 3.5 years later they gave me a six month Lupron shot and two months later I started 8+ Weeks of salvage radiation. They do it in a shorter time now, but they give you more radiation in each session.

Here is the recommendation from the standards group, I’ve included a link to the actual article so you can read the whole thing.

From Ascopubs about what PSA to do salvage radiation.
≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

This article discusses the above;
https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/

Forgot to include info for your last question.

They radiate the prostate bed and lymph nodes around it. That is the most likely place for the cancer to start back up.

It is not unusual for the PSMA PET scan to come back without finding anything.

@jeffmarc thank you Jeff. Very helpful.

Listen to your medical team/oncologist rather than anecdotal information from non-professionals. It's very hard to compare oneself to others as each person's particular situation is different. For what it's worth, your doctor's advice is similar to the recommendations I received when my PSA reached .20 two years post surgery. I too had a negative PSMA. I'm now three days into an eight-week regimen of radiation therapy of my prostate bed.

Best of luck!

@abinoone
Do you know who ASCO is? They are the American Society of Clinical Oncology. They’re one of the groups that set the standards for treatment.

If the American Society of Clinical Oncology is anecdotal information then I’m wondering who you would depend on for actual advice.

I included their recommendations for what to do when the PSA starts rising after a prostatectomy, as well as the whole article that discusses it.

This was real factual information from medical experts, not anecdotal information.

Interesting that you also mentioned your .2 PSA and having 8 weeks of radiation, wasn’t that exactly what I was telling him is usually done before adding in the ASCO expert medical advice.

@jeffmarc why are you so aggressively defensive? I simply advised the gentleman to listen to his medical team rather than laymen, as I'm sure any qualified professional would do.

@abinoone I agree with jeffmarc. No reason for the comment.

Gentlemen, I believe @abinoone was simply agreeing with @jeffmarc, that professional medical advice should be followed; he did not cite ASCO recommendations, but simply stated his own experience in starting IMRT sooner rather than later…
This could very well be the old COMMENT vs REPLY issue we know and love…someone posts, someone ‘replies’ instead of ‘commenting’ and it looks like a challenge to the previous post...kinda sucks when that happens😖
Phil

@heavyphil good observation! Sorry if my comment was unhelpful. Given the purposes of this forum, I do think it best if comments stayed constructive and positive rather than critical.

There has been much discussion on this topic. There are a number of reasons why the PSMA PET scan results were negative:
1. There were actually no PSMA-positive lesions.

2. Your PSA was so low (0.17); at that low PSA, PSMA PET scans will miss about 70% of prostate cancers even though you suspect something is wrong due to the rising PSA.

3. About 15% of prostate cancers do not express PSMA (or very little PSMA). (This is referred to as being PSMA-negative or PSMA-naive.) So PSMA PET scans won’t even see them even though you suspect something is wrong due to the rising PSA.

Has your doctor recommended using a older type of PET scan, one that isn’t dependent on PSMA - like the older Axumin or Choline C11 or FDG PET scans - which might be able to detect the location of the recurrence that is causing your PSA to rise? (Mayo Clinic often uses the older C11 Choline PET scan for this purpose.)

Dr. Kwon (of Mayo Clinic) indicates that only 1/3 of men who have recurrence following prostatectomy have recurrence only in the prostate bed, and that they should not get salvage radiation there unless they’re absolutely certain of the location of recurrence. He says to first confirm where the recurrence is. See Dr. Kwon’s presentation about recurrence (https://youtu.be/Q2joD360_pI) and what actions to take if uncertain.