Puzzling about PSA rise 7 years after prostatectomy

Ask your radiation oncologist if their department does Proton Beam therapy. That is your far-better choice of treatment with fewer bad, consequential outcomes vs standard radiation which has many more.

Just my 2 cents but my experience was that my PSA rose very quickly after going from .2 to .3
I was then at 14 and then 18 before I reacted properly. GS pathology 8 years prior was 4+3, so somewhat aggressive.
Recent PSMA/CT scan reflected growth in 4 lymph node locations, 0-1.5 cm. I think timing is very important. I could have caught it sooner. Grateful I’m down to .02 after 4 months ADT.
Still, just my 2 cents. Willing to provide more detail if desired.

@jeffreyg thank you for sharing your experience. I got some valuable talking points from you at the on coming appointment with the oncologist.

@rlpostrp Yes, a PSMA PET scan (no matter whether Gallium68, Pylarify, or Posluma) will have difficulty detecting prostate cancer when PSA is very low (see attached chart), which is why they sometimes wait until the PSA is 0.4+ (following prostatectomy) to be certain before doing anything aggressive. (But, waiting that long is tricky…..)

As it turns out, PSMA (prostate specific membrane antigen) is not really “prostate specific.” There are other organs, tissues, and fluids that naturally express PSMA (without being cancerous) and will show up as physiologic tracer uptake (i.e., “light up like a Christmas Tree”) on a PSMA PET scan - particularly in the lacrimal (tear) and parotid (salivary) glands, blood, liver, spleen, pancreas, ganglia, and more, as well as the kidneys, ureters, bladder, and urethra (as the body tries to quickly excrete the radioisotope that was injected).

At low (but concerning) PSA levels, with a PSMA PET scan they may be able to see if the body is simply expressing naturally-occurring background (“normal”) levels, or whether there is a recurrence somewhere. It takes a trained, experienced eye to see this, so choose the best.

PSMA PET scans typically do out-perform the older, pre-PSMA PET scans (F18-FDG, F18-NaF, Choline C-11, and Axumin). Yes, PSMA is that good of a marker.

However (as you allude) with lack of PSMA expression, PSMA PET is sometimes as blind as a bat. In those instances, it’s often beneficial to fall back and use one of those older pre-PSMA PET scans.

Mayo Clinic regularly falls back to Choline C-11 in those cases. Others use F18-FDG if they believe that the recurrence is advanced but PSMA expression too low to be detected or if the prostate cancer is PSMA-negative (which 15% of the time it is). (Insurance no longer covers FDG-NaF.)

The pre-PSMA PET scan that’s more often used in these instances is the F18-Fluciclovine PET/CT (trade name: Axumin® that was FDA approved in 2016).

Axumin doesn’t rely on PSMA. Axumin works by exploiting the fact that prostate cancers absorb amino acids at a much more rapid pace than normal cells. Axumin is made up of a radioactive tracer linked to an amino acid. Cancer cells absorb the amino acids more avidly than normal cells, so when Axumin is used, the radioactive tracer concentrates inside the tumor cells. When the patient is imaged, the areas that have a high concentration of the imaging agent signal the location of the cancer in the patient’s body.

Insurance still covers Axumin. In these instances it’s always worth discussing this with one’s medical team and see if they’ll consider it.

@beachflyer
You should be aware that doubling time is not that critical when it comes to having your PSA rise after your prostatectomy. If your PSA hits .2 you want to have salvage radiation, You don’t want to wait for it to rise much higher or there are risks involved. 3 1/2 years after my prostatectomy my PSA Rose to .2, I know dozens of other people that have the same thing with different time between surgery and PSA rise. I had 8+ weeks of salvage radiation and had no side effects at all the time, Six years later, I started having some incontinence, but I’ve had radiation and surgery so who knows what caused it. That does not happen to everyone.

Below are the standard set by the American Society of clinical oncology (ASCO) For what to do if you have a PSA rise after a prostatectomy. If your doctor is not aware of this, you might get a second opinion.

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/

@melvinw

Thank you for sharing your story of BCR. I am 69 and 14
months post RALP for G7. So far undetectable, but I asked my surgeon what happens if if returns, He said nothing if PSAdt (doubling time) stays above 12 months. I get the impression that meant even if it PSA rises above .2 over the years, long PSAdts are indicative of an indolent tumor mass (G3 versus G4)so do nothing.
Hmmmm.. not sure, I would not want to seek salvage radiation like you did. Anyway I did not know they could do prostate bed biopsies. Obviously they were concerned there was mire than one metastasis, but it might have been interesting to know what Gleason score cells had escaped the prostate.