When to start salvage treatment after BCR?

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

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.

I should not but I will.

BCR occurs in about 30% of men. Correlations with Gleason grade are well established. Time frame to BCR may stretch from months to a decade or more. PSA is our predictor albeit with imprecision. PSA post initial TX, is a different marker to that of pre. Post TX is all about velocity, staging, comorbidity, quality of life and some educated guess work. There is no academic consensus of when, if, and how. Considerable variance twixt centres is evident. Dated papers of 10 years or more are of the view that intervention is not overly fundamental in longevity. What value do we place on an extra month/year? Inevitability beckons us all. Prediction is becoming the new baseline. Not just mets, micromets or indeed nodules. Their scatter patterns are salient. So why the focus on BCR? Not if, but rather when. Time is not our friend, but it can be a very convenient comfort when used wisely.