Post prostatectomy: What do rising PSA levels mean?

Hello Colleen. I had my prostate removed September of 2019. Robotically! Awesome process! PSA level before surgery was 7.50. 3 months after surgery 2.50. Finished radiation treatments May 14th 2021. One month after radiation PSA is 3.28. Do we think this just to soon to check my numbers or should I be concerned?

Can i ask about my prostate issues or lack of a prostate issue?

@kujhawk1978 Thanks,

Dave – biological chemical recurrence – it's when your PSA rises after surgery or radiation but there is no clinical evidence of metastases as demonstrated by imaging.

His doctor is "not wrong…" .3 is a low PSA, the challenge is if and when to treat. That requires data, multiple PSA tests over time to show a continuous upward trend, determine doubling and velocity times and enable imaging to locate recurrence…The contra to that is as PSA rises, it is more difficult to achieve a "cure" in say, SRT There is also a theory that says metastases are responsible for seeding new metastases that while initially no bone or organ involvement, the new metastases may now spread into the organs or bones, marking a new and more dangerous phase of the cancer. So, some say strike early and hard, reduce or limit the additional spread of metastases. Others say that is a false theory since some studies say it can take up to 8 years to see metastases thus just because you treated early doesn't mean you changed the course of the cancer. That's why clinical data is important, both past and present. In my case, GS 8, only 18 months to BCR and rapid doubling and velocity times were indicative of aggressive cancer and so we acted and treated aggressively. Those with less aggressive cancer as supported by clinical data may want to actively monitor and have decision points to implement treatment. If your husband's doubling and velocity time were 12 months or greater, hey, may not be any reason to treat. If they are three months or less, well, may be time to act. It's a heterogenous cancer, not homogeneous, inform yourself, obtain clinical data – PSA, Alk Phosphate, Imaging, symptoms, then make a shared decision with your medical team based on age, health, quality and quantity of life preferences.

@kujhawk1978 Kevin, I found your response interesting, thanks for posting. One question, what does BCR stand for?
Thanks, Dave

@kujhawk1978,@dandl48, @colleenyoung, Thank you. Reading through your comments made feel better. I am waiting and praying for the best for everyone who is on the same situation. @dandl48, Good Luck next September! kujhawk1978 Tanks for the video. It was really informative. I learned a lot. I did call my husband's doctor, he still think that .3 is slightly increment and kept saying not to worry too much. Thanks again.

Another informative video https://www.urotoday.com/video-lectures/pet-psma-imaging-in-prostate-cancer/video/mediaitem/1987-diagnostic-molecular-imaging-for-prostate-cancer-in-the-united-states-a-focus-on-lesion-localization-and-distribution-using-18f-dcfpyl-pet-ct-at-biochemical-recurrence-lecture-discussion-andrei-h-iagaru.html

Here’s an informative videos that may help in your decision making.
https://www.urotoday.com/video-lectures/pet-psma-imaging-in-prostate-cancer/video/mediaitem/1978-the-biology-of-the-prostate-cancer-metastasis-and-what-psma-imaging-is-teaching-us-presentation-and-discussion-kenneth-j-pienta.html

Assuming your placement of the decimal point is correct and his PSA is ..3, up from .01, then it's time to throw the BS penalty flag on his doctor. After surgery, BCR is commonly defined as two consecutive increases in PSA, generally 90 days apart. Of course, with the introduction of the USPSA, there is uncertainty since the conventional PSA used for so long had undetectable at <.1 so then anything .1 to .019 was reported at .2 and thus "detectable."

So, a .3 is considered "detectable," especially if his previous reading was .01. You don't say the timeline for his PSA testing but I'm assuming in the first year after his surgery it was every three months then in the 2nd year every six months.

As to the doctor saying " we'd have to wait six months…" again, BS, it's your call, he can recommend and explain why he wants to wait six months but it is your decision, he simply has to write the lab order.

So, a rise from .01 to .3 may indicate BCR. You are within your rights to ask for a PSA sooner, (it's called shared decision making between you and your medical team) could be 30 days, could be 90 days. If the next test shows a rise to .4 or higher, you've confirmed BCR. If it goes back down or stays the same, ok. I have had mine go from .07 to .16 to .29 (I test every 90 days) then back down and stay there.

If the next PSA shows a continued rise, consider imaging. There are three approved by the FDA, C11 Choline, Aximun and PMSA Gallium (the latter at only two location in California, though FDA approval is expected soon for other locations currently in clinical trial status). The challenge will be at PSA <.5 even the most sensitive imagining will locate the site of the recurrence 30% of the time. It jumps to 60% when PSA climbs to .5 to .99 and 80% at 1.0 to 3.9. A 2mm tumor has 8 million cells, a 3 mm tumor 27 million cells, PMSA can detect those, a one millimeter tumor has one million cells, PMSA generally cannot detect that.

If you decide on treatment based on the clinical data – his pathology report, PSADT and PSAV, time to recurrence, then consider that more and more data sows the recurrence is not limited to the prostate bed but often includes the pelvic lymph nodes. So, imaging may inform your treatment decision. Consider systemic therapy which would combine some form of ADT for a limited duration, six, 12 or 18 months with radiation to the prostate bed and pelvic lymph node fields.

No reason to hit the panic button, if there is BCR, the options for treatment are many but it means you need to inform yourselves through research, there are many valuable website resources, https://www.pcf.org/guide/prostate-cancer-patient-guide/ is one, the NCCN is another https://www.nccn.org/patients/guidelines/content/PDF/prostate-advanced-patient.pdf.Many advances in the treatment of advanced PCA have been made in the last 5+ years since I was diagnosed in 2014 and many more are in the pipeline through clinical trials. It may be that we are entering a period where we live with this cancer rather than die from it for many.

Kevin