Post RT 6 years after RP with Rising PSA now at .28.

@lifutang
As you probably heard everybody is different. Your results sound great, but you don’t give us any idea what your initial biopsy showed. Your PSA wasn’t too high so it sounds like your cancer wasn’t too aggressive.

What was your Gleason score?

Did you have anything found in your biopsy like cribriform, Seminal vesicle invasion (SVI). ECE, EPE or intraductal? All of those can make your cancer more aggressive and can increase the chance of it reoccurring.

@jeffmarc

You ask...". I feel something needs to be done now or am I jumping the gun?"

There is not necessarily a "right" answer the forum can give you.

In part, clinical data can guide discussions with your medical team, PSADT, PSAV, GS, GG, pathology report. I think the further you get in this journey the less the latter "matter."

You don't say if you have had imaging to locate the site (s) of "activity." Results can certainly inform discussions with your medical team. At the PSA you describe PSMA imaging has statistically a roughly 2/3 chance of locating activity.

So, if not, discuss with your medical team.

I have criteria in conjunction with my medical team about clinical data that constitutes a decision to image.

MY criteria;

Three or more PSA tests spaced three months apart showing increases.

AND

PSA between .5-1.0

At that point we image and then discuss treatment choices.

You will have choices:

Do nothing until PSA reaches a level you and your medical team agree upon.

There are clinical trials that indicate with Oligometastatic disease MDT can push back the need for systemic therapy. There are others which point to combining short term systemic therapy with MDT to manage recurrence - https://www.urotoday.com/conference-highlights/astro-2025/astro-2025-prostate-cancer/163508-astro-2025-intermittent-adt-comprehensive-stereotactic-body-radiotherapy-for-hormone-sensitive-oligometastatic-prostate-cancer-crop-mature-results-of-a-prospective-trial.html?utm_source=newsletter_14672&utm_medium=email&utm_campaign=astro-2025-advancing-prostate-cancer-care-from-reducing-toxicities-to-milestones-in-metastatic-disease

You could skip imaging and just gp on systemic therapy. Your clinical data says there is activity. This is the "throw away" course of action for me, I want to know where it is and see what my radiologist can do. I do keep in mind that imaging won't show all activity, aka micro metastatic disease so short term systemic therapy is always in play for me.

At what level do you and your medical team decide to "act!?"

Again, follow the clinical data and discuss with your medical team. Were this BCR for the first time after surgery likely you "missed" the window to act...it's not...

Again, discuss with your medical team, what do they say? I have seen some say anywhere from 2-10!

Me, I am high risk, so somewhere between .5-1.0 is time to do something

Kevin

It's good to be proactive but the "doing something" is limited. I'm told that if the source of the rising PSA is still the site where the prostate was, further surgery nor radiation is not normally an option. Usually the next step is androgen deprivation therapy. And I'm told this has a good success rate. I'm also in this position but not quite there yet. My Gleason was also 7. I wasn't told that I had a positive margin until 2 years post RP when I had SRT. My last two levels were .2 six mos ago and .14 last week. My urologist and my radiologist do not have an explanation. The possibilities so far are that surviving healthy prostate tissue, which does regenerate is causing this. Or it could be surviving cancer cells at the treatment site (My radiologist doesn't believe this to be possible). Or there has been a metastasis. I'm being told that when the level is consistently above .2 it should be possible to see what is causing the PSA to rise with a PET scan.

@zhit
My PSA was undetectable after SRT, Not everyone has it happen immediately.

The cells get damaged by the radiation and can die over time, Sometimes people wait three years before their PSA hits the minimum after radiation.

The fact that your PSA has continued to go down is a good sign. It could mean that the cells that got radiated are dying off, But in your case, they are taking a little longer than expected by the doctors.

@jeffmarc I'd better explain in more detail. Had RP in 2015. 6mos later PSA was < .015. PSA gradually increased to .034 by 2017 at which time I had SRT. 3 mos later PSA had only dropped to .019. Since then it has increased steadily to .2 this March and .014 this last week. My urologist likes to mention that the increases are small and I'll die from something else.

@zhit
This is a little confusing

“PSA increased steadily to .2 this March and .014 this last week” .014 is a lot less than .2 and you say that was what you had last week which means your PSA dropped. That’s really considered undetectable.

Was there a typo somewhere in this information? If you want to correct it, I can comment more.

Normally, when somebody’s PSA starts rising after having salvage radiation, they are put on ADT. That will drop the PSA back down unless the person becomes castrate resistant.

Not quite sure what is going on.

@jeffmarc Yes typo. .14 is correct. So far since there are no immediate issues, we will wait until a scan can determine where the PSA is coming from. Then, if it is a remote site it can be treated with either surgery or radiation or both.

It's good to be proactive but the "doing something" is limited. I'm told that if the source of the rising PSA is still the site where the prostate was, further surgery nor radiation is not normally an option. Usually the next step is androgen deprivation therapy. And I'm told this has a good success rate. I'm also in this position but not quite there yet. My Gleason was also 7. I wasn't told that I had a positive margin until 2 years post RP when I had SRT. My last two levels were .2 six mos ago and .14 last week. My urologist and my radiologist do not have an explanation. The possibilities so far are that surviving healthy prostate tissue, which does regenerate is causing this. Or it could be surviving cancer cells at the treatment site (My radiologist doesn't believe this to be possible). Or there has been a metastasis. I'm being told that when the level is consistently above .2 it should be possible to see what is causing the PSA to rise with a PET scan.