Slight rise in PSA 24 years after radical prostatectomy!

I wouldn't panic until if & when it starts to rise significantly (& how fast). Your lab may have just obtained a more sensitive test mechanism.

And if it does rise, I wouldn't panic either.

I have been corrected several times about calling this cancer cured. I was a 3+3 and wanted to get it while it was contained. LARP - Post-Op confirmed containment. That was 6 years ago. Still undetectable. I am 74 now. So if I get another 20years . Thumbs up. You can move the can down the road with this cancer but it sure works on your mind and manhood the rest of your life. Lets hope its nothing.

I'm trying not to go into "panic mode" at this point. No idea what this urologist will say or do. I haven't been to a urologist for 20 years. Always had my PSA checked through my PCP, and it has always stayed undetectable. I live in Macon, Georgia. PCP referred me to two different urologists locally. Both denied the referral.... one said he couldn't see me unless I had the records of my surgery from 23 years ago. The other said I could go back to the doctor who did my surgery. That was on the other side of Atlanta, which I avoid as much as possible at my age. So I called the office of a urologist about an hour from me and they agreed to see me. Crazy that I have two huge groups of urologists here..... 20 minutes away.... yet neither would see me. 🙁 Perhaps they thought it was not serious enough to be concerned about? Mike

Last June, I was diagnosed with a local recurrence (age 72), ten years after a RARP in 2015. Post-surgery pathology showed a Gleason score of 3+4, with one positive margin. My PSA was undetectable (< 0.1) through that ten years, then during my annual urologist visit in 2025, it had risen to 0.11. The kicker though, was that a year earlier a small nodule was detected in my prostate bed. The PSA level of 0.11. combined with the palpable nodule put further evaluation into motion. First was a PSMA PET scan. The nodule lit up like a Christmas tree on the scan, strongly suggesting it was cancerous. That was followed by seeing an oncologist, and then doing a pelvic MRI, which further confirmed that the nodule was cancerous. Fortunately, neither scan detected evidence of distant mets. After seeking opinions from two other oncologists, I underwent 38 sessions of radiation therapy last fall (IMRT). In the three months from initial PSA rise to the start of therapy, my PSA had not changed. Radiation side effects were minimal (mostly fatigue) and my PSA dropped below 0.1 (0.086 on an ultra sensitive PSA test) three months after finishing radiation. Anyway, so far so good.

Radiation therapy has advanced tremendously since your surgery 23 years ago, and even has made big advances in the last few years. The treatments are much more precise and side effects have been reduced.

It does sound like a PSMA PET scan is the next step. These scans don’t always detect lesions at PSA levels below 0.5, but it sure did in my case. But, at 0.2 PSA, you meet the criteria for a possible BCR, so I expect a scan will be recommended.

In terms of cancer aggressiveness (if you do have a relapse), the long time to relapse (23 years) and the unchanged PSA over three months and low Gleason score (6) are strongly in your favor. Dr. Patrick Walsh’s book, “Guide to Surviving Prostate Cancer” has a chapter in which he gives tables with statistical estimates for survivability and development of distant metastases. The tables use Gleason scores, time to first recurrence after surgery, and PSA doubling time. They are definitely worth having a look at.

I was surprised when I was diagnosed with a recurrence at ten years, although with a positive margin and a Prolaris score that gave a 53% chance of BCR at ten years post RARP, I was not completely shocked. We both are statistical outliers, but relapses do occur even after ten and twenty years.

If I was in your position, I would collect all the data I could, and get multiple opinions from oncologists. I would get a PSMA PET scan as soon as possible, then proceed from there. Test PSA again in three months, or just before initiating salvage radiation.

Hoping that your recent PSA readings are just flukes, but even if not, you have much better options than 23 years ago and some breathing room to make some decisions about treatment.

@domiha I dont think you should get too concerned yet...even at worst case, you have gotten it very early on..but my guess is just a mild uptick which could be caused by any number of things...so maintain your cool..what you might do for now is order another PSA in 6 weeks and see what that ones reads, then go from there...

I’ve heard from a few people that have had it reoccurring after 20 or even 30 years. Prostate cancer can go dormant, and it will come back when there is stress on the body. It may take some time before it actually shows up, however.

The fact that your PSA has not moved is a good thing. Normally someone that has had a prostatectomy and has their PSA rise to .2 usually has it continue to rise.

A PSMA PET scan would make sense, but with such a low PSA it may not show anything unless it is pretty large. Since your PSA has not been increasing, that’s unlikely to be true.

I suspect your urologist is going to tell you to wait until your PSA start starts to rise. The fact that it is not rising, is a very significant factor,

At this point, you need to get involved with a radiation oncologist because that would be the next treatment. Of course your urologist might put you on ADT, Which would probably drop your PSA back down to undetectable And give you a few more years before anything needs to be done.

Just so you know, here are the recommendations for what to do when the PSA rises after a prostatectomy. This information is from the American Society of clinical oncology.

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/

Did you always get the same ultra-sensitive psa test? At such low levels there can be substantial noise between different assays.

I also wonder what a urologist could tell you at this point, other than giving you a further referral to an oncologist.

@xahnegrey40 Actually, I should share a bit more. In Nov. 2023, my PSA came back at 0.2 .. at the time of my annual physical. I was in the midst of recovering from two back surgeries and PT, and the PCP didn't say anything and I didn't notice. In Nov. 2024, it was at 0.19. And again I missed it. Then, in Nov. 2025, it was at 0.2 and I noticed it. According to the American Urological Society, two subsequent readings of 0.2 indicates that further inquiry should be made. So the PCP made recommendations to the two local urologists, neither of whom would take me as a patient. In February, I asked them to recheck the PSA to see what the reading was. That one also came back at 0.2. So I now have two "subsequent" readings of 0.2. I called the office of the doctor who did my surgery, and it turns out that they have satellite offices all around Atlanta. The closest to me is 45 miles away, and when I called there I had no problem getting an appointment. It's not the doctor who did my surgery 23 years ago, but the offices are connected. So, my PSA has actually been "hovering" around the 0.2 since 2023. And since it has not rapidly increased over 3 years, I feel a "bit" more reassured. But I know it still needs to be checked, and I'll just have to wait and see what this doctor recommends. I'm going to ask about the PET scan if he doesn't recommend it because I'm the type of patient who wants to "know for sure" if anything is there. Judging by the comments of others here, the side effects of radiation may not be as bad as I had read/heard. I'm sure so much has changed in 20+ years. Best wishes! Mike

@topf Good point. Check to be sure the result wasn’t reported as < 0.2. An ultra sensitive test should really be reported to two places after the decimal.

@topf Yes, the same ultrasensitive test done by LabCorp. And I am also thinking that the urologist may refer me on for a PET scan and depending on the results send me on to an oncologist. Thanks!