What does Salvage Therapy after Radiation look like?

The way that it was explained to me when I was making my decisions, is, if you do radiation therapy for your primary treatment, and you need salvage therapy, a prostatectomey can be performed, but it is a much more difficult operation and recovery given the damage done to the tissue via radiation. This operation is preformed by an even smaller specialized group than the basic RARP. Granted that was about 4 years ago now, it may be different.
This was one of the primary reasons I elected to have the RARP so that radiation was available for the salvage treatment, as it turns out, I neeeded it.

I was told the same thing. I elected for NSRARP so that salvage radiation could be performed. Mine has been 6 years and I have not needed the radiation. As far as whats involved with Salvage treatment. IDK.

Ask what the Proton treatment plan is. Most salvage radiation is to the prostate bed and that can be treated with the initial radiation but falls outside what is removed with RP. Salvage treatment if distal recurrence will be the same as with RP: Systematic treatment with ADT, Chemo, etc. If confined to the prostate than whole gland Cyro or HIFU is usually used. Salvage RP is very unusual due to scar tissue left by the radiation. At your age most patients are strongly encouraged and chose RP over radiation. If it looks like it might not be contained in the prostate EPE, etc. than you might have salvage radiation within a year or 2 of RP. That would be a reason to choose radiation over RP. Likely to have more side effects from ADT than radiation but if short 4-6 months at your age should recover fully. If you go for ADT get the pill (Orgovyx) vs. a Lupron shot. Once you are jabbed, you are stuck in more ways than one.

Radiation can be very effective. The one drawback is that you never really know what your Gleason score was or if there were other issues inside your prostate that weren’t seen in the biopsy. I was a 3+4 after biopsy but a 4+3 after surgery. I’ve run into many people that are 4+5 after surgery.

I had 40 sessions of salvage radiation 12 years ago and The only side effect was incontinence starting six years after the Radiation. I had a prostatectomy before that so that could be the cause too.

I know a lot of people that I had radiation and 10 or 20 years later don’t have problems. One thing though, If you have surgery you can usually have the nerves spared, which can allow you to get an erection after. If you have radiation, they cannot spare the nerves and burn them up. That frequently leads to ED after a few years.

People who have radiation as their primary treatment have been told by doctors that surgery isn’t really an option if there’s a reoccurrence. Other options are not really mentioned..

This study shows that both salvage focal therapy (HIFU and cryotherapy) and salvage surgery were equally effective at extending the life of a patient that started off with radiation.

Those that had focal therapy had fewer perioperative complications.
https://jamanetwork.com/journals/jamaoncology/article-abstract/2844900
Some more information about future issues due to radiation

In a study of about 145,000 men with prostate cancer, the Stanford team found that the rate of developing a later cancer is 0.5% higher for those who received radiation treatment than for those who did not. Among men who received radiation, 3% developed another cancer, while among those who were treated without radiation, 2.5% developed another cancer.
https://med.stanford.edu/news/all-news/2022/070/prostate-radiation-slightly-increases-the-risk-of-developing-ano.html

@jeffmarc Thanks so much for your comments Jeff. Much appreciated!

The most recent studies have looked at patients for 15 years. Here’s a link to a recent study: https://www.nejm.org/doi/full/10.1056/NEJMoa2214122

(At 65y - for a 4+3=7 w/PSA of 7.976 - during April-May 2021, I had 28 fractions of proton radiation @ 2.5 grays per fraction + SpaceOAR Vue + 6 months of Eligard. My most recent PSA was 0.366.)

They usually do not recommend ADT for a 3+4 unless there are other risk factors. An ArteraAI prostate test will let you know if ADT would benefit your treatment.

I did not choose Proton SBRT due to reported increased risk of urinary bother. (See Dr. Rossi’s comments on this topic at the PCRI 2023 Mid-Year Conference: starting around timestamp 4:30:45 at https://www.youtube.com/live/WTqPnSRYtW4)

Dr. Rossi has a lot of information about proton in his portion of the conference Starting at about 3:38:45 at that same link. (If you watch his entire presentation, he covers much of what you’ve asked, and more.)

As for “long-term effects of radiation (10-20 years down the road),” remember that what radiation doesn’t hit, it won’t affect. Work with your external radiation team to use the latest technology and expertise so as not to overshoot your prostate in order to avoid hitting nearby otherwise healthy tissues and organs (i.e., minimize entry-dose, scatter, and exit-dose).

As for “possible recurrence and what salvage treatment looks like,” you’ll often hear things like “if you choose radiation first, you cannot have surgery later.” Though that does have some truth to it, it’s very old-school and doesn’t consider modern treatment techniques. With modern radiation, if there is local recurrence following primary radiation you have many options - focal therapy (e.g., cryo), brachytherapy, SBRT (because they’re all very targetable), and even re-radiation with standard radiation in some cases. Salvage surgery would still be my far (far) distant choice (and one that I probably would never choose).

I personally know two guys who had primary SBRT, then had recurrences of just 1 lesion. Both of them had salvage SBRT; their PSAs plummeted and they’ve had no issues since. It really depends on the nature of the recurrence.

Very good and thoughtful questions. Feel free to ask more.

Hi, do you have any other relevant data other than your Gleason Score?
Have you had a Decipher or any other genetic test?
These can be very important in choosing your primary treatment as they gauge the aggressiveness of your cancer.
Unfortunately, the Gleason score is Quantitative, not Qualitative. Not all 3+4’s are the same!
Phil

@jim18 thanks for your comment Jim, Good things to think about

@brianjarvis thanks so much. Good insight and thanks for references.

Hi,
One thing about Proton beam radiation is that you can treat the same general area various times where some X-ray based radiations will max out an area. Proton radiation has a fixed beam length so damage past the cancer site is rarely effected. Other type of X-ray based radiation go completely through your body hitting other organs and tissue.

Dave 3+4