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

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.

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

@clevelandguy
Excellent question

I'd consider getting both the MPmri and psma scans to have a more thorough review.

Why Both Are Recommended (The Combination):

• Complementary Strengths: mpMRI is superior at showing the exact anatomical location, size, and T-stage of a tumor, whereas PSMA-PET (a metabolic scan) can better detect smaller, subtle cancerous spots that might look normal on an MRI.

• Reduced False Negatives: Combining the two can achieve up to 97% sensitivity in detecting prostate cancer, reducing the number of missed diagnoses that occur if using only one method.

• Better Targeting: Using both allows for more precise targeted biopsies and reduces the need for unnecessary, random biopsies.

• Improved Staging: PSMA PET is highly effective at identifying if the cancer has spread (metastases), while mpMRI excels at characterizing the tumor within the prostate.

The scans are quick and provide a great targeting map. Otherwise they're kind of shooting in the dark. I too had no margins, no vesicles, no EPE, etc.

But I did have +PNI which means mine probably slipped out the prostate via that rout. So I've been under treatment for 8 years with what's characterized as indolent lymphotropic oligometastatic prostate disease, and have had five PSMA PET scans helping to keep it that way.

I'm sure your Doc will have a game plan already developing in his or head based on the hundreds of guys they've treated with exactly your condition.

They caught it early and in era of detection and treatment which way eclipse those of even ten years ago.

So that augurs very well for you.

I know the cribriform and ultraductal are some of the bad actors. But they're only so if they're still active to be so. The value of the PSMA PET scan is its ability to detect these lesions at relatively low PSA so they can be eliminated.

Additionally, ADT (with all of its side effects) doesn't have to be a constant companion here.

On this score suggest you see this information on a clinical trial in which I'm enrolled NCT05588128.

"ASCO 2025: Prospective Monitoring of PSMA–positive Biochemically Recurrent Prostate Cancer: Preliminary Data from 6-Month PSMA Follow-Up" It's still recruiting.

A major value in what you gained with the prostatectomy is you have the best picture of where things stand. They've actually eyeballed the disease and its extent and whether it escaped the prostate in major way. Yes. It's not all great news. But at least now you know and can take appropriate actions.

I'm reminded of an adage that was drilled into my head as an infantry lieutenant training for Vietnam:
"Lieutenant-Always bring the Old Man bad news first. Good news takes care of it self."

Ironically Nam is probably where I got my dose thru Agent Orange (On permanent VA disability) On that score - maybe we shouldn't have been in that war. But once there - if they hadn't used Agent Orange there'd be a lot more names on the Wall. Including probably mine. So no tears here.

In any case you have a lot good news, eg, negative margins, no EPE, no seminal vesicle invasion and though not said probably N0 M0, only +PNI.

You'll get good news too from the scans in that they'll tell you EXACTLY where you stand and what your team can do about it

And my bet ---

it'll be local regional oligometastatic lymphtropic disease which you've caught early and it can be targeted, whacked, and if not totally eliminated, at least treated without lifelong ADT, as mine has been for over 8 years

GOOD LUCK!!

Everyone's cancer journey is unique. Do your research. Get input from survivors and experts.
My cancer journey started in 1969 when I was exposed to Agent Orange in Vietnam. It appeared in 2016 as a small lump on an otherwise normal prostate. My PSA was 2.3. Gleason score was two 6s and one 7. Experts said it was stage 1. Upon removal four months later Gleason scores were all 10s and I was terminal, stage 4 with 1.5 to 5 years to live. Each treatment brought my PSA down this >0.05. I'm still alive. The first treatment after removal was radiation which worked for 16 months before the PSA moved up. Radiation was the only negative in all the treatments I had. I'm now dealing with Radiation Cystitis. Another large challenge.
Do your research an make informed decisions. Accept the results.

@29modela
Semper fi, me too 1968 -1969 DaNang area for 3 months, An Hoa Valley, Marble Mountain, then through the pass North toward the DMZ , passing what was left of Hue, which was one of the most beautiful cities in Vietnam for something like a thousand years, now nothing but dust and rubble.

I think the agent Orange got me too but mostly near the DMZ very heavy vegetation until the spraying of Agent Orange particularly near LZ STUD and Khe Sanh during the major battle 6 month battle 1968 with 3 NVA divisions of over 20 to 40 thousand troops against a handful of Marines about 5,000.

Prostate cancer is just another challenge when you put in it prospective of war.

@clevelandguy wrote: "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? "

Salvage radiotherapy in the absence of a PSMA avid target is incredibly common and will typically involve radiation to the prostate bed and the optional addition of the pelvic lymph nodes.

The majority of post-RALP BCR starts with regional spread in the prostate bed and PLNs, hence the validity of this approach. Of course there's no guarantee that there could also be distant spread that's missed, but that's always going to be the case since PSMA PET has a detection threshold, and some PCa is not PSMA avid.

@notpetecrowarmstrong
Makes sense, I guess. Still kinda get a weird feeling that your just irradiating an area but not sure the cancer is present. Some people have said wait till something shows in a scan the hit that area. Two different approaches I guess. Don’t know which one I would choose.

Dave 3+4

@clevelandguy

I think that "some people are saying" is not relevant until it is scientifically proven to be a better approach. For now it is not, not even close.

For the time being multiple studies showed benefit of doing RT in pelvic region upon PSA rise even if PSMA does not show anything since there is 35 % chance that cancer is there and in the other 35% of cases it is at least partially there. For that 35% where it is definitely there RT could possible be CURATIVE , not just "controlling" it .

If scientist found a medication that works in 35% of cases as a cure - they would be ecstatic and that institution would get a major recognition for that discovery.

So, bottom line, sRT is done in hope of the cure and there is about 35% of chance of that happening if cancer is caught in time. If one waits till something shows up cancer could possibly send multiple mets all over the body in that "waiting period".

@surftohealth88
Hmm, interesting. So based on what you are saying there is a 65% chance of not curing the cancer if you radiate an area with no detectable cancer, just a rise in PSA. Don’t like those odds very well.