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When to start salvage treatment after BCR?

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User
Posted 28 Jul 2025 at 15:42

I was watching a Dr Scholz video on reviewing various PCa research. At about 8mins 30secs, he mentions abstract 382 which deals with BCR and salvage treatment.

https://youtu.be/xbH31zSCstk?si=VTmKVceN9xZ2G60U

It seems that research indicates that it may be better to wait until your BCR PSA is .4 before considering salvage treatment and that is not beneficial to act before that.

He also infers that there is corelation between PSA and the success rate of PSMA scans in locating the source of the rise, .4 giving 40%, and .9 giving a 90% chance of finding the exact position of the remaining cancer and targeting it much more effectively. Which is better than 'guessing' it's the prostate bed and zapping that area.

When to start salvage treatment and follow up scans to detect where it is, are often discussed on here. Unless I've misinterpreted the video, Dr Scholz seems to be advocating that it may be advantageous to delay salvage treatment a little longer than once thought. Or have I got that wrong? 🤔

 

User
Posted 28 Jul 2025 at 15:42

I was watching a Dr Scholz video on reviewing various PCa research. At about 8mins 30secs, he mentions abstract 382 which deals with BCR and salvage treatment.

https://youtu.be/xbH31zSCstk?si=VTmKVceN9xZ2G60U

It seems that research indicates that it may be better to wait until your BCR PSA is .4 before considering salvage treatment and that is not beneficial to act before that.

He also infers that there is corelation between PSA and the success rate of PSMA scans in locating the source of the rise, .4 giving 40%, and .9 giving a 90% chance of finding the exact position of the remaining cancer and targeting it much more effectively. Which is better than 'guessing' it's the prostate bed and zapping that area.

When to start salvage treatment and follow up scans to detect where it is, are often discussed on here. Unless I've misinterpreted the video, Dr Scholz seems to be advocating that it may be advantageous to delay salvage treatment a little longer than once thought. Or have I got that wrong? 🤔

 

User
Posted 28 Jul 2025 at 18:21

Hi Adrian 

I agree with your interpretation of Dr Scholz's view and I have seen another video in which he acknowledges that this is something of a dilemma but nevertheless his personal preference would be to be patient. This partly reflects his general bias towards avoiding overtreatment.

I think it is a pity that the evidence is not more clearcut because on the one hand there is evidence that sooner is better for SRT while on the other hand the PSMA PET scans are not yet as accurate as one would wish at PSA levels below 0.5. So the worry would be that you could wait in order to have a scan but that scan might not show anything and you would then fear that you might have worsened your chances to no purpose.

Objectively my inclination is to agree with Dr Scholz. In practice I am not sure how I would react when faced with that situation since waiting would be rather nerve-racking, especially if one's medical team did not take the same view as Dr Scholz! It might depend on factors such as Gleason score and, more especially, the rate of PSA progression - adopting a patient approach would feel much more comfortable with a doubling rate measured in years rather than months.

 I am of course (like yourself I am sure) hoping that I don't have to make that decision and that, if I do, the guidance might have become a bit clearer by then.

Kevin

 

User
Posted 28 Jul 2025 at 21:46

Have a look at this from Dr Kwon, within the first five minutes he starts talking about where recurrence is. In his clinic only 33 percent have recurrence in the prostate bed only. I find his lectures quite easy to watch.

Check out this video from this search, Dr kwon do it yourself https://share.google/sK9CuP9rPwEimwxh9

 

Thanks Chris 

User
Posted 29 Jul 2025 at 15:19

Dr Kwon's video is interesting and his view is clearly similar to that of Dr Scholz. If anything he takes an even more clear-cut approach by saying that men should not have SRT until they are "absolutely certain" about the kind of recurrence they have, presumably on the basis that there is no point in just irradiating the prostate area unless you are one of the 33% with purely localised recurrence.

This sounds like an attractive strategy but a problem that I have with it is that it seems to assume that the "kind of recurrence" is something immutable and that you fall into one category or another right from the start. Dr Scholz seems more willing to accept that there may be a trade-off involved. My understanding is that quite a few studies have shown that SRT has more success if given at lower PSA levels, though the optimal cut-off point varies a bit. One possible reason for this would be that some recurrences may start off as purely local but then metastasise if given time to do so. If this is so then simply waiting for a "certain" diagnosis may not be risk-free.

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User
Posted 28 Jul 2025 at 18:21

Hi Adrian 

I agree with your interpretation of Dr Scholz's view and I have seen another video in which he acknowledges that this is something of a dilemma but nevertheless his personal preference would be to be patient. This partly reflects his general bias towards avoiding overtreatment.

I think it is a pity that the evidence is not more clearcut because on the one hand there is evidence that sooner is better for SRT while on the other hand the PSMA PET scans are not yet as accurate as one would wish at PSA levels below 0.5. So the worry would be that you could wait in order to have a scan but that scan might not show anything and you would then fear that you might have worsened your chances to no purpose.

Objectively my inclination is to agree with Dr Scholz. In practice I am not sure how I would react when faced with that situation since waiting would be rather nerve-racking, especially if one's medical team did not take the same view as Dr Scholz! It might depend on factors such as Gleason score and, more especially, the rate of PSA progression - adopting a patient approach would feel much more comfortable with a doubling rate measured in years rather than months.

 I am of course (like yourself I am sure) hoping that I don't have to make that decision and that, if I do, the guidance might have become a bit clearer by then.

Kevin

 

User
Posted 28 Jul 2025 at 21:46

Have a look at this from Dr Kwon, within the first five minutes he starts talking about where recurrence is. In his clinic only 33 percent have recurrence in the prostate bed only. I find his lectures quite easy to watch.

Check out this video from this search, Dr kwon do it yourself https://share.google/sK9CuP9rPwEimwxh9

 

Thanks Chris 

User
Posted 29 Jul 2025 at 15:19

Dr Kwon's video is interesting and his view is clearly similar to that of Dr Scholz. If anything he takes an even more clear-cut approach by saying that men should not have SRT until they are "absolutely certain" about the kind of recurrence they have, presumably on the basis that there is no point in just irradiating the prostate area unless you are one of the 33% with purely localised recurrence.

This sounds like an attractive strategy but a problem that I have with it is that it seems to assume that the "kind of recurrence" is something immutable and that you fall into one category or another right from the start. Dr Scholz seems more willing to accept that there may be a trade-off involved. My understanding is that quite a few studies have shown that SRT has more success if given at lower PSA levels, though the optimal cut-off point varies a bit. One possible reason for this would be that some recurrences may start off as purely local but then metastasise if given time to do so. If this is so then simply waiting for a "certain" diagnosis may not be risk-free.

User
Posted 29 Jul 2025 at 19:36

Ks25, I had the very educated guess salvage RT to the prostate bed at around 0.27. There was obviously something in the bed but there was obviously something elsewhere has the PSA started to rise again after SRT. Subsequent PSMA scans seem to show that the treatment to the prostate bed was successful.

Thanks Chris 

User
Posted 29 Jul 2025 at 20:19

I completed 20 sessions of SRT last November. PSA was 0.2 which my onco suggested was the 'entry level' for SRT. She doubted that at that level, any scan would give a reliable output and recommended irradiating the prostate bed and lymph nodes even though the post op pathology did not indicate a spread to the nodes. She said it was possible that micro mets in the nodes could be missed hence the belt and braces approach whilst being treated. Over treatment? Increased side effects? Possibly. I'll never know. But I do recall her saying that early treatment had the greater chance of success. That seemed sensible to me and so I didn't question the evidence behind her logic.

I suppose time will tell.

Peter

User
Posted 30 Jul 2025 at 21:04

My oncologist has recommended starting srt almost immediately with psa of 0.07. 8 month doubling time but from undetectable 14months ago after prostatectomy 

 He also wants to include ht for 6 months. Epe, negative margins , 4/3 gleeson. Any thoughts or advice? 

User
Posted 30 Jul 2025 at 21:52

Hanoi, my post op PSA was 0.03, it took 16 months to reach 0.06 then 8 months to reach 0.13. EPE and positive margins. I had the educated SRT to the prostate bed, without HT because of a stricture at three years post op with a PSA of 0.27.Something was in the bed because the PSA went down, but something was presumably beyond the bed because the PSA started to rise. 5 years on from SRT I was having SABR treatment to a pelvic lymph node, a year after that more SABR treatment to another pelvic lymph node. 8 years after SRT the cancer has spread further and HT has started. 

I may have benefited from earlier intervention and having HT. Recent PSMA scans did not show any activity in the prostate bed, so do we assume the SRT to the bed was successful but the cancer had already left the bed. Might be worth a slightly wider area of the prostate bed being done.

Thanks Chris 

User
Posted 01 Aug 2025 at 22:23

Some good stuff on here. I first met the Oncology Consultant 10months ago and she was very flexible. Mainly because my psa was low and doubling every 3yrs.

Since then I had a reading 25% higher in 5 months.

At the meeting I was offered immediate RT at psa  0.11 or Review at just over 0.2 or if 3yr doubling continues then go on hormones at 10ish around the age of 90.

I was offered a psma scan at around 0.2 although was a bit concerned about waiting lists for it and if the scan hospital will accept it.

I was told my doubling was typical of prostate bed but probability is only 56% based on her record which is higher than average.

My preference was to take Scholz guidance to know where it is with a psma scan.  Ensuring psa <0.25 based on perceived increase in risk above that level.

I haven't yet viewed the video but 0.9 sounds highly risky in my layman opinion.  I continue to hope a PSMA scan and RT will still be an option around 0.22... assuming a wait during which it may rise to near 0.25.  If the psma scan finds nothing I'll need to think about the doubling rate and would favour wide angle RT.

 

 
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