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Low, But Rising PSA--Wait for Imaging or Act Now?
I watched the entire PCRI conference on 4/25 (https://pcri.org), with two well-known experts: Dr. Epstein (Pathology) and Dr. Kwon (Relapse). Both were very relevant to my situation: 72 years old; RALP on 9/22/25; PSA on 12/30: < .01 (standard); PSA on 4/15: 0.171 (ultra sensitive) (next test on 5/4 to determine trend). My "bad news" and "good news" data are below. I have appointments at Johns Hopkins and MSK in NYC to get their recommendations on next steps.
Dr. Epstein emphasized the greater likelihood of BCR and worse outcomes if Cribriform is present, as this group had discussed before. But he emphasized Intraductal Carcinoma (IDC) as even more important (and flat out said a patient should get a BRAC2 test if he has IDC, which I am scheduling).
Dr. Kwon made a strong case for waiting for imaging results before moving ahead with salvage RT and/or hormone therapy. He argued that in relapse cases prostate cancer frequently does not start in the prostate/pelvic area and spread from there but it can be anywhere in your body and shooting radiation “blind” to the pelvic area carries significant risks. He also cited 3 studies showing better outcomes by waiting for imaging results before proceeding (at 3:54:10). Subsequent Q and A near the end with Dr. Scholz emphasized the value of MR imaging in these situations and how under-utilized it is.
I have emailed Dr Kwon to ask if his general approach still applies to someone like me with a lot of high risk factors (see below), but haven't heard back yet. As this group has discussed, studies show better outcomes in high risk cases by starting treatment with lower PSAs (and thus not waiting for cancer growth large enough to be seen on imaging). I looked at 2 of the 3 studies and didnt see discussion of this issue. I will let you know if I get a response.
"Bad News":
GL 7 (4+3)
IDC
Cribriform
EPE
.89 Decipher score
"Good News":
Clean margins, lymph nodes, seminal vesicles during surgery
Clean CPMSA PET scan on 8/25/25 (pre-surgery)
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@surftohealth88 Yes, exactly - and those unfortunate souls who do not respond favorably to SRT are those who have to go on to more rigorous protocols: second line ADT drugs, docetaxel, Pluvicto, etc…
So yeah, let’s not wait for that to happen IF there’s a chance we can avoid it; and the only way to do that is to undergo SRT and see what happens. Best,
Phil
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4 ReactionsI’m likely one of the least informed people on this site, so I’ll withhold opinions and tell you that my doctor did. He didn’t prescribe treatment for rising PSA after prostatectomy and salvage radiation for Gleason 9 until PSA rose to .5 which for a PSMA scan to detect hot spots at a rate of 40-60%
@edinmaryland I had the RP August of 2025, after the surgery my Urologist sent me to an RO for a follow up if there was a need for salvage radiation. What he told me is if my PSA got to .1 we would be making plans to treat with radiation. If my PSA went to .2 we would begin treatment. The reason for using PSA as a baseline for treatment was that a PetScan would not see it till it was far beyond when treatment started. Just mine and my doctor’s 2 cents here.
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3 Reactions@lsk1000 Did hot spots show?
Also my PSA has been less than .005 every blood test after the surgery. Undetectable
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1 Reaction@lsk1000
Thanks for adding your experience. Just curious: Did you have IDC, Cribriform and/or EPE along with your Gleason 9?
@bikeman1 Honestly, I don’t know. Something I’ll have to take up with my doc.
@dhasper Yes, limited near the bladder. On Orgovyx and Nubeqa.
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2 ReactionsThis podcast is a discussion about a new PET scan agent that is on FDA's fast track for approval. it promises a dramatic improvement in the ability of PET scans to detect smaller lesions. The current clinical trials appear to be fully subscribed, so you can't sign up to have this. The discussion puts into perspective the limitations of the current PET scans in situations such as yours. https://podcasts.apple.com/in/podcast/is-copper-the-new-gold-co-psma-trial-in-european-urology/id1504841665
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3 Reactions@bikeman1
Just wanted to point to the fact that lsk1000 had RP, than salvage, and when it failed THAN he waited to 0.5 to see where is the met. located. That is different scenario all together than having initial salvage radiation.
Also, it is strange and unfortunate that salvage failed if he had radiation to the whole pelvic floor which would include area around the bladder : ((((.
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3 Reactions