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

Posted by bikeman1 @bikeman1, 4 days ago

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)

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

bikeman1 | @bikeman1 | 5 hours ago

Surftohealth 88 and Wheel1 are making me think I have been focusing on the wrong thing with the studies Dr. Kwon put up showing benefit to waiting (see attached; sorry for the poor quality; see 3:55:43 of the PCRI YouTube video cited at the top). I have been trying to find out if these studies included people like me with high risk factors. Perhaps I should have been focusing on the quality of the studies themselves, and whether they were true randomized studies or other indicators of their quality. I guess I just assumed they were "the gold standard" if Dr. Kwon was citing them.
In any event, I think this decision will be made for me when my next PSA test is taken on Monday. I think/fear it will show a very tight doubling time, which
should make the decision for action much easier.

clevelandguy | @clevelandguy | 4 hours ago

Bikeman, it looks like your PSA is indicating that your cancer is growing but you don’t know where. Sometimes it can come back in the Prostate bed area, or hips, or neck, ect. How would you propose they treat it now? Overall body radiation? Chemo? ADT will suppress your PSA number to a certain extent and weaken your cancer but how do you aggressively attack the cancer if you don’t know where to attack?

Dave 3+4