Summary of Mayo Consult (PSA Recurrence, PSMA-Negative)

Summary of Mayo Consult (PSA Recurrence, PSMA-Negative)

I had my consult at Mayo following a rising PSA (now 0.24) after prostatectomy. My PSMA scan was essentially negative, with one very small indeterminate pelvic node that their team ultimately felt was unlikely to represent cancer.

Because of the negative imaging, I was offered participation in a clinical trial comparing immediate salvage treatment vs PSMA-guided observation. The observation arm involves close PSA monitoring and repeat imaging, with treatment triggered if/when disease becomes more clearly detectable.

The rationale they explained is that older studies supporting early salvage radiation were done before PSMA imaging, and may have included patients with more advanced disease than we can detect today. The trial is designed to see whether some patients can safely delay or avoid treatment without compromising outcomes.

We had a very balanced discussion of risks:

Immediate treatment (standard approach): reduces risk of progression/metastasis but carries known side effects from radiation and short-term ADT.
Observation (trial approach): may avoid or delay treatment and its side effects, but carries uncertainty about timing and potential disease progression.

They were clear that both approaches are reasonable, and the decision comes down to individual risk tolerance.

My decision:
I chose to proceed with standard treatment — radiation to the prostate bed and pelvic lymph nodes with ~4 months of ADT. My reasoning was that, given my pathology (cribriform/IDC features, LVI, early recurrence), I am more likely to need treatment eventually, and I prefer to treat early rather than accept the uncertainty of delaying.

The trial made sense to me and I think it will be important in answering a real question in the field — it just wasn’t the risk profile I wanted for myself.