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

Posted by erustand @erustand, 3 days ago

I'm 57 years old and had a Robotic Radical Prostatectomy on 12/1/2022. Since then I've been diligent in my post operation blood work and PSA monitoring.
In January of 2024 my PSA went from undetectable to .04 and three months later .07. Then fall of 204 and into 2025 my levels went to .11 and now the most recent .17. I've consulted with an oncologist and it has been suggested to begin targeted radiation with testosterone suppression. My formal radiation oncology appointment is tomorrow.
A PSMA PET scan showed no signs of cancer but my doctor is suggesting that it is absolutely the beginning of a clinical recurrence and better to start earlier than later with this course of treatment. To me it seems confusing that the PET came back negative but a positive oncologist is so certain that it is there.
Am I better to begin with the assumption that cancer is back and not actively monitor for a period of time? How do we know where to target the radiation if nothing is showing on the PSMA PET scan?
What am I not asking or what am I missing in the advice I have gotten so far?

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sriddle1 | @sriddle1 | 19 hours ago
In reply to @jeffmarc "@sriddle1 The problem is he does have an aggressive case of prostate cancer and, it is..." + (show)
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@sriddle1
The problem is he does have an aggressive case of prostate cancer and, it is not a very big rise in PSA. The question is, does his case fit into the below guidelines for why someone should have Adjunct radiation, And not wait until PSA hits .2 for salvage radiation.

I know his Gleeson score is a nine so that hits one of the risk factors. Does he have one other of those below listed Risk factors?

I think this is something that @surftohealth88 Also was looking into. Maybe she can comment about why they decided to wait.

Adjunct radiation
Dr. Efstathiou concluded as follows:
* Early salvage radiotherapy is favored over adjuvant radiotherapy in most patients
* Consider adjuvant radiotherapy in otherwise fit, motivated, very high-risk patients with ≥2 of the following risk factors:
* pT3b-4
* Gleason score 8-10
* pN+ Lymph node Metz
* Decipher score >0.6
* In high-risk patients, use lower thresholds to initiate ‘ultra-early salvage or adjuvant-plus’ radiotherapy
* If giving adjuvant radiotherapy, it implies high-risk disease. Thus, Dr. Efstathiou would recommend treating the prostate bed and pelvic lymph nodes, in addition to short-term versus long-term ADT, depending on risk factors
* May consider genomic classifiers or artificial intelligence tools to help with informed decision-making
* The goal is to avoid (or delay) radiotherapy in those who we can, without missing a window to cure patients who are guaranteed to recur

Here is a link to the article supplied by @surftohealth88 originally
https://www.urotoday.com/conference-highlights/apccc-2024/151546-apccc-2024-debate-how-to-best-manage-a-fit-patient-with-high-risk-localised-and-locally-advanced-prostate-cancer-how-to-select-patients-for-adjuvant-therapy-after-radical-prostatectomy-and-how-to-treat-them.html

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@jeffmarc thank you Jeff. I will read the link you sent and thank you for pointing out the important information on your reply.

I guess we’ll be starting this journey of more treatments.

Thank you

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robertehughes | @robertehughes | 8 hours ago

I’m a firm believer in do nothing until the PSMA/PET shows exactly where the recurrence is located.

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beachflyer | @beachflyer | 1 hour ago

Hi Crustand,

This has been a great thread and Jeff touched on the topic of PSA doubling time (PSADT) that might be worth an additional comment as medical professionals may treat aspects of PSADT differently. It is safe to say that there is on ongoing effort to figure out how best to determine the aggressiveness of an individuals PC in order to decide if intervention is in order. That applies to pre-treatment and post-treatment such as the case in BCR following surgery or RT. That effort is something of a holy grail in cancer research as I see it. While we obviously use rising PSA (the check engine light of PC) as one of the factors to diagnose PC, it can also be used to help determine cancer aggressiveness and or the need for additional therapy. PSA doubling time (PSADT) plays a role in the treatment decision process.
The reason for this discussion is that I am enrolled in a University of California Irvine Medical Center longitudinal PC study conducted by UCI Medical Center under the guidance of former Director of Urology Dr Ahlering. When I selected Dr Ahlering as my surgeon 14 months ago, I had to agree be a research subject in his surgical technique during the robotic prostatectomy and be a part of a 20 year follow up study. I asked him last month at my 1 year post surgery follow-up tele-med call ....what happens if my PSA rises? He said based on the PSADT, he would likely recommend active surveillance. I said what happens when it hits .2 ng/ml ... the normal trigger for additional treatment? Dr Ahlering said ..."well, prior to hitting that number we would look at the PSADT and if your doubling time was 12 months or greater...the PC producing the PSA is likely "indolent" and additional treatment may not ever be necessary". He said if the PSADT was under 12 months, we will look at additional treatments.

I mentioned to Dr Ahlering that my original PSA doubling time was under the 12 months (.8 to 1.8 psa). He said "that is because you had a prostate that was incubating Gleason 7 cancer and that "mothership" is now gone". Anyway without going into the weeds here, the "mothership" theory is explained in Dr David Walsh's book "Surviving Prostate Cancer". Dr Ahlering supports Dr Kwon's research that not all BCR is in the prostate bed so "salvage radiation" to the prostate bed may be unnecessary.

Crustand, with your Jan 2024 PSA of .04 and "Fall 2024" PSA of .11, your doubling rate is around 8 months and would probably fall under the guidelines of rapid PSADT ; the time frame of < 3-9 months PSADT suggests a more aggressive PC. I would expect your medical team to propose additional treatment. This is a tough decision as pointed out by other posters cause if it is in the prostate bed early treatment provides better outcomes. None of this is medical advice as I am only sharing my story of the PC train ride and that different practitioners prioritize medical information differently. It is always good to get second opinion whenever possible.

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