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

Posted by bikeman1 @bikeman1, Apr 27 9:14am

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.

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surftohealth88 | @surftohealth88 | May 11 2:39pm
In reply to @bikeman1 "Thanks again for the input. I have decided that I want to get "treatment" as soon..." + (show)
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Thanks again for the input. I have decided that I want to get "treatment" as soon as possible and have asked for a PSMA-PET scan as soon as possible.
I am wondering why Dr. Nagur was so reticent to give his opinion and why, when pushed, he recommended a standard/basic treatment course (Orgovyx for 6 months and an unspecified course of radiation), when I don't have a "standard case" (I have IDC, Cribriform, EPE, GL 7(4+3)). In terms of urgency, he just said get the radiation done during the 6 month window of ADT.
My appointment with Dr. Greco at JH (where I will be treated) is 5/14. Should I push for hormone therapy right away? Or is the sRT the higher priority ? It will take a few weeks to get the results of the Decipher test on the prostate tissue, the ALTERA, and hopefully a PMSA-PET scan. Thanks as always

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@bikeman1
My husband has all those aggressive features plus gleason 9 and he has the same proposed treatment.

Six mos of Orgovyx and 66 gys of radiation to the whole pelvic floor and nodes.

This is a new approach that is based on the newest research done which showed that no significant extension in OS was achieved with longer ADT for initial localized sRT.

For low and intermediate cancer it is now suggested that no ADT should be used. There is definitely new approach to the ADT usage at present moment. (Google POSEIDON study, dr. Amar Kishan , for some reason I can not paste the link here ) .

Addition of ARSI might help but those are still used only in trial setting so ARSI is not available unless PSMA shows possible lymph node invasion. I think that ADT +ARSI + sRT study results will be available this summer.

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dhasper | @dhasper | May 11 3:56pm

I have the same features and am at Mayo getting radiation to the beds and pelvis and am getting 4 months of ADT. Thanks very much for your post it is extremely valuable information. I intend to ask Mayo for additional ADT and also am seeking a second opinion from U of Mich, my home state.

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