Last June, I was diagnosed with a local recurrence (age 72), ten years after a RARP in 2015. Post-surgery pathology showed a Gleason score of 3+4, with one positive margin. My PSA was undetectable (< 0.1) through that ten years, then during my annual urologist visit in 2025, it had risen to 0.11. The kicker though, was that a year earlier a small nodule was detected in my prostate bed. The PSA level of 0.11. combined with the palpable nodule put further evaluation into motion. First was a PSMA PET scan. The nodule lit up like a Christmas tree on the scan, strongly suggesting it was cancerous. That was followed by seeing an oncologist, and then doing a pelvic MRI, which further confirmed that the nodule was cancerous. Fortunately, neither scan detected evidence of distant mets. After seeking opinions from two other oncologists, I underwent 38 sessions of radiation therapy last fall (IMRT). In the three months from initial PSA rise to the start of therapy, my PSA had not changed. Radiation side effects were minimal (mostly fatigue) and my PSA dropped below 0.1 (0.086 on an ultra sensitive PSA test) three months after finishing radiation. Anyway, so far so good.

Radiation therapy has advanced tremendously since your surgery 23 years ago, and even has made big advances in the last few years. The treatments are much more precise and side effects have been reduced.

It does sound like a PSMA PET scan is the next step. These scans don’t always detect lesions at PSA levels below 0.5, but it sure did in my case. But, at 0.2 PSA, you meet the criteria for a possible BCR, so I expect a scan will be recommended.

In terms of cancer aggressiveness (if you do have a relapse), the long time to relapse (23 years) and the unchanged PSA over three months and low Gleason score (6) are strongly in your favor. Dr. Patrick Walsh’s book, “Guide to Surviving Prostate Cancer” has a chapter in which he gives tables with statistical estimates for survivability and development of distant metastases. The tables use Gleason scores, time to first recurrence after surgery, and PSA doubling time. They are definitely worth having a look at.

I was surprised when I was diagnosed with a recurrence at ten years, although with a positive margin and a Prolaris score that gave a 53% chance of BCR at ten years post RARP, I was not completely shocked. We both are statistical outliers, but relapses do occur even after ten and twenty years.

If I was in your position, I would collect all the data I could, and get multiple opinions from oncologists. I would get a PSMA PET scan as soon as possible, then proceed from there. Test PSA again in three months, or just before initiating salvage radiation.

Hoping that your recent PSA readings are just flukes, but even if not, you have much better options than 23 years ago and some breathing room to make some decisions about treatment.