Rising PSA after 17 years

Dear stu6060, sorry for the confusion that occurs frequently here. I don’t know if you realize this but there are two ways to post here: COMMENT and REPLY.
COMMENT refers to the original subject mentioned - in this case, your rising PSA.
You will note in my post that I am REPLYING to another poster’s comments - more than one poster, in fact…..it says so at the top of the posting ( In reply to…). I was not COMMENTING on your original question since there was no need to do so; other members said everything I would have and more.
The beauty of a “forum” is that a question or topic elicits multiple responses from different members - some not at all related to the original question, but germane to the overall conversation. PSMA’s go to PSA’s which go to other health issues such as dialysis, which then go to high blood pressure. See? It’s a forum!!
Your original thread was not killed, since members can see the topic being discussed and decide to COMMENT if they feel they can contribute to the conversation.
Did you really think I randomly decided to start a conversation about HBP and dialysis on my own, merely for the sake of “pontificating”?😖 I was replying to jeff marc and stratjag’s conversation, NOT COMMENTING on your post…capeesh??

shut up

Ah…the response of the truly ignorant…

The question you ask is what many face after surgery and a rise in PSA at some point after that.

Clinical data may inform your discussion with your medical team. Some of that data may be in your pathology report from surgery:

Gleason Score
Grade Group.

Other clinical data may be from labs - PSA Doubling and PSAV

MSKCC has some nomograms which may be useful in any decision making - https://www.mskcc.org/nomograms/prostate

I had BCR 18 months after a "successful" surgery. My clinical data is indicative of high risk which factors into my decision making - GS 8, GG4, 18 months to BCR, rapid PSADT and PSAV.

I have seen general rules of thumb with regards to PSADT:
< 3 months - treat
between 3-12 months - use in conjunction with clinical data to decide treatment
>12 months - consider continuing to actively monitor

Another factor in play is imaging, the likelihood that a PSMA PET shows where recurrence is. Intuitively, the higher one's PSMA, the greater the likelihood a PSMA scan shows the recurrence.

I guess the question is, what are your clinical risk factors and how aggressive do you want to be?

You have choices:

Continue to monitor with labs and consults, image at some point, then discuss with your medical team. When you and with what agent you would image is a discussion with your medical team. A consideration is any risk in waiting for an increase in your PSA to image. That questions may be a function of your clinical data and risk stratification, high, intermediate, low...

Act now,,,,

If you decide to make a treatment decision now or later, you have even more choices,

You could do radiation to the prostate bed, SRT
You could do SRT and also the whole pelvic lymph nodes (WPLN)
You could do SRT, WPLN and add ADT for a definitive time, 6-12 months.

Imaging may better inform these decisions.

If the latter, you may face two other decisions on ADT, which agent, whether to add an ARI,

As to the side effects of radiation, today's radiation is not our father's. I had SRT, WPLN and SBRT, 69 treatments, 160 Gya total, zero SEs, testimony to the advances in planning and delivery as well as the skill of my radiologist and her team.

The SEs of ADT are well known but can be mitigated:
Exercise
Diet
Managing Stress.

For short term, especially when using Orgovyx, recovery of T can be fairly rapid, starting at 3 months.

I am not 17 years after my surgery, experiencing what you are, but, were I you I would:

Do nothing right now.
Continue with labs and consults every three months.
Discuss with my medical team about decision criteria on when to image.

If, when I reach that point, image, then decide informed by all the clinical data possible,

There is some evidence that MDT in the case of oligometastatic PCa can push the need for ADT down the road.
There is also the likelihood that when imaging shows where recurrence is, there is micro-metastatic PCa too small to be seen so systemic therapy is added to MDT.

ADT + ARI may be overkill if the PSA drops to undetectable in the first three months of SRT+ADT or SRT+WPLN+ADT.

Kevin

This may be useful in your discussions with your medical team and decision making.
https://www.urotoday.com/conference-highlights/eau-2025/eau-2025-prostate-cancer/159158-eau-2025-how-to-optimize-outcomes-in-men-with-biochemical-recurrence-after-local-treatment-with-curative-intent.html?utm_source=newsletter_14011&utm_medium=email&utm_campaign=emerging-evidence-in-advanced-prostate-cancer-care-from-the-european-association-of-urology-eau-2025
Kevin

Same thing happened to me. I had a radical prostatectomy in 2005 (Gleason 6) , and thought that took care of my problem. Then, ten years later, a blood test as part of my annual physical revealed an elevated PSA level. A scan showed cancer cells near my bladder. I underwent cyberknife surgery which lowered my PSA level to near zero, but then six months later the level began to rise. Since then we've been playing whack-a-mole with the cancer cells, which now are in my lymph nodes. After four rounds of radiation therapy I've been told that further radiation might cause tissue damage, so I am now in what is called systematic therapy, which uses two medications, a Lupron injection every three months and a daily Erleada pill. I'll be checking in with my oncologist at Georgetown University Hospital next week to assess the efficacy of this protocol. More to come.

Stu, if you spend some time reading, what’s going on in this Mayo clinic forum You will find that people respond to messages with new problems, and as a result, we like to respond to those problems as well as the initial persons request for help.

@heavyphil Was just responding to other people’s issues that were posted in this thread, but don’t directly relate to what you have going on. I did the same thing more than once in this short thread. Yesterday somebody posted a brand new question with a lot of information in the middle of a 2024 question. Definitely not the right place to post it, But a lot of people try to help, even though it’s posted in a conversation that’s totally different from the original conversation.

We all still want to help with the original discussion.

Thank you very much for your input. I feel better

Thank you for your response, all the best to you.