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PSA now .04. What might be next steps?
My husband has now been taking Orgovyx and Nubeqa for five months. His post-prostatectomy persistent PSA has dropped from 4.7 to .04. Before the medications the PSMA scans showed cancer in some pelvic and abdominal nodes that the docs did not want to radiate because of delicate areas in the abdomen. My question for the group is this: With a PSA of .04 and the likelihood that nothing will show up on a new scan, what might be the next steps the doctor will recommend? Also, what would you suggest we should we ask him at our next appointment?
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You say ..."His post-prostatectomy persistent PSA has dropped from 4.7 to .04..." I just have not seen someone with a persistent PSA of 4.7 after surgery, detectable yes, but one to two decimal places more common.
So, he had surgery...what was his PSA just before surgery, what did the pathology report say, frequency and results of PSA tests since...?
I ask because as I read your post that clinical data is useful in shaping the group's response...
Is he on doublet therapy for a defined time,,12, 18, 24, 36 months, "indefinitely...!?"
Things like PSADT, PSAV, GS, GG, any genomic testing...all factor into treatment decisions.
His response you describe from 4.7 to .04 in five months is a positive indicator treatments working and if it is for defined period, a clinical data point indicating longer PFS and RPFS.
Imaging at .04 may be as doctors like to say about some supplements, just result in expensive urine...!
The decision to image is generally a function of the purpose, why, what do we do with the results, does it change our treatment plan...also, what are the statistical probability it locates anything...pretty darn low at .04!
There is also the insurance coverage issues sometimes and any financial toxicity associated with that.
Knowing the little I do from what you post, what would I do were I he? Remember, I am not your medical team!
Continue treatment for whatever period the original decision was for.
I would not image at that PSA.
I would discuss with his medical team the clinical criteria for coming off treatment at the end, if not before, of an agreed upon defined period.
I am not in the camp for indefinite treatment, fired one urologist who said that's what I should do, there are diverging views on intermittent versus continuous so you, your husband and your medical team are going to have to discuss that. It has worked for me...we have clear criteria for coming off, monitoring while off and what constitutes sufficient clinical data to go back on. My breaks have been almost five years after triplet therapy and 21 months and continuing after doublet. T had recovers in the first 3-6 months which is a factor. There are some whose T does not recovery, age, baseline T, duration and type of agents used in systemic therapy as well as lifestyle all may be factors. Those on this category may not "enjoy" their breaks as much...
If you have not, consider consulting with another radiologist about treating those spots, doesn't hurt. As my radiologist says, get a group of medical specialists together in a room to arrive at a single solution, good luck with that!
As to the duration of systemic therapy, that is a function of the clinical data, GS, GG, PSADT, PSAV, Pathology Report, testing such as Decipher, Genomic...
Kevin
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4 Reactions@kujhawk1978
Thanks for unswerving ucla , I always find your responses useful and interesting and I wish I know how to make that diagram that you have for your PC history. You should make an "app" ; ) for that and make some nice money with it !
BTW - you can find Ucla's husband full PC history in her profile .
@surftohealth88
I get lazy on checking the profiles...
I'll do that now!
I use MS Excel for the graph. Then I add text boxes for the "events"
Kevin
Thanx.
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1 Reactionok, now that I read his clinical data from your profile...
My husband, 64 yr. old, has metastatic PC. Rising PSA noticed in 2024. Diagnosed in early 2025,
PSA of 10. Gleason 9, PSMA pet scan showed large tumor in prostate and two positive pelvic nodes.
Prostatectomy June 2025 at UCLA Westwood. Three of seven pelvic lymph nodes removed were positive.
PSA after surgery was 1.9 and continued to rise up to 4.7.
My thoughts - Unsure why when three of the lymph nodes positive, a PSA of 1.9, GS 9 and GG 5 his medical team didn't recommend adjuvant therapy immediately, but, water under the bridge..
Placed on doublet ADT in September, with plan for follow-up radiation. PSA down to .7 in November.
My Thoughts - This sounds right though not sure why was whole pelvic lymph node radiation a part of the treatment decision vice follow-up?
New PSMA pet scan shows some positive node activity in pelvic region and abdomen.
My thoughts - so, while he was on Doublet Therapy, new activity was detected? That would indicate castrate resistance!?
Radiation put on hold. Chemo is suggested as possible next step, combined with the ADT.
My thoughts - Chemo is certainly an option though the data points to greater effectiveness in high volume which does not seem the case here. Still, I did chemo in conjunction with ADT +WPLN and I was not high volume so there's a study of one, I did have an almost five year break from treatment as a result of the ADT + WPLN Radiation + Chemotherapy so...
PSA down to .1 by end of November 2025.
Doc is pleased with results, puts chemo on back burner, says it may not be necessary at this time. Doc said the great response to the ADT is an excellent prognostic sign going forward.
My thoughts - His Doc should be pleased...I think most, if not all, on this forum would agree chemo may not be necessary at this time...yes, great response to ADT is a favorable prognostic indicator, see the EMBARK Clinical Trial.
Update Feb. 2026 - PSA .04
My other comments may still be pertinent.
Given his clinical data, the duration of systemic therapy is likely 24-36 months, leaning towards the 36.
For now, stay the course, systemic therapy...
What lies ahead, nobody can say. If when he will need to go back on treatment and with what. That will depend on the clinical criteria you , he and your medical team agree on that constitute the need to go back on treatment, what imaging shows , what the guidelines say and results from clinical trails entering mainstream clinical practice at the time. As an example, there are clinical trials exploring moving radio isotopes such as LU-177 into the HCSPCa space - https://clinicaltrials.gov/study/NCT04443062 and https://www.urotoday.com/conference-highlights/esmo-2025/esmo-2025-prostate-cancer/164097-esmo-2025-phase-iii-trial-of-177lu-lu-psma-617-combined-with-adt-arpi-in-patients-with-psma-positive-metastatic-hormone-sensitive-prostate-cancer-psmaddition.html
What I am uncertain of - is he castrate resistant or not? I would think not given the timeline you lay out.
Kevin
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4 Reactions@kujhawk1978 Thank you for such a thoughtful and informative response. I will try to fill in the blanks for you as best I can.
In hindsight we recognize the ADT should have been started sooner. Not any radiation because of needing time to heal but the ADT, yes, right away I would think with 1.9 PSA post-prostatectomy. Water under the
bridge…we didn’t know then all that we know now.
The PSMA scan that showed new activity in abdominal nodes was done very shortly after the start of ADT, around a week or so. We assume there were micrometastacices that decided to show themselves at that time that didn’t show up on the initial scan.
The first time we met with our oncologist he made it clear he recommends a minimum of two years ADT.
I don’t think he is castrate resistant. The meds are working well and our doc would have told us if he had become castrate resistant.
We have brought up the Pluvicto option with him and he was receptive to it, making clear that may be something for the future and/or some appropriate radiation and/ or chemo.
We have an appointment this week. Anxiously waiting to hear what he has to say about the .04 PSA.
@kujhawk1978 One other thing you asked about was other testing. His hereditary and genomic tests didn’t show anything significant. Of note though is that lymphoma and prostate cancer run in his father’s family.
@surftohealth88 Thank you for your support. 😊
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1 Reaction@ucla2025
To become castrate resistance, the PSA has to rise while on ADT. That usually takes at least two years and for some people much longer. Richard Wassersug PhD Who wrote a Popular ADT book made a claim about that in the posting I wrote about using estradiol instead of ADT.
He says If there are few cancer cells to mutate, there is little chance of the cancer becoming castrate resistant. In contrast, if there are gadzillion cancer cells around, the chances go up that some cosmic ray will damage a chromosome in one of the cells and lead to a mutated cell that is both castrate resistant and proliferating quickly.
He’s been on estradiol for 22 years and has not become castrate resistant.
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5 Reactions@ucla2025
Thanx, I understand as to the timing of the imaging generated ADT.
I'm guessing at your appointment, your doctors going to say .04 is great, see you in three months!
Mine's been stable at .03 for 20+ months now.
I do think it may be possible for many, albeit not all, high risk patients to manage their high risk PCa as a chronic disease
I think you and your medical team are making appropriate evidences based decisions.
Best wishes!
Kevin
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