Rising PSA years after radical prostatectomy

In 2021 I was all set to have REZUM therapy when my Urologist decided I should have a PSA test. It came back 4.3. That opened Pandora's box regarding "do I have prostate cancer etc?". I was 79 years of age then. This has led to other tests specifically PSA Free which looks at free antigens to determine risk of PC and prostate MRI which detected a 7 mm lesion at Pirads 4 which means "cancer likely". . I have received conflicting recommendations regarding having a biopsy. Today I still have not had REZUM out of concern for its impact on "possible" PC lesion. So needless to say it has been a somewhat stressful couple of confusing years. I guess if my original PSA had come back 3.9 we probably would have gone ahead with the REZUM therapy. I am now re-assessing everything considering my age. I am sitting tight for now and learning as much as I can before moving forward...if at all.

I am 63. I was diagnosed April 2018. My doc prescribed all the treatments. Lupron, RP, chemo, & radiation.
The goal, in the Doc’s words, was to have zero PSA. And, for four years it was non-detectable. (>0.01). Success.
In my Doc’s opinion, you can’t produce PSA without a prostate. So IF, PSA becomes detected the cancer has returned.

Which It did this past December. So, I underwent more radiation. And if that doesn’t work they plan to put me back on hormone therapy (most likely Lupron)

In summary, it makes sense to me that if your prostate has been completely removed you should no longer produce PSA. If you still have a prostate, you’re gonna have PSA. If you don’t have a prostate but there is PSA present in your blood, you have cancer somewhere in your body.

Just to agree,

"3) With ultrasensitive PSA, some research centers believe it to be actionable as low as 0.03. ..."

Post RALP, my salvage radiation was started when I went from .039 to .091 in three months. I was very comfortable with this. There are those that would consider this to be aggressive, i can understand that.

...and PSMA PET was negative at that time. There is a chart on here posted by someone who's done a lot of research indicating the chance of finding something on the scan with such a low PSA is rather low percentage wise. .2-.49 would only have a 30% chance of being a positive result. Given that, not surprising that .091 would be negative (doesn't hurt the brain to hear it though....lol)

This thread started out with a rather simple question: After radical prostatectomy, when do ultrasensitive PSA [uPSA] scores require action. I had this same question before my last appointment.
Background information I think I've correctly understood:
1) Historically, PSA post RALP was not considered actionable until it reached 2 [ng/ml.]. However, this was when PSA was reported as >1, 1,2,etc., so this only meant it was measurable (reached 1) and rising (reached 2).
2) Biochemical recurrence is defined as PSA >0.2 using a typical uPSA.
3) With ultrasensitive PSA, some research centers believe it to be actionable as low as 0.03. (Notice we've now dropped almost two levels of magnitude from 2.)
4) My urologist told me, if I understood correctly, he believes we should act [in my case] when it reaches 1.0. (Since I'm always a bit emotionally aroused in these discussions, could it have been 0.1? I don't think so, but....)
5) There is always someone somewhere who will prescribe more diagnostics or more treatment whatever our scores are.
6) All of us with prostate cancer [PC] diagnoses are prone to some level of anxiety regarding recurrence.
Why? Prying minds want to know, especially PC minds (with no reference to political correctness.)
As I understand it, the tradeoff is between overtreatment, just in time treatment, and too late treatment.
-Unfortunately the goal is never to eradicate the PC. Rather it is to delay its progress in the killing journey.
-Overtreatment is not only expensive, sometimes 100s or 1000s of times as expensive, but it runs the risk of using tools too soon, with some possibility they will not be available or as effective when they should be used. It also lowers quality of life (incontinence, erectile dysfunction, muscle mass, hormones, etc.)
-Just in time treatment is hard to identify because there is always more cancer there than any tool can measure, but every tool at its limits has "maybe" as the answer.
-Too late treatment is only evident when people die earlier than necessary, but even with too late treatment PC typically kills between 10 and 20 years, making good evidence hard to come by. uPSA testing has only been around for maybe 25 years? How long has it been commonly measured? (I think some studies have gone back and re-assayed old samples using uPSA methods.)
Anyway, it turned out my uPSA scores were in 0.01x range and the third was as low as the first, so "my time has not yet come." Still, if the third had been higher than the second, instead of back down to where the first was, I would have worried. AND I will now make a point of testing about the same time of day, although I don't think biking or sex are likely to have much effect in my post-prostate world....
Please, corrections are most welcome!

My info may be outdated, however my understanding is that the PSMA PET scan has a certain level of sensitivity, and will only be able to detect a certain minimum size of met, because the larger the met, the more PSMA so the stronger the signal.

Glennh23: Time for Urologist/Oncolgist consult; agree with gkm and others responding to you.
Your PSA is in the investigate/treatment zone.
Sorry. Best to you, and all.

I assume your Urologist is running your tests and you've been happy with his treatment over the years. If that's the case he should guide you with your next course of action. Good Luck with everything.

Based on the consistency of your PSA scores I personally would not be overly concerned. Unfortunately, the medical profession has instilled an “overreaction” attitude if your PSA goes up slightly or even a little more than that. Monitor your situation consistently, (at least on a quarterly basis) and do whatever you need to do to be prudent in addressing whatever needs to be adequately addressed. I’ve observed far too many men getting far too excited, worried and agitated over PSA changes that don’t about to anything to be concerned about. They spend more time upset and worrying than appreciating every day they have in life in remission! Prostate Cancer is a very slow growing and progressive cancer for the vast majority of patients. If you are responsibly monitoring yourself on a consistent basis you should be well in front of the curve regarding the discovery of anything that really requires your immediate attention or the consideration of treatment options if required. Once you have Cancer it becomes a “Lifetime Affair!” You May be FREE of cancer but you are never FREE from cancer.
There are absolutely NO guarantees about it and you are hopefully grateful for everyday you’re in remission. If at some point in the future you’re not in remission then you address it like every other patient I know who has done to get back into remission again. We can only do the best we can do at any given time. That’s it! We get the very best results and outcome we can get and that’s what we get! Cancer is by default, really crappy stuff! MIT’s not a club that anybody wants to be a member of. However, once you become a member, and usually reluctant so………you do the best you can, PERIOD. GOD SPEED

It would appear that you have had recurrence like 30%-40% of men who have a RP. You should see your urologist or oncologist ASAP as it appears that the cancer has returned and you need to take action.

ditto to PSnowden...we are the first person responsible for our health. React to your PSA and form your own web of info. Survivors, Treatment web sites...their reviews, referances, Walsh's book, and understand the treatment options & talk to potential treatment providers. My approach to the latter is the 'front office'...in my opinion if your calls are met with a lack of interest and/or poor answers to your questions...RED FLAG...if the providers cannot build/staff a "front office" operation it may signal poor quality into the treatment group.
And by web site...get beyond the gloss, look at Creds for the docs, etc.
edk