Low, But Rising PSA--Wait for Imaging or Act Now?

@brucemobile
Thanks so much Bruce

I am really in the data collection phase and will see a RO at Hopkins in three to four week. All this information is super helpful. She already has me set up for some labs but I do not know what they might be yet, She was recommended by others on this list and luckily I will be able to see her

Does radiation after RARP connect with more incontinence or regression?

@bikeman1
I am seeing Dr Paller as well

@dhasper
Agree. Same here. Similar PC diagnosis. 10 months Post RP PSA rose to .2. PSMA PET/CT scan showed 1 lesion in pelvis. Biopsy confirmed cancer. Immediate SBRT in pelvis and started Orgovyx and Nubequa. PSA now undectable and side effects very manageable. Just tired a lot and weak. Still shot 82 last week - just need to adjust swing tempo! lol. Onward.

I kind of just going through this now, 5 yrs after prostectomy undetectable, then PSA starting to rise and at .5 and PSMA PET/CT showed pelvic leasion small and possible left hip, but may have just been bone growth area absorbing tracer. Treated with radiation and PSA undetectable for 22 months with ADT & Bical, then started rising again .11, then .23, then the 4wks later .47 , so rapidly rising doubling every 4 weeks.

Medical Oncologist willing to wait to .5 to see if PSMA PET/CT with Pylarify could pick up anything. Had the scan when PSA was .47 and it showed nothing at all, the prior lesions were totally gone so both my Radiation Oncologist and 2 Medical Oncologist said start treatment with xzanti and continue ADT.

These are some very smart physicians, Harvard undergrad, Harvard Medical School, Professor of Medicine at Harvard, Dana Farber Cancer Research, another one Penn Medical and Yale so I have to listen to what they are telling me and it is a great way to stop worrying about every PSA tic or if I am doing the right thing, that is the biggest challenge.

So my advise make sure you take the time to assemble a top notch group of physicians that you can believe in and focus on fighting this disease and reduce some of the anxiety that we all have.

Reading many post some patients really don't like or trust their doctors, which is not the best situation IMO, get a good team and live your life to the fullest today none us know what tomorrow will bring.

That is clearly up to you in what level of calculated risk that you are comfortable with. Clearly some will feel regardless because they have more aggressive characteristics in their cancer they must immediately begin treatment for BCR and that is fine if that is their decision. The newer emphasis on treatment on the PET image driven push versus the prior PSA increase treatment protocol is clearly not something thought up on a whim regardless of cancer characteristics. This decision is between you and your physician. The PET only became standard FDA approved imaging tool for detecting prostate cancer recurrence and staging in high risk patients in 2020-2021. The BCR PSA number generally accepted in the US is .2, yet under EAU guidelines it is .4. More studies are coming out showing comparable outcomes with image driven at a higher PSA then PSA increase at a lower level. Since the PET image driven studies clearly are around the five year level and not long term are very encouraging, although not long term and that can worry people. Regardless someone with aggressive characteristics may decide not want to wait, that is fine if that is what they want. I would not dismiss the PET driven. It goes back to how everyone regardless treated Gleason 6 (3+3) immediately with radiation or surgery. Today their is also a school of thought that Gleason 6 is not considered cancer yet. That is how active surveillance came in and now as earlier studies have shown in cases AS can continue with into Gleason 7. Aggressive Gleason 8 and 9’s prior to PET were almost always thought to have left the prostate capsule which clearly today that is not necessarily the case. Even today patients hear they have Gleason 6, and statistically have nothing at the present time to worry about, they do worry about being in that percent that maybe it turns aggressive and decide they want to have their Gleason 6 immediately treated with surgery or radiation and giving up their existing quality of life for who knows what side effects and how many years they might have gone without any treatment. The key is do you have confidence in waiting longer and that it will be caught in 6 months, another year by the PET imaging and that the end outcome won’t be any different. It was concerning in the past that things were so much worse if a person’s cancer had left the capsule, was in a lymph node. Yes, every additional characteristic is worse, but again it is the long term outcome and again if relatively the same, then it could be additional time with no additional new side effects. Many patients also feel once their diagnosis regardless of degree if treatment isn’t started within three months begin to panic when clinical studies clearly show 6 months between diagnosis and treatment is fine in outcome. The studies sure are not long term and everyone is thinking of themselves being here long term, but I think each person individually with their individual circumstances with their physician especially if from known cancer centers of excellence and up to date in all available information can balance this risk. It certainly is not one size fits all.

@gtin723
While putting you on Xtandi Could bring your PSA back down it is not the standard of care most doctors follow. Here’s what the American Society of clinical oncology recommends if your PSA rises after having a prostatectomy. If they can’t find a metastasis using a PET scan, this becomes even more important.

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/
Some doctors want to wait for metastasis to show up so they can zap them. With such a fast rising PSA that seems a little different from SOC. I know I would want to ask my doctor why they are not considering salvage radiation.

@jeffmarc I went 6 years after my prostectomy undetectible, then 1st BCR and salvage radiation and target radiation after PSMA PET/CT showed small pelvic leasion moderate uptake of Gal8 tracer.

This time 22 months on ADT and Bilcal, could not tolerate Zytiga, liver enzymes issue so used bical. That is where I am now and I do trust my physician team.

@jeffmarc

Yes, every single study showed those results and they were done on thousands of patients and were randomized.

I am yet to find and TRUE randomized study that shows that waiting for lesion to show is a good idea ! I think that people do not necessarily know difference between different kind of studies (randomized, retrospective, case controlled ) and also where were they done (one location, multiple, single country or multiple ) etc. etc.

There is no single randomized study that was even done to compare patients who waited and did not - to the contrary , every single world renowned organization who DID randomized studies confirmed - do salvage if all possible BEFORE 0.25 after RP for the best possible outcome.

Members here are starting to mix salvage RT post RP with salvage RT after initial salvage failed - those are completely different categories.

Also, age of patient and comorbidities can make a major difference in proposed recommendations for further treatment.

There are randomized studies for salvage RT post RP that went into 0.05 increases and compared results and that is how they not only came to 0.2 but to 0.25 as a cut-off for the best results.

My sincere advice to all is to read, read and read - find studies and "study". Answer is very obvious regardless what business oriented PC influences on the web say ;).

@surftohealth88
Absolutely find studies and more studies to review from all reputable sources especially centers of excellence. Don’t stop there, but look into the current clinical studies regarding these things. See how far along they are Phase 1,2 or 3. Getting to a phase 3 has taken considerable review processes that a certain treatment or approach will work. There must be some empirical evidence supporting it. There may be interim studies updating results. Don’t limit yourself to just US studies why does the EAU have a higher threshold. They have studies too.

@wheel1
Exactly what I said : ))) - randomized multi center studies are the best. Read them all. If lets say 10 of 11 show the same thing, that 1 is probably not what you wish to follow.