PSA still rising after RP and SBRT.

[Odon]

I am 66 . After Rp in 2014 my PSA was undetectable for 2 years and it began to rise in 3 years until 0.32. PSMA PET/CT Ga 68 found 2 little points in my pelvic area that was treated with 7 SBRT treatments. After it PSA 0.19. In 2 years arrived at 0.52 but PSMA PET/CT, and MRI didn't find anything. Now I am wandering what would be the next step. ADT ot watching? This is the advice of my oncologist. Just now I am waiting. Unfortunately (I am living in Romania) We do not have so many treatment possibilities like in the western society and Heath insurance don't cover anything. Thanks for your advice.

[GP24]

As a European patient, you could follow the European prostate cancer guidelines on this:

"Based on the lack of definitive efficacy and the undoubtedly associated significant side-effects, patients with recurrence after primary curative therapy should not receive standard HT (ADT). Only a minority of them will progress to metastases or PCa-related death.

The objective of HT should be to improve OS, postpone distant metastases, and improve QoL. Biochemical response to only HT holds no clinical benefit for a patient.

For older patients and those with comorbidities, the side-effects of HT may even decrease life expectancy; in particular, cardiovascular risk factors need to be considered"

So, according to the guideline, you should observe now. You could get another PSMA PET/CT when the PSA has reached 2.0. Then chances are much better to see the mets.

[Odon in reply to GP24]

Yes of course but I would like to avoid mets.

[GP24 in reply to Odon]

The mets are already present, they are just too small to be detected with a PSMA PET/CT. It usually takes years for visible metastases to develop from single cells.

If you start ADT now, you will become non-metastatic castration resistant. Doctors often estimate that you become castration resistant after two to three years, but depending on the tumor volume it can be a much longer time. In your case it will be a longer time. But all patients become castration resistant when they use ADT.

[Fairwind]

What was your Gleason score ? Prostate cancer comes in different flavors..

[Odon in reply to Fairwind]

My original presurgery was 3+4

[Tall_Allen]

It's hard for me to understand why anyone who has had bone metastases would not have ADT. While SBRT provides good local control, it does nothing for the millions of cancer cells that you have circulating in your body - only systemic therapy (with ADT) can kill them. By doing nothing, you are only allowing them to proliferate.

[Odon in reply to Tall_Allen]

Thanks. As I know ADT not cures cancer, just keep under control the PSA level. And what about castrate resistance ? This is what about I am afraid. Am I right?

[Tall_Allen in reply to Odon]

No, that is a mistaken belief. Castration resistance will occur whether you use ADT or not. In fact, it has now definitively been proven that more ADT, using stronger anti-hormonal agents, slows progression and extends survival more.

Castration resistance is part of the natural course of the disease, it is caused by the genomic breakdown that always occurs in metastatic cancer cells. Genomic errors are not corrected in cancer cells, and they are immortal unless killed by an external medicine. Your mistaken belief stems from your understanding that ADT exerts selective pressure, allowing only castration-resistant cells to survive. That is true, but is only part of the story. The much bigger part of the story is that ADT dramatically cuts the cancer cell load so that there are many fewer cells that can replicate and cause other cells to turn cancerous and to change healthy tissues to make them capable of hosting tumors (they do that too!).

ADT alone doesn't cure metastatic prostate cancer, nothing we have so far does, but it can slow it down in many men to the point that it can become a disease one can live with, sometimes for a very long time.

[Odon in reply to Tall_Allen]

Thank you I will consider your advice.

[dadzone43]

There you have the spectrum of options from watch and wait through ADT. There is no clear path. You do not need to decide in a hurry.

[Odon in reply to dadzone43]

Thanks. As I know ADT not cures cancer, just keep under control the PSA level. And what about castrate resistance ? This is what about I am afraid. Am I right?

[dadzone43 in reply to Odon]

Don't know. It appears from these pages that men eventually become castrate-resistant. Which? How? How many? I do not know. But castrate resistance comes _after_ lengthy treatment with ADT, doesn't it? The CR cells emerge after long exposure to anti-androgens. I do not think that means if you delay ADT, the "train will leave the station" and ADT then will not work for you.

[Odon]

Thank you. Now I am in a waiting period.

[BruceSF]

I had a video conference with my oncologist last week. I had RT + whole pelvic radiation and I n January I finished 2 years of Lupron +Zytiga for G9 PCa with 10 regional pelvic lymph nodes invaded. My PSA has been undetectable. The oncologist said that if BCR happens, they will wait till the disease shows up on a PSMA scan, and if possible hit it with SBRT and give me one more year of Lupron (or maybe Relugolix) plus zytiga. Dr Morris’ talk about the Condor study at ASCO last week describes the philosophy. I believe the idea is that the effect of the hormone treatment is higher when used with the highly focused SBRT radiation, and the combination is potentially curative.

[Odon in reply to BruceSF]

Thank you for sharing your experience.