Post Prostatectomy 6 years. PSA <.01 until now. Anyone else?

@jeffmarc

I find this discussion thread very relevant to my situation, as I am currently on BCR watch a year after my prostatectomy. My PSA remains undetectable, but I recognize that I have several significant adverse risk factors for recurrence, including pT3b disease with seminal vesicle invasion, extracapsular extension, lymphovascular and perineural invasion, and a high-risk Decipher score of 0.75. My preoperative PSA was also 14.5 ng/mL. On the favorable side, my surgical margins were negative.

Given this risk profile, my current thinking is to consider early—or even ultra-early—salvage radiation therapy if my PSA begins to rise, perhaps before it reaches 0.1 or 0.2, even if the recurrence is not yet visible on a PSMA PET scan. I believe this is consistent with 2026 NCCN and 2024 AUA/ASTRO/SUO guidelines.

However, I know that prominent oncologists such as Dr. Kwon and Dr. Scholz seem to favor waiting until recurrent disease is visible on a scan. I am not sure whether they would recommend the same approach for a patient with my particular combination of pathological and genomic risk factors.

Each approach has potential advantages and disadvantages. I am hoping that rapid advances in increasingly sensitive PSMA PET imaging will eventually make this distinction somewhat moot.

Any thoughts?

@soli
As you bring up, some doctors will do adjuvant radiation Others want to wait. They look at where your PSA is and how quickly it is rising. Some people can go a long time before their PSA starts to rise. As far as when to do adjuvant radiation, this is one of the guidelines for it. As you can see you qualify for at least three of the guidelines. The real question is, Is your PSA really rising at all or is it stable?.

Adjuvant radiation
Dr. Efstathiou concluded as follows:
* Early salvage radiotherapy is favored over adjuvant radiotherapy in most patients
* Consider adjuvant radiotherapy in otherwise fit, motivated, very high-risk patients with ≥2 of the following risk factors:
* pT3b-4
* Gleason score 8-10
* pN+ Lymph node Metz
* Decipher score >0.6
* In high-risk patients, use lower thresholds to initiate ‘ultra-early salvage or adjuvant-plus’ radiotherapy
* If giving adjuvant radiotherapy, it implies high-risk disease. Thus, Dr. Efstathiou would recommend treating the prostate bed and pelvic lymph nodes, in addition to short-term versus long-term ADT, depending on risk factors
* May consider genomic classifiers or artificial intelligence tools to help with informed decision-making
* The goal is to avoid (or delay) radiotherapy in those who we can, without missing a window to cure patients who are guaranteed to recur

Here is a link to the article supplied by @surftohealth88 originally
https://www.urotoday.com/conference-highlights/apccc-2024/151546-apccc-2024-debate-how-to-best-manage-a-fit-patient-with-high-risk-localised-and-locally-advanced-prostate-cancer-how-to-select-patients-for-adjuvant-therapy-after-radical-prostatectomy-and-how-to-treat-them.html

You are absolutely right @jeffmarc . Given my adverse pathological and genomic risk factors, and based on what I learned from this site and from reviewing the guidelines, I knew last year that I had the option of adjuvant radiation treatment after recovering from surgery.

My surgeon never brought up this option, but I was aware of it. As I see it, I had several possible strategies:

1. Adjuvant radiation after surgery, without waiting for evidence of recurrence.
2. Very early salvage radiation, triggered by PSA doubling time and/or a very low PSA level, perhaps 0.1 or lower, even if the PSMA PET scan shows nothing.
3. Early salvage radiation when PSA reaches around 0.2, even if the scan still shows nothing.
4. More conventional salvage radiation, waiting until PSA reaches 0.5 or even higher.

I ruled out the first option for several reasons. It could mean unnecessary treatment if I never experience a recurrence, and it could expose me to treatment-related side effects years before treatment is actually needed. If recurrence occurs many years down the road, I may also be able to take advantage of advances in imaging, targeted radiation, and systemic treatments that are more effective and/or have fewer side effects.

I also ruled out adjuvant radiation based on my personal quality-of-life priorities. I am now in the fourth quarter of my life, and my goal is not to maximize longevity at any cost to my quality of life. I want to strike a reasonable balance between longevity and quality of life.

My current thinking is to opt for Option 2: early salvage radiation. But my strategy is dynamic and not set in stone. Based on consultations with my doctors and new developments in treatment standards, imaging, or other technologies, I may choose a different option in the future. For example, if advances in ultrasensitive imaging make it possible to pinpoint the location of recurrent disease with a high degree of accuracy at a PSA of 0.2, but not at 0.1, I might decide to switch to Option 3.

In the coming months, I plan to refine my current BCR monitoring strategy in several ways. If BCR occurs, treatment will most likely be led by a radiation oncologist, so I am considering switching my follow-up care from a surgeon to a radiation oncologist. I would like to discuss the pros and cons of ultrasensitive PSA testing, since my current surgeon uses the standard PSA assay. I also want to establish specific PSA parameters for considering early salvage radiation, including both the absolute PSA level and potentially PSA doubling time.

In the meantime, I am hoping that advances in imaging, targeted radiation, and hormonal treatments will continue to make these options more effective and less burdensome by the time I actually need treatment.

This PSA testing results makes me wonder. I got a standard PSA test 6 weeks and 16 weeks after PR. Both times it was .06. Oncologist told me their machine wouldn't go to anything <.04. They would just watch to see if got up to .1. That makes me wonder, if a person gets a uPSA test would my .06 maybe be a .05 or .04 as the testing machine is more sensitive? After typing that if it's more sensitive, I guess it could go up from .06? Oncologist didn't say it, but sounded like they rarely do uPSA and have to send it off of they do a uPSA. Is that unusual to have to send it off, this is a big hospital and cancer in Topeka KS (Stormont Vail)?
Then one hour later in same building the RO said I need 40 sessions IMRT now, but would wait 8 months for me to get over incontinence. Said if didn't wait 8 months I never would get over incontinence. The reason he said I needed radiation and not wait on PSA levels was I had Seminal Vesicle Invasion left side. But they were removed so I don't see why that was issue. So within 1 hour I got 2 different opinions! Going to KUMC in Kansas City which is one of those excellence centers and talk to that RO who I have seen before and liked for another opinion.
I posted my pathology in another thread and it had a small <3mm margin also. But I still would rather wait and see what PSA does, the Topeka guy said some bad side effects of radiation I didn't like. Sounds like they just blast away and hope they hit something? If I had to have radiation at some time KUMC has several other options I seen like proton and SBRT and some other I don't remember. It's all confusing, which it was just black or white decision.

@soli I guess the PSA velocity is the only way you can make that decision; speed usually indicates BCR.
As for Dr Kwon, I am not a big fan of waiting to see flames coming out of the second story windows before I call the Fire Dept…where there’s even the smell of smoke, there’s fire.
Phil

@jeffmarc Yes. My uro said he checks to make sure there are no other lumps or other concerns. Yes he is old school, but a very personable and good doctor.

@kennethb
Nothing wrong with old school, I wish my old school PCP hadn't retired. He did DRE on my annual wellness visit (actually did a complete physical) - not like current new doctors who have you answer some questions and draw a clock. Might listen to heart.

Totally agree, ,after 7 years now .28 up by .02 in 6 months. Had a PET scan, all clear!,"no cancer in your body that is visible.
I am sick of paying AUS$ 260.00 every few months to a Urologist when the same results come up in my G.P. 1/2 yearly full blood count....
On my government record graph (which everyone with P.C has in Australia) it is a gentle rise and at aged 80 I am not going through all the crap some of my friends have for what seems a result that an ordinary count picks up anyway.She will refer me on when she sees the need.I trust her more than some of these "specialists."

@bobbyjay54321
I know people that have had their prostate cancer come back 20 and 25 years after Treatment. It’s not at all unusual for the PET scan to find nothing. In fact that’s usually what happens with a low PSA..

It took 3 1/2 years before my PSA started rising following a prostatectomy.

If you had surgery as your first treatment, they should be talking to you about having salvage radiation. If you had radiation as your first treatment, then you are not in a position where they need to do anything yet. The standards here in the USA are that you don’t treat somebody with a rising PSA until it hits two points above the lowest it ever hit 2.02 in your case.

Australian may treat it differently, but it is still Something you should treat or should wait to treat.

@jeffmarc Well, yes, I guess that about sums it up.