Recent PSMA PET does not detect cancer, what’s next?

I went 3 1/2 years after surgery before my cancer came back. As soon as it hit a .2 PSA They set me up for salvage radiation. That really is the standard for what they are supposed to do next. It is possible that you now have micro metastasis that cannot be seen by the scan. They’re almost always in the prostate bed at this point, And that’s why they do radiation next. After salvage radiation, my PSA stayed at < .1 For 2 1/2 more years without ADT.

I had absolutely no side effects from radiation. Some people do have a little fatigue and other issues. I was 65 when they were doing this. I had radiation first thing in the morning and went to work on computers at clients offices every single radiation day for seven weeks. It Didn’t slow me down a bit.

You can go on ADT now, But that is not the normal Sequence of events and may not get the best results.

Yeah, well…..nobody likes it so you’re in good company😄. I just finished 25 salvage treatments (ask about this because it’s a newer protocol - less visits/higher doses - and side effects the same). Finished 6 months ADT yesterday…not as bad as advertised in my case.
You learned to adapt after surgery so this is just another phase of adaptation - again, not so bad.
The PSMA does not show anything below .5-.7 PSA so you can’t rely on it being “clear”. But your PSA of .23 means your cancer has returned and treatment is probably necessary. Best
Phil

Sorry to hear that the PCa has recurred.

The clear PSMA pet scan is a good thing; absent identifiable tumors, the cancer is believed to reside residually in the prostate bed and floor, and possibly in the pelvic lymph nodes.

Salvage Treatment was the next step for me, and 2 acquaintances following persistent PSA of .19 for me and BCR w/in about 1 year or less for the other fellows. 37 IMRT radiation txs to the prostate floor and pelvic lymph nodes. I had 4 mos ADT; they each were prescribed 6 mos ADT.

Possibly good news for you: A different friend recently had BCR after about 5 yrs following RP. His PSA rose slowly into the .2 range. He is being treated currently with radiation only at a MD Anderson facility in NJ, with no ADT. MD Anderson said ADT was not necessary because his PCa was considered slow growing based upon his history.

Best wishes.

Bey Mike, this is the stuff that drives me nuts. Your friend at MD Anderson is not getting ADT because they feel his cancer is slow growing….
So slow growing that it came back?? I realize he may have had a low Decipher score but for me - also recurrent after exactly 5 yrs - I wanted ADT and actually changed my RO from one who said I didn’t need it to one at Sloan Kettering who said I did.
My personal feeling is that just like sequential biopsies can go from 3+3 to 3+4 to 4+3, so too can the PCa cells increase in both aggressiveness and growth rate. For me, the PSA velocity in my last 4 blood tests showed me that something was gaining steam and needed to be stopped, so I wanted ADT as a boost.

Steve

Something is "up," question is, what and what do you want to do about it?

We face many dilemmas in our treatment decision making:

When, too soon, too late...and what are the risk versus benefits...
What, too little, too much...mono, doublet, triplet...
With what - ADT, which agent, ARI, which one, radiation, where, which type, which machine...
How long 6, 12, 18, 24 months, or more?

Kind of hurts one's head trying to make a decision.

Here's an example of a choice - https://www.urotoday.com/component/content/article/2662-library-resources/esmo-2024-quick-takes-library-resources/155692-esmo-2024-quick-take-insights-a-focus-on-aranote.html

You could choose to do doublet therapy now, an ADT + ARI for a defined period, come off treatment and monitor. If so, have decision criteria about coming off treatment, did your PSA drop to undetectable in the first three months (or six) and stay there? If yes, then you may be an early responder which may portend a longer progression free survival (I am...).

Given the clinical data you describe, I don't see triplet therapy in play, no need for chemotherapy as it doesn't seem to benefit low volume MHSPC.

As to radiation, surprised your medical time pulled the trigger on imaging at that PSA as it's less than 37% statistical probability of showing where the PCa is. More and more I see people imaging between .5-1.0, I did, it located the recurrence. So, you can wait, if the PSA continues to rise, image again (assuming no issues with insurance) and if it shows where the PCa is, can inform your decision on radiation. You could also just go the nuclear option with radiation and do the prostate bed and whole pelvic lymph node system, they have standard "templates" for that (I liken it smart versus dumb bombs,,). I've had radiation three times, SRT to the prostate bed, WPLN, and SBRT., 69 treatments, 155 Gya, zero side effects. I have an excellent radiologist, and the planning software and delivery systems are advanced. The SRT was done without imaging, the other two were based on imaging, guess which one wasn't successful...!?

If you ask, what would I do...I would wait, let my PSA rise to between .5-1.0, image, then decide. I don't think waiting entails any degree of risk in a treatment decision I could make now not working later, it may inform a better decision. Keep in mind, I'm not a educated, trained, or board certified medical person and given the heterogeneity of PCA, my PCa is not yours.

That's what I did this last go round, waited for the PSA to reach between .5-1.0, imaged, then my medical team and I decided, SBRT + 12 months ADT for micro-metastatic PCa, hold the ARI unless PSA did not drop to undetectable in the first three months, decide at 12 months whether to come off treatment or continue to 24 months. We came off at 12, nine months later, PFS continues, T has returned, life is good, until the next time...!

As others have said, ADT sucks but may be manageable through lifestyle:
Diet
Exercise
Managing stress

I've done 18 months of Lupron, 12 months of Orgovyx. Side effects, yeah, hot flashes, fatigue, muscle and joint stiffness, genitali shrinkage, no loss of libido though (to my wife's dismay...). What changed in my life, nothing, went to the gym, rode my bike, went skiing, took vacations, attended concerts, celebrated birthdays, graduations, anniversaries...

Kevin

2.2 psa followed by PSMA which was clean followed by 6 mos. ADT and 25 salvage radiation treatments which I am currently doing. So far, no big deals.

Kevin - Thanks for sharing your thoughts. My Onc says start 6 months ADT soon, both the testosterone killer and the uptake blocker, and radiation also. Going to see a local radiation Onc next week. I am considering tightening down on my diet with continuing daily exercise and checking psa in a month to see if it is decreased. Plenty to think about.

Steve

I’m in the same boat as you are. Going in for another PSMA-PET in one week. I’m also hoping to avoid ADT.