Increase in PSA 12 years after prostatectomy.

Not really. You Should’ve immediately been set up for a PSMA pet scan. Your PSA has risen a lot and you actually should have Been treated already.

I realize your surgery was 15 years ago. It took 3 1/2 years for my PSA to start rising to .2 after my prostatectomy. At that time they did salvage radiation right away.

This is one of the groups that sets the standards for what to do when your PSA starts rising.

From Ascopubs about what PSA to do salvage radiation. After prostatectomy
≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

This article discusses the above;
https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/
Now it’s possible the doctor you’re going to wants to find whatever metastasis shows up and zap them rather than do salvage radiation. That may work that may not, but they should’ve already done the PET scan By the time you hit .44.

Are you going to a center of excellence? What kind of oncologist are you seeing? You want to work with a Genito Urinary Oncologist, Because they specialize in prostate cancer, unlike medical oncologist who work with all different kinds of cancer and can’t specialize.

At this point, I would want monthly PSA tests. You’re already taking a chance find yourself better treatment.

Age could be a factor? How old are you?

@ozelli I know age is a factor for elevated PSA when the prostate is still in place, but would it still be a factor after the prostate has been removed?

If he had his prostate removed in his early 70s and is now approaching 90 I would think that would be a factor. Monitoring would seem appropriate to me if that were the case.

@ozelli
prostate in mid 60s and now 78! Does that make a difference?

It is odd but not unheard of for PSA to rise even many years after RARP…
However, this is a pretty substantial rise and warrants - at least! - a repeat PSA almost immediately. No need to wait ( infection, bike ride, sex) since you have NO prostate.
@surftohealth88 recently posted about Covid and other viruses raising PSA…not sure if this applies to your situation. Best,
Phil

I am interested to hear what procedures the dr did b4 starting radiation to determine the location of the cancer cells (outside the prostate bed perhaps) . For example did they do a MRI and biopsy?

Layman view:
I would not wait for annual PSA and re-test sooner rather than later.
And as noted above, treatment in range of .02 - .04/.05 seems to be the most widely accepted recommendation.
PSMA PET scan to rule out or identify metastasis and radiation to WPRT and pelvic lymph nodes, with or w/o ADT would seem to be the course of treatment.
Perhaps a Radiation Oncologist opinion might be helpful.
Best wishes.

Well...

@jeffmarc is not "wrong..." then again...

If your decision was to do SRT, then it may be too late.

But, life is not over....

You could at this point ask your medical team for a PSMA scan. Statistically at your PSA that scan has a 2/3 chance of showing where any PCa activity is. Keep in mind that if it does, there may be micro metastatic cancer too small to be seen by even the most sensitive imaging.

The question you and your medical team may want to discuss is what clinical data constitutes a decision to treat?

You have some...
Prior treatment
Pathology report
PSA
Age

There are other pieces:

Imaging
PSADT and PSAV
Genetic Testing
Life expectancy
Health - co-morbidities

Once you have the clinical data the next questions are:

Do we treat?
When?
With what?
For how long?
What would our decision criteria be to come off treatment?
If we come off treatment, what then, how often and what tests to we do?

There will be choices, there may not be a single right answer, rather, good choices.

Those can include:

Do nothing but continue to monitor. There is some data that suggests it may be 8-10 years before metastases become impactful. If this is your decision you can of course at any time the clinical data indicates, start treatment.

You could treat now. If imaging shows where activity is there is some data which may indicate MDT can push back the need for systemic therapy.

You could combine MDT with short term systemic therapy for the micro metastatic disease. What is "short term," anywhere from 6-18 months, maybe 24.

If you and your medical team decide on systemic therapy then more decisions, which ADT agent, do we add an ARI, which one, when, at the start or do we wait to see if the ADT drops PSA to undetectable in the first 3-6 months, if yes, maybe no ARI, if not, maybe add it.

Talk it over with your medical team, read through the guidelines such as NCCN and AUA.

There are organizations such as PCF and PCRI which have a wealth of patient centered educational resources.

Kevin

Similar course for me and I agree with your doc's advice and what you are doing. I had surgical removal 2015. 8 yrs later, PSA 0.1, now 0.5 which it has been for the last 9 months per 3 tests. Two negative PSMA scans. You've gone many years, with an extremely slow growing cancer. The likelihood of a positive PSMA PET scan following surgery is around 20% at 0.2 ng/ml, 50% at 0.5 ng/ml, and ~90% at 1.0 ng/ml or higher. So at .44, you have a less than 50% chance of finding it. My urologist is of the opinion that the likely location is the prostate bed, which can be effectively treated with targeted radiation once it shows up on a PET (vs radiating everything because you don't know where it is). The course of treatment for men who have a rising PSA within a year or two of surgery compared to you and I whose PSA rises many years after surgery is significantly different. My only suggestion is PSA testing every 3 months. All the best brother.