Rising PSA at 5 months post-RALP

There are two schools of thought in the Oncology world developing for beginning treatment on BCR. One is PSA driven by reaching the established 2.0 PSA considered BCR threshold. The other emerging is the image driven treatment determined by it being seen on the PSMA-PET. This would typically exceed the PSA 2.0 level before being seen. The arguments include better focusing of radiation and results showing no detrimental effects on outcome. Similar to the studies that show awaiting initial treatment beginning up to six months post cancer diagnosis to determine what you are going to do has shown no overall change in outcomes. I think though that you might set your own upper PSA number if something is not showing on the PET that you pull the trigger. Clearly that number is what everyone wants to figure out. Definitely consult and you are in 2nd opinion territory again before deciding your course.

@wheel1

This patient had RP , so his BCR is definitive at PSA 0.2 , not 2.0.

@animate , I am so sorry that you have to deal with this : ((, my husband is in similar situation, his PSA is slowly rising and it is tremendously stressful.

I can totally understand your fear about PSA rising to almost 0.2 and doctors still taking their time to act and do all tests but is it always like that : (((. That is why we did uPSA every single month (on our cost) so we would not be "surprised" *sigh.

Try to insist on things moving faster, call every day to check for cancellations etc.

Wishing you all the best and may RT completely and forever eradicate your cancer 🍀

There are two schools of thought in the Oncology world developing for beginning treatment on BCR. One is PSA driven by reaching the established 2.0 PSA considered BCR threshold. The other emerging is the image driven treatment determined by it being seen on the PSMA-PET. This would typically exceed the PSA 2.0 level before being seen. The arguments include better focusing of radiation and results showing no detrimental effects on outcome. Similar to the studies that show awaiting initial treatment beginning up to six months post cancer diagnosis to determine what you are going to do has shown no overall change in outcomes. I think though that you might set your own upper PSA number if something is not showing on the PET that you pull the trigger. Clearly that number is what everyone wants to figure out. Definitely consult and you are in 2nd opinion territory again before deciding your course.

@wheel1

This patient had RP , so his BCR is definitive at PSA 0.2 , not 2.0.

@animate , I am so sorry that you have to deal with this : ((, my husband is in similar situation, his PSA is slowly rising and it is tremendously stressful.

I can totally understand your fear about PSA rising to almost 0.2 and doctors still taking their time to act and do all tests but is it always like that : (((. That is why we did uPSA every single month (on our cost) so we would not be "surprised" *sigh.

Try to insist on things moving faster, call every day to check for cancellations etc.

Wishing you all the best and may RT completely and forever eradicate your cancer 🍀

After recurrence a PSMA PET scan is definitely called for. The problem is that your PSA being so low it is unlikely anything will be found. I do know one person with a PSA as low as yours, whose doctor was having them get a pet test every three months, Because if something is growing, they can see it. In your case, if There is a significant metastasis it could be seen.

You are correct it’s usually below detection at that PSA level.

The reports you have gotten showing no spread are really not relevant if you actually are having reoccurrence, it could happen anywhere in your body. One thing people don’t realize is that when the cancer starts it sends dormant cells throughout the body to all different organs. At some point they can start to grow and become metastasis. As a result, you could have almost anything in bone or tissue.

I like your doctor being careful about waiting for your PSA to rise more, But the thing is when you have surgery, your PSA should stay undetectable. In your cases, it might come up a little and not be anything, but that is really unusual. As long as you have salvage radiation in time, you would not normally be required to have ADT. It depends on how quick your PSA is rising and whether or not the PSMA PET scan found anything.

Here are the recommendations of the American Society of clinical oncology for what to do when the PSA starts to rise after having a prostatectomy.

From Ascopubs about what PSA to do salvage radiation.

≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

This article discusses the above;
https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/

@jeffmarc

Thank you very much for your detailed response.

I do agree that the PSMA PET will help to rule out any possible spread, although it wold have to be significant enough to be picked up by this study.

I like your comment regarding normally not requiring ADT under my situation, if SRT is started on time. That is what I am hoping for. However, the Oncologist did lay out for me that, even though we are still waiting on the upcoming test results, ADT would be preferably required. I still need to go over this with him but I just need to have strong arguments to present my case for not wanting to have ADT, if this is really of no significant added benefit.

Thank you for the article and for the American Society of Oncology recommendations. At this time I am right at the 0.2 PSA value threshold but who knows what this value will be at the 5 weeks after this last test was taken, when a treatment decision will be finally made.

@animate
When my PSA hit .2 3 1/2 years after my prostatectomy, I was put on a six month Lupron shot and Two months later had salvage radiation. I was a 4+3. The reoccurrence is one reason they like to put you on ADT to prevent further reoccurrences after. I never even noticed there were side effects to the Lupron shot. I went to work every day in my consulting business, and it didn’t slow me down at all. I am, however, one of the people that never had fatigue from any of the drugs. They didn’t know at the time I had BRCA2, That’s the reason it keeps coming back.

My brother was a 4+3 and decided on SBRT radiation. Again they gave him Lupron two months before treatment and then one more three month shot when the first one expired. He was 77 at the time and it was no big deal. His biggest problem was the hot flashes.

Different people have different reactions to ADT, Don’t be too afraid of a six month shot.