@jasonnyc The kicker was the palpable nodule in combo with my RARP (2015) pathology that showed a positive margin and a Prolaris score that predicted a 53% chance of BCR in ten years. I had a new urologist when my PSA hit 0.11 and at first his response was that it was probably just lab variation. But when he got my old records and detected the nodule, he immediately referred me to another urologist who specialized in advanced prostate cancer and also put in an order for a PSMA PET scan. That was followed by an MRI. And here is the crazy thing about the PET scan—despite my low PSA, the nodule lit up with an SUVmax of 13.4! That 0.5 cut off for PSA and detectability of the PET scans is only a statistical association. My first RO wanted to start IMRT with six months of ADT immediately, but I decided to tap the brakes a bit and get second and third opinions. I didn’t even know my PSA doubling time. In the end, it was 3 months before I started IMRT (without ADT, my call), and my second PSA came back again at 0.11, and a simultaneous ultra-sensitive PSA test from Labcorp came back at 0.094. Studies that I read indicated that starting salvage RT at such a low PSA yielded better outcomes, and again, given the definitive presence of a nodule/lesion, I felt pretty solid about doing that. If not for the nodule, I suspect that surveillance would have been the recommended route.

The biggest hurdle in getting a PSMA PET scan with PSA < 0.2 is getting insurance to cover it. Mine did, and again I think the nodule and the pathology data were key factors.

My recurrence seems to be a bit of an oddball case. My first RO cited the SPPORT trial to support his recommendation for RT+short term ADT. But I dissected that paper, then discussed it with him. Amongst other things, the SPPORT trial disqualified any candidate with a palpable lesion. So, when I pointed that out to him and asked, how the results of the SPORRT trial applied to me, his answer was, “ only by extrapolation”. I appreciated his honestly, but that’s when I moved on to get other opinions, and ended up with a different RO that was more aligned with my priorities from the get go.