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post surgery PSA; radiation next?

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Posted 7/15/2017 4:10 PM (GMT 0)
My brother, 67, had his prostate removed mid-May. On his first follow-up with the urologist they said his PSA blood test was a 0.49. So they're talking about sending him for 39 radiation treatments.

Has anyone been down a similar road (complete prostate removal and then needed radiation)?

What kind of questions should we ask?

(I am involved more than normal as my brother has suffered 2 strokes and he has left side weakness and gets around in a wheelchair).
Posted 7/15/2017 5:16 PM (GMT 0)
So sorry for the report. Most important that he hopefully had a Bone scan and MRI before starting RO. Find a well recommended RO. They be able to give you all the options available.

I had Robotic March 2014 and went two years undetectable, but then began to rise. Just finished 39 treatments June 1st. No big problem.
Posted 7/15/2017 5:31 PM (GMT 0)
Yes, RT is pretty much standard with persistent PSA after surgery, as long as they feel there are no distant mets...(determined from scans) If he had a + margin after surgery, that's a good thing at this point.....
Posted 7/15/2017 7:41 PM (GMT 0)
You didn't mention any information from his pathology report, which is important. Also, if he was "high risk" before his prostatectomy, what was his PSA then, and did he have a bone scan/CT? Lacking that data, here's my list of questions for a radiation oncologist who would be planning his salvage radiation treatments:

Questions for a Salvage Radiation Interview.

1. How many patients have you treated with adjuvant/salvage radiation?
2. How has your practice of salvage treatment changed, if at all?
3. What is the probability that my salvage treatment will be successful? Do you calculate that from a nomogram?
4. Do I need any further imaging to rule out distant metastases, or is my PSA too low for that?
5. How large a dose do you propose for the prostate bed? (should be near 70 Gy)
6. Do I need pre-treatment, concurrent or adjuvant ADT?
a. Why? 
b. What's the evidence that it's useful?
c. For how long?
d. Does it make sense to have it for a longer time before radiation starts in order to allow for better restoration of continence?
7. How do you decide whether to treat the pelvic lymph nodes? 
a. If so, at what dose? (50 Gy)
b. How do you plan to prevent bowel toxicity? 
c. How will you account for the separate movement of that area and the prostate bed?
8. What do you think of doing this in fewer treatments (hypofractionation)?
9. What kind of machine do you use? (e.g., RapidArc, Tomotherapy, Vero, etc.) Why do you prefer that one?
10. What is the actual treatment time for each treatment? (faster is generally better)
11. What kind of image guidance do you propose? fiducials in the prostate bed? Using the fixed bones only? Soft tissue?
12. How will inter- and intra-fractional motion be compensated for?
13. What measures do you propose to spare the bladder and rectum?​ (ask about treatment margins and dose constraints)
14. ​What side effects can I reasonably expect, and how do we handle them?​(discuss in detail!)
15. What probability of a cure can I reasonably expect, given my stats? Is there a nomogram you use to come up with that?
16. How will we monitor my progress afterwards, both oncological and quality of life?
17. What's the best way for us to communicate if I have a question or issue?
Posted 7/15/2017 10:29 PM (GMT 0)
I too went down that path. about 4 years ago I had robotic surgery with positive margin. Two years later my PSA hit 0.2 so I had 38 treatments of IGRT/IMRT totalling 70.2 grays or radiation. For me it was a none event. Went to work everyday and stopped off on the way home for a treatment. I didn't change any thing during or after treatment. Never had any urinary or GI problems during, after, and to the present time.
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