Is there a generally accepted protocol to follow after failed SRT?

I really like the latest ideas suggesting no ADT until absolutely necessary. But I still have many questions.

What PSA level to start bone scans? What about soft tissue scans? Should one wait until many mets and start ADT/Chemo? Or, start earlier with ADT only. What about drugs to slow progression: Avodart, Metformin and a statin? Try all at once or one at a time?

And finally, is the 2011 Harvard study on the benefits of vigorous exercise still valid? Researchers indicated a 61% reduction in PCa specific mortality with vigorous exercise. Here is the link for the paper:

ASCO Physical Activity and Survival After Prostate Cancer Diagnosis (From 2011)
jco.ascopubs.org/content/29/6/726.full.pdf.

I'm just trying to get as much info as possible so I can start looking for an oncologist that is willing to look at new ideas. Not easy to do in small town (Pensacola). Of course my PSA might just stay low and all my worry will be for nothing.

While .09 looks a little scary it is still in the noise. I would wait to see the next result before doing anything. It may well drop. What is the doctor saying?

I understand wanting to be prepared should it clearly start heading up. I'm in the same boat but just getting started. From all the studies I've seen ADT/Chemo seems to be the best approach. It doesn't just lower the PSA hiding the problem but appears to knock the cancer down a notch or two.

We can both hope for the vaccine to be released in 2016 or some other magic in the next couple of years.

I have seen a paper or two suggesting not all high grade cancers evolve to bone mets even with rising PSA. There are studies trying to fined markers to identify which one stay local. Not a likely solution but one worth watching.

Carlos, if I get to the point where I am sure of a recurrence{I'll know}, I plan on very watchful wait with medical guidance to a point where I intuit mets forming. I will not wait till symptoms but hopefully hit the sweet spot for treatment, if needed. At 78, I think you are in too much of a rush to judgement. Chill brother…do not let this "pest" ruin the experience of aging. At the risk of a mixed message, I offer the following " aging is like being increasingly punished for a crime you didn't commit" Seen on a birthday card… I personally do not see it as a punishment. Just thought that was a clever line. Your Gold Carlos, read Castaneda for perspective….

pushes up this interesting topic for more inputs...

Here are some comments from the New Prostate Cancer Info link with their position about when to start ADT:

Here are some really important facts that are worth remembering about the use of ADT:
• It is very, very effective at ameliorating the bone pain associated with late-stage, metastatic prostate cancer (as initially demonstrated by Huggins and Hodges some 75 years ago).
• Because it suppresses the normal levels of testosterone in men, it is associated with a whole series of serious adverse side effects that can vary in intensity from patient to patient and which include loss of libido, loss of erectile function, weight gain, changes in body form, gynecomastia, and effects on mental capabilities over time.
• If there is a survival benefit associated with ADT, it is small, and may only be evident in a subset of patients (who we are currently unable to define in advance).
• Early initiation of ADT introduces significant risk for early induction of the development of androgen-resistant prostate cancer cells, which has the potential to lead to early onset of metastatic, castration-resistant prostate cancer.
• Overly early initiation of ADT may therefore mean that ADT never gets the chance to be used to do the one thing we know that it is really good at — ameliorating the bone pain associated with metastatic disease!

There are good reasons why many experts in the management of prostate cancer advise their patients with progressive disease not to start treatment with ADT just because their PSA is rising, but to start ADT only if and when there are other good reasons to do so, such as a PSA doubling time of 9 months or less, or a PSA level that has risen to 50 ng/ml and/or evidence of metastatic disease (even if there is no actual pain associated with the metastasis).

This should make a good starting point to talk over with my oncologist.

Hi Carlos, as you can see from my signature, my PSA is on the move, had a bone and CT scan last month which showed no visible cancer or mets, my specialist seems is reluctant to start me on HT until my PSA doubles or reaches 10+. I am happy with that, I will be 75 in July.

Mal.

After failed SRT I tried to find the source of rising psa. So taking the advice of other Gleason niners , I talked to Dr Dattoli who referred me to Sand Lake Imaging in Orlando for more accurate ct pet and MRI scans.
They found two suspicious iliac lymph nodes so I'm having all pelvic nodes subjected to DART and I'm on triple ADT plus metformin . This is aggressive outside the box therapy. But I'm willing to try once more to stop progression in its tracks. Dr Dattoli subscribes to 13 months of triple blockade but he prescribes meds to offset SEs including estradiol patches for hot flashes, cabergoline for libido, and propia for breast enlargement. The only SE I have is mild fatigue. I can't say enough about the great job Dattoli is doing to attack recurrent PCa. SOP for this situation is typically ADT only, which I don't find aggressive enough.
Bob

Break60 and logoslidat, you present two radically different approaches to SRT failure. If I fail (having another PSA Friday), I'm inclined to say screw it, I'll just enjoy whatever time I have left without further radiation, hormones, etc. From some studies I've seen, even after SRT failure most guys hang around for a long time. However, it's encouraging that DART can be done without a lot of SEs. Like you said, who knows.