Rising PSA years after radical prostatectomy

Jackie, Just finished salvage radiation (25) and 6 mos Orgovyx. No major issues to report. Some extra BM’s first week or so after completion of therapy but all resolved now. No Urinary issues at all.
ADT is controversial - especially for G6’s and low Decipher scores; however, anything that “comes back” is tougher than G6 would imply, right?
Also, be absolutely sure you get radiation to the pelvic lymph nodes as well - something like 35% failure rate in salvage therapy if the nodes are not treated. Best.

Phil,
Thank you for sharing your experiences with salvage radiation. I am so glad that it has worked out well for you. Two questions: did you have the radiation done at a “center of excellence” or a local facility. Was it IGRT or IMRT or proton radiation?
At this moment I am in a different “place” than in March, 2024. I am in “watchful waiting” mode. Following my last post (March 3, 2024) I have had the following PSA results: 3/12/24 0.9, 4/30/24 0.09, 9/28/24 0.11, 10/22/24 0.11, and 1/03/25 0.11. Based on the latest results (and having a Decipher score of 0.36) I have decided to just sit still for a while and see how this plays out. The decipher report says that, in my case, radiotherapy prior to a rise in PSA above 0.2 does not lead to improvements in the outcome. So, in the future I will be having PSA test every three months and when the PSA gets to around 0.2, and assuming my overall health is favorable, I will probably have salvage radiation. Because of the low PSA and the Decipher results I probably will not do any ADT.
My radiational oncologist and urologist tell me that they have not seen many cases where the PSA “stalls” for a significant period of time. They both speculated that perhaps the entire prostate was not removed but that is unlikely. Time will tell.
To people who see an increase of PSA after radical prostatectomy I would say that there are three important considerations: 1) your PSA doubling time, 2) your Decipher (or similar genomics tests) results and 3) the actual value of your PSA. My feeling is that you treat aggressive recurrent cancer at a low (lower than 0.2) PSA and you treat recurrent cancer that is not aggressive at a higher level of PSA (perhaps, even a bit above 0.2). I must emphasize that I am not a medical doctor and those are simply my opinions based on what I have read.
Thanks again for sharing your story with me. I will write a continuation of my “journey” when I start salvage radiation.

Hey Jackie, sounds like you have a plan - a good one. I think the docs are right in that PSA doesn’t just stall out; but mine took quite some time (5yrs) to hit the magic .2 and even then it bounced up and down for the last year until finally hitting .18.
I had IGRT radiation, since every day at treatment the machine would do a cone beam scan of my insides to check for gas, stool in the rectum, bladder fullness and relative position of all the organs to each other. Only once in 25 sessions was I kicked off the table for too much gas in the rectum, which is a very critical area.
Still amazed at the technology, even though we always use terms like fried, zapped, cooked, etc to describe what was done. My RO explained that they can actually “shape” the beam to go around the rectum but not thru it; the machine - a Varian TruBeam- actually goes underneath you and radiates you from the back as well….really amazing technology.

Phil,
Thank you for sharing your experiences with salvage radiation. I am so glad that it has worked out well for you. Two questions: did you have the radiation done at a “center of excellence” or a local facility. Was it IGRT or IMRT or proton radiation?
At this moment I am in a different “place” than in March, 2024. I am in “watchful waiting” mode. Following my last post (March 3, 2024) I have had the following PSA results: 3/12/24 0.9, 4/30/24 0.09, 9/28/24 0.11, 10/22/24 0.11, and 1/03/25 0.11. Based on the latest results (and having a Decipher score of 0.36) I have decided to just sit still for a while and see how this plays out. The decipher report says that, in my case, radiotherapy prior to a rise in PSA above 0.2 does not lead to improvements in the outcome. So, in the future I will be having PSA test every three months and when the PSA gets to around 0.2, and assuming my overall health is favorable, I will probably have salvage radiation. Because of the low PSA and the Decipher results I probably will not do any ADT.
My radiational oncologist and urologist tell me that they have not seen many cases where the PSA “stalls” for a significant period of time. They both speculated that perhaps the entire prostate was not removed but that is unlikely. Time will tell.
To people who see an increase of PSA after radical prostatectomy I would say that there are three important considerations: 1) your PSA doubling time, 2) your Decipher (or similar genomics tests) results and 3) the actual value of your PSA. My feeling is that you treat aggressive recurrent cancer at a low (lower than 0.2) PSA and you treat recurrent cancer that is not aggressive at a higher level of PSA (perhaps, even a bit above 0.2). I must emphasize that I am not a medical doctor and those are simply my opinions based on what I have read.
Thanks again for sharing your story with me. I will write a continuation of my “journey” when I start salvage radiation.

@olanordman, you may also wish to read these related discussions:
- Post prostatectomy: What do rising PSA levels mean? https://connect.mayoclinic.org/discussion/post-prostatectomy/
- High PSA three years post op https://connect.mayoclinic.org/discussion/high-psa-three-years-post-op/
- PSA numbers: Questions about new treatments https://connect.mayoclinic.org/discussion/psa-numbers/
- Follow up after proton beam treatment: GREAT PSA NUMBER https://connect.mayoclinic.org/discussion/great-psa-number/

You ask a good question. What can rising PSA levels means years after having had a prostatectomy?
There are several reasons why one's PSA level may rise after being stable for a time. This article explains it well:
– PSA levels after prostatectomy https://www.medicalnewstoday.com/articles/323899.php

Here's an excerpt from the article:
"Seeing a rise in PSA level does not always mean that prostate cancer is returning or spreading. The test is very sensitive and can pick up small changes in PSA levels. Doctors will usually want to know how quickly levels of PSA in the blood are rising. To find this out, a person will need to have regular PSA tests. If levels of PSA remain stable or rise very slowly, treatment may not be necessary.

In some cases, high PSA levels in the blood are not due to cancer cells. Some factors that can affect PSA levels include:
– older age
– ethnicity
– medication
A doctor will take these factors and the person's medical history into account when looking at test results. This can help them decide if PSA levels are high enough to cause concern."

The PSA test alone is not enough to determine cause or next steps. Your oncology team will consult with you and likely order other tests. Did you have other treatments after surgery?