ADT or Salvage Treatment after primary RT

I wonder why so many men with recurrent cancer following primary radiation who would be candidates for a salvage treatment choose not to seek a curative solution but to begin ADT at some point instead.
Is it because the cure rates for these salvage treatments are ~50% and with potentially serious side effects? You could have the treatment and 3-5 years later have another recurrence, side effects from the treatment, and still need ADT with its side effects now added to the failed treatment.
Is it because these salvage treatments aren’t mainstream and lots of urologists and MOs don’t know much about them so the patient is told ADT is the standard of care?
Is ADT as bad as I think it is? Most of what I read says it is. Many members of HW who are taking ADT seem to despise it and long for a holiday from it.
My urologist, who has said he wouldn’t pursue salvage treatment, has many patients he says who have been taking ADT for years and are doing well with a pretty good quality of life. My primary care doc says much the same.

I have been on lupron and xtandi pills for over two years, and still a <0.1, started out a gleason score 9. Had my prostate out dec. of 2018, couple months later psa started rising had radiation of prostate bed, was good for a couple years, then rising again, then started the lupron and xtandi. terry

Treating local disease is curative attempt when the disease is truly local. Since the scans can not detect micromets, you never know that disease is local and cured after salvage until the passage of many years untreated. And this would not necessarily be cured, rather a long and durable remission.

You have to decide whether SRT in your situation offers a very high probability of controlling the disease indefinitely and is justified given the risks of negative treatment induced side effects. Your doctor can not make that decision for you.

As to how terrible the ADT side effects are depends on the man and often his attitude. In any event they are minor compared to the effects of advanced and end stage PCa. I was on ADT for more than three years and was alright. I was able to effectively counter the side effects so that quality of life was not greatly affected. I took the attitude that this is what I have to do and will make the best of it and adjusted my life style in ways that were known to lessen the effects. These changes were not at all major or life altering.

I was not about to let the treatment control me. I have seen many other men take similar attitude and life style adjustment and do just fine. But, if you think it will be terrible, guess what? It will be for you. Is the glass half full (and a blessing)? Or is it half empty (and a curse). Same glass. The results are dependent upon your outlook.

Let me add another excerpt: There is no consensus on the best salvage treatment for failure after radiotherapy. Androgen deprivation therapy is currently the most common and most conservative approach. Although at times, it may be appropriate, it is purely palliative and exposes the patient to the many side effects of testosterone ablation. Given that a significant proportion of biochemical failures after EBRT may be attributable to local recurrence, robust local therapies are important. By eradicating residual disease, in the absence of micrometastases, a second chance at cure is possible. Several local treatments, such as salvage prostatectomy, SBRT, cryotherapy, HIFU and brachytherapy have all been used with varying degrees of success. However, all are associated with higher toxicity than when used in the primary setting.

Amongst these options, brachytherapy is an ideal salvage treatment for localized disease, delivering a high dose in a very conformal manner, minimizing dose to adjacent organs. Although most published experience concerns whole gland salvage, focal salvage has been made possible by improved imaging and is being explored, particularly with HDR, with the potential advantage of further reduced toxicity.

My chances of being a candidate for salvage treatment may have fallen some after yesterday's PSMA report. Fortunately still no metastatic disease but the report did note that I had "similar high-grade PSMA-avid focus" which I take to mean a Gleason 8 or higher. The PSMA from February which would be the "similar" reference did not mention high-grade. I suppose characterizations vary depending on the radiologist. I have biopsy on Tuesday so I'll know soon enough. PSA tomorrow and have almost no idea what to expect. A doubling time of < 9 months and a Gleason of 8 or higher will all but eliminate me from consideration for salvage. Cure rates for these men are very low, owing to most having micrometastases at treatment.

PSA of 5.59 yesterday keeps me in the running for salvage treatment I think with doubling time > 12 months and an unlikely recommendation from MO to start ADT.
I had transperineal biopsy today and hope the only cancer found is in the one and only identified in the PSMA and mpMRI and is less than Gleason 8. I know a Gleason in the 7's is unlikely in view of the scans but I can hope. IMO, any other cancer found in the prostate or seminal vesicles would be a sad commentary on the accuracy of PSMA and mpMR.

Post Edited (hrpufnstuf) : 10/9/2024 4:30:03 AM (GMT-4)

Biopsy results are Gleason 4+3 with PNI in the tumor identified in the PSMA and mpMRI scans. No other cancer found in prostate or seminal vesicles. I assume that means I will probably qualify for salvage cryotherapy or brachytherapy. I have meeting with Polascik the Duke urologist who would do the cryotherapy on Oct 28. Meeting with the Zelefsky the RO in New York on Nov 19 for brachytherapy discussion. My guess is based on this biopsy report either doctor will recommend short term ADT in combination with the salvage treatment.