Yeah, just when you think...

First thing to think about may be discussing and developing "decision criteria" in coordination with your medical team - when to treat, if so, with what, for what period...

Part of that is what clinical data to you want to have in making any treatment decision?

Some you may already have from the pathology report and labs and jabs since, GS, GG...

Some you can determine from the data you have, PSADT and PSAV.

Some you may not have, Genomic testing results, testosterone levels, CV health, Lipids, CMPs, etc. that show liver, kidney function and other useful health data in making treatment decisions.

Then discuss the criteria...

How many PSA tests, spaced how far apart and that show a continuous increase? As others have said, to the extent possible, you want to control the conditions of labs and jabs, same lab, same time of the day, same pre-draw routine.

At what PSA will you act? That may depend on what treatment you and your medical team are thinking about. If SRT to the prostate bed, the decision is made for you, .2

If something else, then the sensitivity of imaging maybe a factor. At below .5, generally a 1/3 statistical chance of PSMA imaging showing recurrence, if .5-1.0 you double the statistical chance.

So, if your decision is SRT, you're not going to wait for PSA to rise above .2 and likely not use imaging. Here's the contra to SRT at .2, it's like dropping dumb bonds, hoping to hit the target. You can choose to be more aggressive and include te pelvic lymph nodes, ratchet up the aggressiveness even further and add short term systemic therapy, six months, though 12-18 is in play depending on the clinical data. Then again, if you miss that "golden" window of .2 for SRT, there is the possibility you lose an opportunity for that elusive cure. Put me in the group that says if surgery doesn't bring you that cure, SRT is not going to either. You are now into managing your PCa as a chronic disease requiring lifelong vigilance and treatment decisions at various points, though not continuous, maybe intermittent. Terms like progression free survival move go the forefront in your decision making.

There is some data from clinical rials that indicates MDT only may push back the need for systemic therapy. That argues for letting PSA rise to between .5-1.0, image and then treat with MDT.

Depending on your PSADT and PSAV, you may consider doing nothing but continuing to actively monitor as PSDAT >12 months supports that. You can always act later if the clinical data indicates.

Read through the NCCN and AUA guidelines, avail yourself of resources from organizations such as PCRI and PCF.

Kevin