Rising PSA years after radical prostatectomy

I sincerely thank all who have responded to my post. I read each reply carefully and learn from each. I particularly want to thank @perrychristopher for reminding me of the Prostate Cancer Foundation and their webinars. I urge you to get a copy of the Prostate Cancer Patient Guide (www.pcf.org). It is full of useful information. The webinar suggested there (Jan 17, 2023) addresses a most crucial issue: if and when to address a rising PSA after RP. From the many posts I have read over the past two years, I haven't seen much attention given to the side effects from salvage radiation. The natural reaction to getting a cancer diagnosis is to quickly and totally eliminate the cancer but in certain milder cases it might be better to just live with it. Of course, it depends on age, health, doubling time, aggressiveness etc. I don't know how my case will progress, the Decipher results and the next PSA will tell a lot. When those results are in, I'll consult with my urologist, medical oncologist and radiation oncologist and decide a “best course” of treatment.
Also, thanks to @spino for pointing out the work by Dr. Sartor at ESMO 2023. It appears that we are in similar “boats” and you have thought about it a bit.
I truly wish the best of outcomes for all in the prostate cancer community.

I just saw this discussion from a current medical conference (ESMO 2023), which relates directly to this thread:

A couple notes:
1) PSA failure is defined as >.1 or 3 consecutive rises. This thread starts with two consecutive rises and PSA just below 0.1 (after RP=radical prostatectomy, the question would be different after initial treatment with radiation.)
2) There was increased toxicity, but no significant advantage found in giving radiation sooner, specifically for people like myself and @jackiepie who have "intermediate unfavorable outcomes."

"Dr. Sartor: At ESMO 2023, an important long-term follow-up was presented with the RADICALS-RT study. This examined the optimal timing of radiotherapy after radical prostatectomy. It has been common in years past to give adjuvant therapy for patients who had poor-risk disease at the time of radical prostatectomy; things like positive margins, pathologic T3/T4, Gleason 7 to 10 disease.

"In this study, patients were randomized to receive adjuvant radiation or radiation at the time of PSA failure. Now, PSA failure was defined by a PSA of greater than 0.1 ng per mL, or three consecutive rises.

"This was a large study, 1396 patients. The primary endpoint was metastasis-free survival, which, as you probably know, has been linked to overall survival in a variety of studies.

"No advantage gained with adjuvant radiation

"What did they find? They found that there was no advantage to giving adjuvant radiation. The overall survival at 10 years was 88% versus 87%. And the freedom from metastatic disease at 10 years was 93% versus 90% — no difference. And I'm simply going to say that waiting until PSA relapse is perfectly appropriate for patients after radical prostatectomy; that you do not have to use adjuvant therapy.

"Adjuvant radiation led to greater toxicity

"By the way, and I didn't mention this, urinary incontinence and fecal incontinence were worse with adjuvant radiation therapy. So, the patients not only did the same, they actually had more toxicity.

"This is the largest study ever conducted with adjuvant radiotherapy and prostate cancer. And these results show no evidence of a meaningful benefit for adjuvant as compared to salvage therapy. And in my opinion, salvage radiotherapy, not adjuvant, should be the standard of care."

@jackiepie I'm about a year and a half behind you--meaning my PSA hasn't started rising yet. For that reason, I'm very interested in what you will discover in your journey. It looks like you switched PSA tests starting in 4/5/22 because all your results are lower than 0.1, but those from then on have values given. The same thing happened to me, but closer to the surgery. Starting out about six months I switched to an ultrasensitive PSA assay from labcorp, which drops out at .006 (my actual results since: 0.012 ng/mL, 0.016 ng/mL, 0.012 ng/mL, now 0.006 ng/mL). If you're using a similar uPSA, your results are maybe 5x higher.
However, the level of fluctuation you show is similar. One of the things clinicians and researchers may look at is doubling rate, but you have not yet had a doubling (first double would be .05x2=.10, but you have always been below .10).
So, trying to understand my numbers, I found some results, perhaps on this forum?, showing that even after RP prostate numbers fluctuate, and perhaps more so when they are very, very low--may have to do with factors that do not relate to prostate cancer.
So, like you, I am very aware the cancer is both elusive and persistent, so that day will come. Yet I also wonder if your cancer is not yet in need of treatment, and this is a good time to enjoy life in your time under the sun as a good gift :-).
Still, a sword of damocles hanging over my head does not immediately induce carefree thoughts :-). All the best, and I hope you will follow up when the decision to treat is made.

Going for my first bloodwork since my PC surgery to remove the little bastard on Aug. 3rd and Doc said he feels good no move up from hopefully 0. If it is even .1.2.3, I will have a PMSA Pet Scan and look for spots of cancer. If any are found where the prostate was, I get foul Lupron for a year to a year in a half. If a spot or spots is found outside where the prostate was, then I get Targeted Beam Radiation as the PMSA PS would mark where to blast and poison the nasty little spots. I hope it is 0. i had a 7 Gleason Score but Bone Scan and CT said no cancer outise at all.
God Bless you all.

Download a January 17 2023 webinar from the Prostate Cancer Foundation titled Rising PSA. It's helpful and gives some numbers when the Urologists and Oncologists want to tale action. Your numbers so far look pretty good. Hopefully your Jan 24 result will be lower.

In re: Rising PSA

Had proton radiation therapy in 2010. Gleason 3 plus 3; PSA 6.1 For about 6 years not PSA indicators. then began rising slowly to now 3.21. No adverse affects from proton radiation (Loma Linda Hospital). What to surmise: Has the cancer returned or just normal PSA rise due to bodies return to "normal"?

Don't know for certain, but watching..so far in the last year PSA has risen just .7 (or 2.51 to 3.21 approx.).
Suggest from reading others...whatever is non-intrusive and healthy..scans and such might be the first step. I intend to have a scan should the PSA rise over 4.0. Cheers! RH/Florida

https://www.pylarify.com/patient/about
This contrast medium was launched May 2021.
Then you might check out Proton Radiation.
wishing you luck

I am 75 and in good health. I had a robotic-assisted radical prostatectomy in 09/2020. I had right and left apex and left inferior positive inferior margins however no adjuvant radiation treatment. Gleason score was 3+4; pT2, pNO. The PSA results were: 12/28/2020 < 0.1, 04/06/21< 0.1, 10/08/2021< 0.1, 04/05/22 .05, 10/.07/22 .05, 03/30/2023 .06, 10/02/2023 .08. The PSA is slowly rising. My Dr. is getting Decipher test done so as to help guide what treatment might be needed in the future. My next PSA test will be 1/02/24.
Is there anything I should be doing between now and then? If the PSA continues to increase, when should I consider salvage radiation? If we get to that point, what kind of external beam radiation therapy (EBRT) should I choose? I understand that the various forms of EBRT are: 3D conformal radiotherapy, intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT) and stereotactic body radiation therapy (SBRT). I put these questions to this forum because over the last two years I have been reading the posts here and I have learned so much from them. Any advice would be welcome.

A PSA of 1 after surgery is high. Your PSMA-PET scan showed the location of the cancer. The cancer is not going to disappear. I would suggest you should start salvage radiation sooner rather than later.

It really depends on what your comfortable with.

I'm more comfortable being a little aggressive. Your PSA doubled in 3 months, that's a little concerning in my book. (assuming it's the same test from the same lab).

+ the PET is telling you you still have active cells in the lymph node (assuming I understand that result)

My PSA went from 0.039 to 0.091 in three months and my PET was negative, my surgeon referred me to the Radiation Oncologist and I got started with him within about 5 weeks, and prescribed Orgovyx (ADT med)

I know it sucks, I was there too, but, if it was me, in that situation, I'd get started with the next step. Whatever you and your team decide that to be.

Best of Luck going forward!
Mike