Should definitive radiotherapy and ADT be offered to patients with PSA > 100 who have no evidence of metastatic disease?

In the setting of no evidence of metastatic disease based upon best available imaging I think it is reasonable to proceed with external beam radiotherapy and androgren deprivation therapy even with very high PSA values. I don't know what the upper limit should be.

The Scandinavian SPCG-7 trial addin...

PSA > 10,000 ng/mL would be a valid indication not to proceed . . . Otherwise, I would not let a case be ruled by labs in the absence of definitive radiological or pathological evidence of incurability . . .

Yes. It might also be reasonable to refer these patients to medical oncology after xrt to discuss 6 cycles of taxotere given the OS benefit reported a couple of years ago at ASCO from the RTOG 0521 trial.

This has not been part of a prospective study, but one retrospective study from Canada showed a long cause specific survival with local treatment (surgery or RT), even in patients with pre treatment PSA of more than 100.

We looked at this in our database in 2012 (presented at 2012 American radium society meeting). Putting the KM curve from the poster below. Not sure how well it will reproduce. We included psa up to 500.

5 yr ffbf Nadir +2 was appx 60% in the 50-100 and 100-500 groups. tTe N was small for the >100 gr...

A recent article hints at possible cure in early stage metastatic disease, so it seems reasonable to offer radiation in localized ultra high risk setting if patient has good performance status.

A Pilot Study of a Multimodal Treatment Paradigm to Accelerate Drug Evaluations in Early-stage Metastatic P...