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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.
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With the aggressive issues, you have getting salvage radiation and going on ADT sound very reasonable. The question is, is four months of ADT enough. NCCN almost never recommends less than six months.
Was your Gleeson score 3+4 or 4+3? I know if higher, they would usually recommend at least 12 months of ADT.
There is a real issue with the combination of cribriform and intraductal. There doesn’t seem to be any treatment that handles both of them with complete success. They almost always end up with BCR, Which is where you are now. If you had Small cribriform Then it’s a lot more successfully treated than large cribriform. Did you find out from the doctors after biopsy which you had?
Sounds like you’re going to the right place, Hopefully things work out well for you.
@jeffmarc I did wonder about the length of ADT and I reserved that as an issue for another day.. I will check on my cribiform size. Thanks for your comments.
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1 Reaction@dhasper Jeff...4 plus 3
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1 ReactionThank you for sharing
I would make the same choice - just too many unknowns for my comfort. 😬
Regarding ADT, it seems that the new approach is to use the least possible amount necessary. When we had adjuvant RT conversations in September 2025 , 4 mos was suggested. Now that we are possibly facing early salvage proposed ADT is 6 mos if nothing is seen on the PSMA. If they find something out of prostate bed than possibly 1 year to 18 mos could be necessary.
BTW: https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/
So you are starting your treatment just on time 👍🍀 ! Wishing you the best of luck !!! Keep us posted : ))) and thanks for the update.
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1 ReactionThoughts:
> PSMA PET scan results will typically show little while on ADT. The lower the PSA, PSMA PET will be “essentially negative.”
Did this topic come up?
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1 Reaction@brianjarvis ❝PSMA PET scan results will typically show little while on ADT. The lower the PSA, PSMA PET will be “essentially negative.”❞
Yes, that's part of why I'm not getting PSMA-PET right now for routine monitoring. With my PSA undetectable (< 0.01) on ADT+Apalutamide for 4.5 years, it might not show much. Instead, I get a combo of bone scans, CT+contrast, and MRI+contrast, all of which could show growths regardless of whether they express PSA (and even, god forbid, if they're a different type of cancer developing), even though the resolution is a little coarser.
(The other reason is that PSMA-PET is used much more sparingly outside the U.S., since there's little evidence yet that it improves overall survival or progression-free survival, despite its finer resolution. I could ask for one if I had biochemical recurrence — my PSA started rising again — but it's not a routine thing.)
@northoftheborder Another possible option —> If a PSMA PET scan is negative or equivocal, Axumin (18F-fluciclovine) is an imaging option. When prostate cancers lack PSMA expression, Axumin may detect tumors that PSMA misses.
I attended a webinar last year that was out of Australia. The speaker mentioned that Axumin is commonly used in these situations. (And I’ve read that Mayo Clinic uses C11 Choline PET CT in these instances.)