Post prostatectomy: What do rising PSA levels mean?

As the discussion evolves to talk about hormone therapies and testosterone blocking, you may find the search function of the group useful to discover other discussions on the topic. For example, here are discussions related to:
- Orgovyx (relugolix) https://connect.mayoclinic.org/search/discussions/?search=orgovyx
- Finestride https://connect.mayoclinic.org/search/?search=Finestride

To find the Search for the prostate cancer support group:
1. Go to the Prostate Cancer support group page https://connect.mayoclinic.org/group/prostate-cancer/
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In my case it meant that cancer was left on the margin and remains where the urethra was connected to the bladder. I have been very fortunate in that it has taken 24 years to reach the point where I have started Orgovyx. I had a radical perineal prostatectomy in August 1999 with a preop PSA of 2.6. My PSA went to near zero (.05) after surgery. PSA started slowly rising and I was diagnosed with a recurrence in 2007. It was recommended that I have radiation to treat the recurrence. I had 35 treatments over 7 weeks and my PSA once again went to near zero. However, it once again starting rising, but very slowly, until it doubled in one year (Jan 2022-Feb 2023). My Mayo oncologist recommended that I start hormone therapy which I rejected. In March I moved to Rome, GA and engaged with the Harbin Cancer Center. I had consultations with a Medical Oncologist and a Radiation Oncologist> My PSA was then 3.62, higher than it had ever been. Bothe Oncologists said that if I did not do something to lower my PSA the cancer was certain to metastasize. That was a wake up call. I started on Orgovxy on September 6. I had my first follow-up visit this week and my PSA dropped from 3.62 to 0.42. My testosterone also dropped from 185 to 3, that of a 50> woman. The most bothersome side effect has been hot flashes that occur throughout the day. I hope this gives some insight when making decisions. I probably postponed starting hormone treatment longer than i should have.

New to group but feel the warmth to part of the community.
Age 57, Prostatectomy in 2020, gleason 3+4, margins were involved on pathology.
PSA levels are as follow
Date PSA
2/28/2020 0.10
4/13/2020 0.10
12/31/2020 0.10
1/6/2021 0.10
3/22/2021 0.10
6/10/2021 0.10
12/18/2021 0.11
8/13/2022 0.14
12/10/2022 0.22
01/07/2023 0.18
02/09/23 0.15
06/10/2023 0.14
11/11/2023 0.17
5/11/2024 0.26
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PET scan was negative in Jan 2023.
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I appreciate your input.
Thank You...

Challenging to respond w/o practicing medicine w/o a license.
My 1st postop PSA was .19. Target was < .01.
Referred to Radiation Oncology for salvage treatment of radiation to the prostate bed/floor and pelvic lymph nodes and short-term ADT (see SPPORT trial).
My understanding is that steadily rising PSA (2 or more consecutive tests) and negative PSMA PET scan suggest cancer cells most likely remaining in the pelvic region.
And treatment considered when the PSA rises to or above .2

Good wishes to you.

Welcome to our group. I’m not a doctor so my opinions are only based on my personal experience with prostate cancer. May I respectfully ask a few questions so that I and others on the forum can better respond to your post?

- If I understand correctly, you had one or more positive margins. Is that correct?
- You did not mention whether or not you had ADT or salvage RT after prostatectomy. Is that correct?
- Are you currently seeing a urologist, an oncologist, or both?
- Was any genetic testing done on the pathology? Decipher or similar?

It’s my understanding as a lay person that PSA levels that are undetectable (0.01 or less) are generally thought of as a curative level here in the US. It is my further understanding that if a a post-RP PSA level is above that and positive margins are involved, the typical standard of care involves at least a short course of ADT alone or in a combination with radiation to the prostate bed.

I’m hoping that your care provider includes a team of a urologist/surgeon, an oncologist, and a radiologist that all communicate with each other and work together. For my first go around with PCa in 2020, I opted for RT instead of RP and the radiologist was also my urologist and my oncologist. There was no team to speak of. When PCa came roaring back in 2023 I changed health systems and now have a care team working together for the best possible outcome. I hope you’re receiving excellent care.

At the time of your January 2023 PSMA PET scan, your PSA was so low (0.18 ng/mL) that the PET scan might’ve miss 2/3s of prostate cancers. (See attached chart.). As your PSA increases, a future PSMA PET scan will be more sensitive to detecting prostate cancers.

(My treatments consisted of 28 sessions of proton radiation (during April-May 2021), 6 months (two 3-month injections) of Eligard, and SpaceOAR Vue. PSA now varies between 0.35-0.55; not bad for still having a prostate.)

A few questions and inputs from a fellow patient.

When your PSA reached above 0.2 (Biochemical Recurrence point - BCR) in Dec ‘22, what treatments were proposed by your doctors?

Were all PSA tests performed by the same lab?

Assuming no change in labs, once a PSA level reaches 0.2, it is considered to be BCR and, as commented upon by others, there are “standard” treatments that most oncologists recommend. Also, as stated earlier, PSMA PET Scans will not detect most cancers at this PSA level.

I recommend assuming that you have residual PC cells, as indicated by your first post RP PSA and that those cells are growing and mutating.

I would also assume that you are still potentially curable, if the PC cells are localized to the prostate bed.

In my case, I choose salvage treatment when my post RP PSA was approaching 0.2. Theoretically, I could have chosen to wait until my PSA rose to 0.4 and a PSMA PET Scan was more likely to show where the cancer cells were located, but I didn’t want to risk that the additional PC cell growth would result in metastasis.

My medical oncologist says PET scan shows nothing if PSA < 4.0. Cancer cells can exist on the head of a Pin.

What does your riding PSA mean, likely there is prostate cancer somewhere.

Question is:

Treat, yes or no?
If yes, when?
If yes , with what and for how long?

To make those decisions you have two choices:

Treat solely on PSA
Wait, image, then informed by the results and other clinical data, decide....

You could read through the NCCN guidelines, they are the science that guides patients and doctors in treatment decisions. Keep in mind they are population based and clinical trials are rapidly changing the landscape of what we know.

At your PSA in Jan 23, you had less than 1/3rd chance of locating anything.

There is no doubt imaging can inform treatment decisions. The questions you have to ask yourself in conjunction with your medical team are:

Will it change our treatment decision?
Will waiting for my PSA to rise, say between .5-1, change the outcome of your treatment?

Search for doublet or triplet therapy, those are more and more mainstream treatment decisions for advanced PCa.

Your future may hold ADT plus an ARI, maybe chemotherapy with those or add radiation to the prostate bed and whole pelvic lymph nodes (I would not do only the prostate bed, that was my epic failure with SRT!)

In part, your treatment decision may rest on several factors:

How aggressive you want to be.
Your risk tolerance for waiting for PSA to rise for imaging?
Overall health , any co-morbidities
Insurance, financial toxicity.

So, you have some work to do to inform yourself, discuss with your medical team and decide together, you and your medical team. The good news, a myriad of choices, the "bad" news, a myriad of choices, You will not be able to know the outcome if your decision until time has passed. As I say, I am a study if one, no clone to test out treatment decisions, no way of coming back in time to say, "that worked!"

Something to think about, whatever treatment decision you decide on, it may be for a defined period, say ADT for 18-24 months vice a continuous and lifelong sentence (see my clinical history).

There's the science - NCCN guidelines, clinical trials, levels of evidence...then the art, how to use the science based on your clinical data!

The forum may not be able to give you a definitive answer, there is not one.

Attached is my clinical history. I have generally chosen aggressive approaches though the SRT was not, only because I let my medical team talk me out of an aggressive approach, the last time that happened!

Kevin

Respectfully my personal experience partially refutes the opinion of your oncologist. My PSA was 0.44 after RP. PET-PSMA clearly showed lymph node involvement. It is my understanding however that cancerous lesions may not show up on a scan if they are less than 10 cm in any direction.

I hope you’re being treated at a center of excellence. If you’re not or don’t have confidence in your own oncologist, I suggest that you consider investigating another care provider. Best wishes for success on your journey.