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Apparent BCR after RALP

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Posted 1/23/2025 2:05 PM (GMT -5)
First of all, I appreciate all the shared wisdom, knowledge, experience and advice regarding PC in general on this forum. Most of you know a lot more about this stuff than I do.

I had my RALP in February 2021. My PSA was <.01 for a while since, then started to rise about a year ago. It was =0.05 in early December. My surgeon ordered a decipher test, which came out as 0.97, which isn't good, and then recommended that I speak to a radiation oncologist.

A couple weeks ago, I met with a RO and a hormone doctor (not sure what that specialty is called) at City of Hope in Irvine CA. They recommended continuing to watch the PSA results, and to start action when it hits 0.10, starting with a PET scan then hormone/radiation therapy. As I recall, the PET scan would provide information as to whether the PC was in fact in the former prostate area, and to see if there were "hot spots" anyplace else.

Last week, I met with an RO here in Honolulu. He recommended starting hormone/radiation therapy now, prior to having a PET scan. (He said that my PSA is so low that a scan now wouldn't show anything but that we know it is coming back and likely is in the former prostate area.)

I contacted my surgeon to have him chime in on the differing advice, and he said that is the nature of second opinions and that they usually do differ, and that either approach should be fine.

I have come to terms with the need for hormone/radiation therapy and how it might affect my life, and am leaning towards the first opinion: having my PSA checked every two months, and starting treatment when the PSA hits 0.10, whenever that is.

I am wondering if you smart people have any thoughts.

Thanks for your input!

PS: That decipher test report sure was sobering (to my ill informed mind), but it was reassuring to talk to those initial doctors and have them put my mind at ease, in that this is treatable and we'd just start treatment prior to the more typical 0.20 threshold due to the seriousness of the score.
Posted 1/23/2025 3:29 PM (GMT -5)
Hi Patrick. Keep in mind what we all know: we aren't doctors. (Correct me if I am wrong, but I'm assuming your post-RP pT3a staging was because of EPE and not bladder-neck invasion.)

Given your overall risk status, I think setting the SRT trigger point at 0.1 (and not bothering with a PSMA-PET scan with that PSA) is prudent. I am under the impression that even for salvage therapy, the thinking is to start the ADT prior to the SRT with the hope of making the RT more effective, as is often done before primary therapy when it involves both RT and ADT. But you can ask your team about this. If you do, kindly let us know their thinking.

I'd also be interested to know the total RT dose, radiation modality (IMRT, SBRT?), and field width (fossa only, slightly wider?) used, if and when you need the SRT.

You might want to think about switching to Labcorp's 3-decimal PSA test, with its better sensitivity and, therefore perhaps accuracy, to make your treatment decision (especially if you decide to start of the ADT before the RT).

I asked above about any future SRT details because I, too, am monitoring my PSA--now about 0.15--very closely with my med team, with a view towards having SRT (probably without a PSMA scan), although my situation differs from yours and we haven't established my trigger point.

Best of luck to you!

Thanks,

Djin
Posted 1/24/2025 11:34 AM (GMT -5)
My understanding of current PSMA PET scan is that it won't likely pick up anything with a PSA of less than .2 and even at that level its "iffy", so I agree with Djin, forego the PSMA PET. I also agree with him however, that we are not doctors LOL, so take that from where it comes.

Patrick, I faced a similar dilemma to yours. Surgery in 2016, became detectable in 2018, at .02. I had a slow rise over the next year to .08. My surgeon recommended waiting until the standard BCR point of .2. I chose to go rogue and consulted 2 well respected RO's. Dr Zelefsky at MSKCC (now at NYU Langone) and another whose name escapes me, at Cleveland Clinic in Florida. They both recommended I not wait and start SRT, citing studies to back that recommendation up. Dr Zelefsky told me that he would have no issue with me not doing ADT, unless I waited for PSA to rise above 1.0. but also that ADT would give me an additional 10% chance of cure. So at .08 I chose to go forward with ADT+ SRT in 2019. As of my last PSA test in May 2024, knock wood, I am undetectable at <.05. My decider score, BTW was lower than yours, at .37, but being aggressive is my nature in life and that carried over to my treatment decision.

@Djin, regarding your comment about starting ADT before SRT, yes, generally speaking, they like to start ADT 3 months before SRT. In my case, I was planning on leaving NY for the winter and heading south, shortly after finishing SRT, and so Zelefsky agreed to start SRT only 1 month into the Firmagon shots.

Hope this helps, everyones experience is different
Posted 1/24/2025 11:43 AM (GMT -5)
With regard to Pratoman's comment about doctors accepting a patient's input in decision-making, I think this especially true where SOC doesn't give us hard-and-fast rules (which is generally the case). For example, my R.O. consultant said that she didn't think I could find a R.O. who would advise starting SRT at a PSA of my (then) 0.123 given my particular status and history. However, she followed this by saying she wouldn't object if I insisted that I wanted SRT now.

When you look at, for instance, ASCO treatment guidelines for salvage thearpy, each statement is graded, A, B, C, as to the strength of the evidence and, as we know, guidelines change as time goes by.

Djin
Posted 1/24/2025 5:48 PM (GMT -5)
Patrickm - My situation was a little different as I was looking at ART in 2018/19 after my first negative PSA test but Uro and RO both said it was my decision and they could support either way. Since that time, endless studies seem to be trending towards not treating as early as back then but there are still disagreements amongst the experts. In your case, the high Decipher score would be the tiebreaker to me. Mine was when an esteemed doctor said if it was him, he would do ART. Whatever resonates with you should be your guide.
Posted 1/25/2025 9:50 AM (GMT -5)
Patrick, sharing my thoughts/experiences (not sure I qualify as smart). Prior to my RP nine years ago I settled on uPSA <0.010 as best indicator and accepted values above most likely indicate cancer remains. Based on my own reading/research, I concluded that remaining active cancer had to be present well before the widely recognized BCR value of 0.2, as well as 0.1. My RP nadir was 0.051 and we accepted cancer remained (had gotten out). My medical team offered a wait and see calmness that I was uncomfortable with; why give cancer time and obscurity?

I self-directed monthly testing and watched my uPSA slowly, steadily rise, accepting cancer was growing and possibly spreading (albeit most likely very slowly). When my uPSA reached 0.11 my medical team recommended the (now completed) STAMPEDE trial - ADT and chemo. Being otherwise very healthy and fit 58, I said no and settled on salvage RT to the prostate bed only, no ADT. As there was no imaging I knew we were shooting blind. Well, we missed, as my cancer had indeed spread beyond the prostate bed.

With my experiences to date, if I had a do-over post RP, when my uPSA rose to 0.030 I would have liquid blood biopsy testing and yes imaging, most likely the PSMA PET CT first. I fully appreciate all the doctor and patient comments about these investigative methods being too early, but I have learned to do all I can to catch cancer as soon as possible. Back in 2017, when PSMA imaging was in trial in US, I learned it was already in use in Europe and imaging began as soon as 0.030 post RP. Their focus was not on how 'unsuccessful' it might be, but rather, an outlook that perhaps only one or two mets exist and just maybe these could be identified and treated with targeted surgery and/or RT. Hope this helps. All the best!
Posted 2/2/2025 12:04 AM (GMT -5)
Patrick,
I too had BCR after RALP, but my BCR arrived immediately following my surgery, despite the pathology report showing “organ confined.” I opted for ADT and 39 IMRT treatments. All 3 of the radiologists I interviewed recommended radiation to the prostate bed only. But knowing that only 3 lymph nodes were removed and tested at surgery, and realizing this radiation was my last shot at a cure, I directed my radiologist to radiate my entire pelvis to ensure the lymph nodes in the area would be hit. She agreed with that approach. I’ve been undetectable for 6 years now. My thoughts for you? Do the ADT and hit it hard and wide with radiation. Best of luck to you.
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