Radiation for Salvage Treatment

[Rams91]

I am about to start salvage treatment after a failed surgery and a rising PSA value of 0.1. However, I would like to know if weeks of external radiation with ADT, is the best treatment option here. The idea of blindly radiating pelvic area with a re-recurrence a few years later does not appeal to me. Not to mention possible lingering side effects from radiation. Are there any other promising treatments such as immunotherapy or vaccines, including ones in clinical trials, that could provide a better outcome? How about treatments outside US? Tall_allen, you certainly know a lot about different kinds of treatments including those in clinical trials. Anything promising? Thanks as always.

[Justfor_]

Similar case here. This is what I elected to do in order to kick the irradiation a bit into the future:

healthunlocked.com/prostate...

[Rams91 in reply to Justfor_]

Not sure if keeping the PSA low by adjusting ADT dosage would keep it from spreading. I rather eradicate it now if possible. The problem is my MO puts the odds of salvage radiation success (cure) at 30% given the presence of a minor pattern 5 in the pathology report. My RO disagrees and puts the odds of a cure much higher at 90%.

[Justfor_ in reply to Rams91]

90% in his dreams perhaps. The highest I have seen in papers is 67%. A negative PSMA scan or without any distant detection can give you an additional 15%, so a 50-50% for a 5 year remission may be a realistic estimate.

[Tall_Allen]

What are the results of your pathology report?

[Rams91 in reply to Tall_Allen]

Surgery Dec 2021. Pathology showed positive margin. Decipher score after surgery 0.54 . PSMA Pet (May 2022 with PSA at 0.085) negative.

A,B.C multiple Lymph nodes , negative for metastatic carcinoma

D- Bladder neck margin, benign fibromuscular tissue, no prostatic gland or carcinoma identified

E- Prostate and seminal vesicle prostatectomy

Prostatic adenocarcinoma, GS (3+4=7)

Tumor focally extends to right anterior resection margin ( focal Gleason pattern 3

, <3mm in length)

Specific Data:

Grade: Grade Group 2 (GS 3+4 = 7), % Pattern 4 = 30%, Minor Tertiary pattern 5 (less than 5%)

Estimated % of prostate involved by tumor : 11-20%

EPE, Bladder neck invasion, Seminal Vesicle invasion, Lymphovascular invasion

NOT Identified

Margins Status: Invasive carcinoma present at margin, right anterior

Primary Tumor pT2, pN category pN0

[Tall_Allen in reply to Rams91]

That's pretty good. It appears there may be some residual pattern 3 (at the focal margin), which could be just watched. If you decide to treat, I'm not sure that adjuvant ADT is needed, and the salvage radiation can be confined to the prostate bed..

[Rams91 in reply to Tall_Allen]

Watching PSA rise from 0.025 to 0.108 in 18 months post-surgery, so I'm encouraged to treat for a cure. And yes, in combination with 6 months of ADT. So, in your opinion TA, is salvage radiation (IMRT) the best and only treatment option here in terms of risk/reward? That's why I was asking for possible other treatments. I also thought you were in favor of salvage treatment at PSA >0.1 post-op?

[Tall_Allen in reply to Rams91]

It is the only way to go for a cure, but your situation may or may not need to be cured.

[Rams91 in reply to Tall_Allen]

Thank you.

[Rams91 in reply to Tall_Allen]

An update and hope to receive your valuable input. Two ROs recommending irradiation of prostatic fossa AND pelvic nodes, plus 6 months of ADT. I'm not sure what kind of additional side effects will pelvic node radiation add to the outcome.

[Tall_Allen in reply to Rams91]

It sounds like overtreatment to me, but you're the one who has to live with it.

[Rams91 in reply to Tall_Allen]

Reading the SPPORT trial results (thanks for the link), I see not much difference in the acute or late grade 2+ toxicity reported between those who got whole pelvic radiation + ADT vs. those who received PBRT. Unless those in whole pelvic radiation group suffered from higher grade '3' toxicity, what other concerns as far as toxicity are there with possible overtreating if it ensures a better oncological outcome?

[Tall_Allen in reply to Rams91]

Those are physician-reported, not patient-reported. But all acute toxicities were significantly worse for whole pelvic salvage radiation. If you need it, you need it. But if you don't, it doesn't provide a better oncological outcome, just excess toxicity.

[jdfamily]

I would also be interested in Tall Allen's reply. As I have had surgery and radiation.

[plato123]

I am 3+4 and had a bioreoccurance. I am 3 month post rads. No issues.

[Hidden]

I've had 10 radiation treatments so far, and 25 more to go. (after rp in March). I refused ADT because the side effects of low testosterone are more damaging than prostate cancer will ever be. so, just consider that. (My T count is 33 as of last week, without ADT). ADT will give you a better chance of eliminating the cancer cells (the MO can tell you how much of a chance to improve the outcome), but there is the cost of Low T. Having had Low T all my life except with the help of TRT, I can tell you the side effects of Low T are worse than the side effects of Prostate cancer (seriously, I've never had side effects of prostate cancer, just side effects from the treatments for pc.). But please do make an informed decision and don't just go with what you read on this site. Google "effects of Low Testosterone" and "side effects of ADT" and do your own research. Doing what you are told to do on this site is as bad as doing what a doctor tells you to do just because they said so. Advocates do best when they tell you the options rather than just tell you whats best for you. And oftentimes, ADT is best. For me, quality of life is more important than quantity of life. And, for what its worth, my MO said that if i do nothing now AND go back on TRT, my life expectancy is 10 to 15 years. She can't or won't tell me what my life expectancy is if I go on ADT and lower my T to 0. And as soon as my radiation treatments are done, I am going back on TRT, with or without a prescription.

[Rams91 in reply to Hidden]

Thanks Outeast for the warning. I too am hesitant on ADT, but both my RO and MO are recommending it. If I do take it, I'll go with the pill form to be able to stop immediately if need be.

[dans_journey]

Hi Rams,

I'm a little more than a year ahead of you. I had a RP in January 2011 (Gleason 3+4, no SVI, LNI, ECE, negative margins), and my PSA was undetectable until September 2015 when it came in at 0.05 ng/mL.

My PSA bounced around and grew at such a slow pace (PSA doubling time in years) that we agreed to monitor for the time being. In July 2021, nearly 6 years after it first became detectable again, my PSA hit the traditional value for biochemical recurrence at 0.21 ng/mL.

Like you, I wasn't keen on blindly zapping salvage radiation not knowing exactly where the cancer was.

I went for a PSMA PET scan at UCLA in November 2021 when my PSA was 0.22 ng/mL (a very slight increase from the July reading). The good news was that the PET scan didn't light up like a Christmas tree. The bad news was it didn't show anything at all that the radiation oncologist could use to guide his zapping.

In January 2022, my PSA jumped to 0.26 ng/mL, indicating an acceleration in the increases. I met with the RO in February 2022, but some unrelated health concerns had to be addressed first, so that delayed the start of salvage radiation therapy (SRT).

By March 2022, my PSA jumped even further to 0.33 ng/mL and in April it was 0.36 ng/mL.

My RO and I agreed to do concurrent ADT, so I was given a six-month dose of Eligard on 3 May 2022, about two months in advance of starting the SRT.

We did 35 sessions over 7 weeks of 70 Gy to the pelvic bed only 7 July - 27 August.

I must have been one of the lucky ones when it came to the ADT because the side effects were minimal: increased but tolerable fatigue, reduced libido, and being in a more emotional state. There was no weight gain, no hot flashes, nothing else.

The side effects from the SRT were more severe for me starting about halfway through the process. The fatigue was significant, and my urinary frequency and urgency increased considerably. Those side effects lasted for a good three weeks after the radiation ended.

My first PSA post-SRT/ADT was in September 2022 and it was 0.05 ng/mL. Another PSA in November was 0.05 ng/mL. We all agreed that reading was more a result of the ADT and not the SRT.

In March 2023 my PSA was 0.13 ng/mL (ADT dose had worn off), and in May 2023, my PSA dropped slightly to 0.11 ng/mL giving an early indication that the SRT may be doing its thing. (The RO said it could take 18-24 months after the SRT ended before we knew if it was effective.)

So here I am a year later, and the fatigue is gone, and I'm back to my post-surgery urinary frequency and urgency. Time will tell if the SRT impacts those more substantially a year or two down the road.

Like you, I would have preferred to have avoided all of that. But I also knew that it was time to act after my PSA jumped from 0.21 to 0.36 in 9 months.

It might have been nice to go for a second PSMA when my PSA reached 0.36 ng/mL, but it took me about a month and a half of battling between the VA, my insurance, and UCLA to get the PSMA scheduled, and when I finally got to talk with the scheduler, the first available appointment was 2.5 months out. Plus, neither my insurance nor the VA would cover the cost at the time, so I paid $3,300 out of pocket for the scan. (My insurance wouldn't pay until my PSA hit 1.0 ng/mL, and I believe that the general consensus is that once your PSA gets above 0.5 ng/mL, the probability of SRT being effective goes down considerably.)

Bottom line: the SRT/ADT went better than I expected for me. The side effects were tolerable and relatively short term.

Good luck to you!

P.S. I've detailed all of this on my blog, dansjourney dot com.

[Rams91 in reply to dans_journey]

Hi Dan and thanks for your reply. Sure glad to see your PSA is low and stable after SRT. I glanced through your blog. Can I ask you if your RO shared with you how they went about delineating your target volume to be radiated since your PSMA scan was clear? Did you have an MpMRI prior to SRT for doing a before/after comparison?