PSA above 0 2 after RP in 2020 but psma pet scan is negative

My story is a little similar although my PSA started up shortly after the RARP. I believe the theory is something like,

"there's obviously some cancer somewhere shown by the PSA rise, since we can't find it elsewhere, it's likely a small amount of cells in the pelvic area still."

My PSA was pretty low and PSMA PET was negative as well. I have an older chart posted by one of the guys here more educated on the subject, it indicates that with a PSA of less than .5 the detection rate is only around 38%. (this chart was produced in 2019). It's floating around here in a couple places but I'll post it again.

I did 39 treatments 30(ish) to the "pelvic area" and the last nine(ish) to the prostate bed alone. I also did two years of ADT (orgovyx). So far so good after three years post radiation and 15 mos post ADT.

Best of Luck to you!

Sorry to hear your rise in PSA. I'm 2 months since surgery and honestly thats my biggest concern. My gleason score was 9 and I'm def concerned about PC recurrence. I also have a genetic issue (BRCA2+) so that also makes it more complicated and is the reason for having aggressive PC.

Please keep us up to date with your progress and good luck on your journey.

As Zack Bryan signs:
In A Life Having the Upper Hand's a Myth
Your Only Fighting Chance Is to be Too Stubborn To Quit

Waiting until psa is 1.0 makes sense in that i now know where the cancer is located with higher confidence and not applying radiation to healthy areas. However, then there is the risk the cancer has spread widely. Dr prefers not to take that chance as the treatment is even harsher

Kind of sucks, but it is what it is and I need to decide

@knoyes01 Radiation these days is a LOT more targeted than in the past. Salvage radiation uses computer assisted guidance to avoid (as much as possible) areas of healthy tissue such as bladder and rectum.
A simulation is done under ideal conditions - full bladder/empty rectum. The Xray computer program will scan you before each session to be sure that your internal organs are in the SAME position as the simulation in order to keep the beams focused only where the RO wants them.
Your only job is to follow the bladder/rectum protocol laid out by your team. You will be fine.
Phil

@heavyphil

I had an RP in 2010. 3 1/2 years later, my PSA started rising and when it hit .2 they gave me a six month Lupron shot and two months later I had salvage radiation. That lasted for 2 1/2 years before it came back again and I went on Lupron full-time. I have BRCA2, which is why it keeps coming back.

The most likely place for the cancer to be growing is in the prostate bed. That’s why they radiate it.

The standard is that when you hit .2 they do salvage radiation. Here is the information from ASCO who set some of the standards for prostate cancer treatment

From Ascopubs about what PSA to do salvage radiation.
≤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/

@knoyes01
Exactly you wait until your PSA hits one and the cancer is probably in your bloodstream and could come back anywhere. It does go dormant sometimes for years or decades, but more frequently. It comes back sooner..

You don’t mention your Gleason score that is a critical number That can tell you how aggressive the cancer is and how likely it is to reoccur.

At a PSA of 0.2, a PSMA PET scan will rarely detect any prostates cancers, which is why they often wait until PSA is much higher.

As for salvage radiation before knowing where the recurrence is, Dr. Kwon (of Mayo Clinic) indicates that only 1/3 of men who have recurrence following prostatectomy have recurrence only in the prostate bed, and that they should not get salvage radiation there unless they’re absolutely certain of the location of recurrence. He says to first confirm where the recurrence is. (See Dr. Kwon’s presentation about recurrence: https://youtu.be/Q2joD360_pI)

What can I say...

You could, as @jeffmarc says, initiate the tried but not necessarily true standard of care and do SRT...and "hope" that works... As a friend of mine said long, long ago, "hope is not a method!"

There are choices, in part, may be a function of your clinical data.

Pathology Report
Decipher Test
PSA test results
Genomic Testing

PSA tests results can be used to calculate PSADT and PSAV,
The pathology report gives you clinical data such as GS, GG, SV, ECE, Margins...
It is useful to understand the risk category in making treatment decisions in concert with your medical team.

You can be aggressive in your approach, including WPLN radiation to and short-term systemic therapy. What is short term, may be six months, up to 12-18 though 24 months is in play.

You can forgo the SRT only and let your PSA increase to between .5-1.0, doubling your statistical probability of locating the recurrence and informing the treatment decision.

I am high risk. When I had BCR after surgery (see attached clinical history), I discussed adding WPLN and short term systemic therapy to the SRT. There was data emerging from clinical trials that indicated in high risk cases, the PCa had already moved into the PLNs. My medical team dismissed the idea, no "long term" data supporting it. I acquiesced, you guessed it, SRT was an epic failure.

Would my way have changed the course of my PCa, would I have been cured, we'll never know! The takeaway for me was be aggressive, I have high risk PCa. The next treatment decision, triplet therapy was in part, founded on my mistake with SRT.

That's my experience though. I don't see enough clinical data in your post to inform your decision.

I'm with @brianjarvis though.

Kevin

@brianjarvis
Thanks

Waiting for my clarity also risks cancer spreading and hormone treatment will be needed. Right now I do not need hormone treatment and will do proton treatment