Need advice- MO recommending radiation. From the wording in the PSMA scan it sounds like a shot in the dark.

[Jabbs4]

Husband on Erleada since Jan 2022. PSA started rising in Jan.,, again in March (almost doubling in 3 mo). PSMA scan stated “Two foci suspicious for tumor deposits located superior to the prostate at the level of the seminal vesicles at midline and inferiorly within the prostate apex (screen capture #1259).” MO referring to radiation thinking it might be the source of his rising PSA. I asked if this means he’s castrate resistant. MO said borderline and thinking radiation might push him back to hormone sensitive.

My husband is very opposed to radiation due to SE and QOL. But agreed to referral to listen.

The wording in the scan sounds to me like it’s not sure that this is cause of his rising PSA. Why subject him to radiation if not sure? I’m just not sure what even to ask. Is radiation called for?

I Btw, thought the MO had ordered the scan prematurely. But by the time I got advice on that, it was too late to call it off. Overall, scan showed Lupron/Erleada was helping. MO is continuing him on Erleada and go back in 2 months. But wanted him to pursue radiation as it might help. ????

[fireandice123]

I can’t speak to the more technical parts of your post but I can say I had few side effects from radiation, much less than ADT. Aside from having to go in every morning for 15 min to have the actual treatments my QOL was not impacted. My side effects were increased urination frequency and some relatively minor diarrhea, both only occurring during treatment. Once RT was over everything went back to normal. For the increased urination my tamsulosin dosage was doubled and I took Citrucel for the diarrhea. Both helped considerably. After RT my tamsulosin dosage was reduced and I stopped the Citrucel.

[Jabbs4 in reply to fireandice123]

Grateful to you for sharing your experience. I shared this with my husband. It helped ease his concerns.

[Justfor_]

A mentioning of the SUV of each of the two suspicious foci would have been helpful. My first move would have been to request a second reading by another (unrelated to the first) radiologist without access of the present report (image files only). Lastly, a debulking RP could most probably get the apical spot with also slim chances of doing the same, or partly the same, for the superior spot (seminal vesicles level). I am too of the opinion that irradiation should be employed as a last resort.

[Jabbs4 in reply to Justfor_]

I did ask about SUV … only because someone on this forum mentioned it previously. For whatever reason, the onocologist said they don’t report it. He didn’t know why not. ???

I have thought about asking for a second opinion. Not sure who to go to.

Thanks you!

[GP24]

I would recommend SBRT radiation to radiate just the two spots with low side effects. If these are affected lymph nodes, which is likely, the PSA value will go down. These foci probably contain a lot of resistant tumor cells you may want to remove.

[Jabbs4 in reply to GP24]

Thank you. We had discussed radiation to just those two spots. Good to hear SE would be low.

[Tall_Allen]

Castration sensitivity or resistance is not either/or - it's a gradual change. It appears that the only detectable resistant cancer is around the prostate. If he can hold back progression and keep him Erleada-sensitive, it may be a good move. So far, the cancer and the adverse effects of the cancer are being well-controlled, but that could change if the resistant strain spreads. But you rightly raise the fact that there may be side effects from the radiation - that is something the RO knows about and can address. Then you and your husband will have to weigh that risk against the benefit.

[Jabbs4 in reply to Tall_Allen]

Once again, thank you for weighing in. It made sense when the oncologist suggested it. (I was second guessing later as I read through the report.) He has handled the Erleada pretty well. Obvious concerns about doing nothing….and what comes next that he may not handle so well. As I said to him, doing nothing is a risk, too. We will get more details as to radiation tomorrow for him to weigh and decide.

[Teacherdude72]

Personal experience: literally no side effects from the 25 sessions of RT. ADT side effects similar as others note.Opinion: I focus on living and not the SE's.

[Jabbs4 in reply to Teacherdude72]

Good perspective. Thank you for sharing.

[Sailing-Todd]

Hi Jabbs4.

My husband has been on Erleada since last April and it is keeping things at bay. They did radiation last September to debulk and it helped his general urinary symptoms and he was able to give up Flomax. He had some mild urinary frequency and mild diarrhoea for the last week of the four week course but no other side effects since. They inserted a spacer gel prior to the radiation, but I guess that is dependent on each patient’s own anatomy. Good luck!

[Jabbs4 in reply to Sailing-Todd]

thanks for sharing your experience. It was helpful to hear.

[RoseDoc]

SE from radiation treatment is minimal. Not sure of your husband's age, Gleason score, but radiation is probably a good choice.

[Jabbs4 in reply to RoseDoc]

Thank you. Metastatic at diagnosis so no Gleason. 73

[maggiedrum]

I believe that the interpretation of a PSMA-PET/CT scan is subject to the ability of the specific reading radiologist. I had a second reading done by a separate radiologist at the UW Radiology Oncology department, not a general radiologist. But even if the RO who did the first reading has a lot of oncology experience, I would ask for a second opinion reading. That does not mean that I disagree or have any other concerns of your husband's report.

I would defer to the opinions/research of those like Tall_Allen for the other issues you raise. However, I would be skeptical that radiation would directly cause a change in the cancer cells from noncastrate sensitive to resistive from radiation. I would believe that it could kill more of one type of cell than the other and that would make a difference in the levels of PSA after the therapies.

To me the real issue would be secondary damage to other tissues, like the rectum, intestines, bladder, etc. That could lead to QOL degradation and was a major reason that I, personally, was reluctant to get radiation (and because mine would have had to have been the entire pelvic floor which would increase the exposure to other tissues).

[Jabbs4 in reply to maggiedrum]

Thank you.

[ron_bucher]

My side effects from radiation in 2008 and again in 2017 have been very minimal. From a side effects perspective, I'd much rather have radiation than ADT.

My radiation in 2008 (without any other treatments) gave me 7.5 years of undetectable PSA. My radiation in 2017 (along with Taxotere and 9 months of ADT) gave me 4 years of undetectable PSA.

[ron_bucher in reply to ron_bucher]

p.s. Did not mean to compare cases, just saying for me radiation was well worth any side effects it gave me.

[Jabbs4 in reply to ron_bucher]

it is helpful to hear other people’s experience. Thank you!

[RMontana]

See if watching this podcast which feature 3 PCa case studies, helps...it revealed a lot of treatment options, testing criteria and general treatment progression discussion I had never heard of. See if there are any other tests that can be done to help make decisions going forward a little easier. We may never be 100% sure of decisions we make moving forward, that they were the best thing we could have done, but we sure double guess ourselves if we moved forward without due diligence and confidence. Check this podcast out; lots of information comes out that may help. Rick

healthunlocked.com/active-s...

[Jabbs4 in reply to RMontana]

Thank you!! I will definitely watch it.