What would you do if PSA stayed at 0.15 after prostatectomy?

After a prostatectomy, your PSA should drop to undetectable. If it doesn’t, then there is prostate cancer somewhere in your system. The most likely location is where the second doctor has recommended you have radiation.

Getting on ADT for six months can stop your cancer from growing and can reduce the size so that radiation works better.

I’ve faced those decisions and know many people that have. I had a prostatectomy and 3 1/2 years later it came back (my PSA hit .2) And I had salvage radiation. That gave me 2 1/2 years before it came back another time. At that point I went on ADT and I’ve been on it for nine years since. Nobody knows I have prostate cancer unless I tell them. I do get hot flashes, but that is the only obvious thing that people see. After 15 years of prostate cancer, I leave a pretty normal life do a lot of exercising every single day. I do have the BRCA2 genetic issue, which is why my cancer keeps coming back. Getting prostate cancer so young can be caused by genetic problems.

Getting an hereditary, genetic test is a good idea. If you have certain genetic issues, there are new drugs to treat them. You can get one free here, If you live in the USA.

Prostatecancerpromise.org

They will send you a kit and in about three weeks a genetic counselor will call you to discuss the results. Don’t check the box to have your doctor involved. In that case they won’t send anything until they speak to your doctor.

Hi Jeff,
Thanks for sharing your story. I can only imagine how tough it has been to deal with prostate cancer coming back multiple times, and your positive attitude is certainly inspirational.

I understand that the number one goal is to eradicate the cancer and I want that. What I am struggling with are the two very different opinions I have received from two hospitals. One wants to take a conservative approach and the other is recommending a much more aggressive plan. If I go the conservative route, I feel like I have a better chance of not losing the progress I have made with sexual function and bladder control, but then I worry about recurrence within the next two to five years.

I lost one set of nerve bundles during surgery, so natural erections have been difficult. I have managed to keep the sensation of orgasm, and I want to preserve as much of my remaining function as possible. That is why I am concerned about moving ahead with ADT and radiation, especially with side effects such as loss of desire, weight gain, muscle loss, and potential damage to the bladder, colon, and nerves.

I have not had genetic testing yet, but I think that is a great suggestion. Will my doctor find value/use in this type of genetic testing as well?

Thanks again for sharing your experience. It helps to hear from someone who has actually gone through this.

That is a tough one, but I would go with Jeff's recommendation. I gave ChatGPT the scenario, and it said it would go with the aggressive approach unless the possible side effects were of very significant quality-of-life importance. I then tried to argue back by saying, 'Well, if it knocks down the PSA, what is the difference?' Here is that portion of the response. ""Alright, let’s put some numbers on the table. These are ballpark figures pulled from the salvage radiation trials (SPPORT, RTOG 9601, GETUG-AFU 16) and modern series. They’re not perfect — since every patient’s case is unique — but they help visualize the trade-offs.

📊 Salvage After Prostatectomy with Persistent/Low PSA
Radiation Only (Prostate Bed)

Chance of long-term control: ~40–50% if PSA ≤0.2 at time of RT.

If PSA goes to undetectable after RT: better odds, but still higher recurrence risk than men who were undetectable after surgery.

10-yr overall survival benefit: not clearly improved in trials unless combined with ADT.

Radiation + Short-Course ADT (4–6 months, e.g. relugolix or leuprolide)

GETUG-AFU 16 trial:

RT alone: 5-yr progression-free survival ~62%.

RT + 6 mo ADT: ~80%.

Clear benefit.

Side effects: temporary ADT toxicities (loss of libido, hot flashes, muscle mass changes). Most reverse after stopping.

Radiation + Nodes + ADT (SPPORT trial)

SPPORT trial (bed + nodes + 4–6 mo ADT):

5-yr freedom from progression ~87% vs ~71% for RT bed only.

Largest bump comes from adding ADT, but node radiation adds a meaningful incremental gain for high-risk patients.

Radiation + Long ADT (2 years, RTOG 9601)

RTOG 9601:

12-yr overall survival: 76% (RT + 2 yrs bicalutamide) vs 71% (RT alone).

BUT: greatest benefit was in men with PSA >0.7. For PSA < 0.6, long ADT added little — and added toxicity.

🔑 How This Maps to “tj1967” (58 yrs, stage 3b, PSA 0.15)

Radiation only (bed): maybe 40–50% chance of true long-term remission.

Radiation + 6 mo ADT (bed): ~70–80% chance of durable remission.

Radiation + nodes + 6 mo ADT: closer to 80–85% chance of long-term remission, especially with adverse features like stage 3b.

Radiation + 2 yrs ADT: probably not necessary at PSA 0.15 — short course is the sweet spot.

🥊 The Trade-off

RT only: Higher chance of keeping erections/energy/sex drive, but lower odds of cure.

RT + short ADT + nodes: Better odds of cure, but temporary loss of sex drive and ADT body changes.

If I were blunt with him: “Radiation alone gives you maybe a coin flip. Radiation + short ADT + nodes bumps you into the 80% range. The question is whether 6 months of libido loss is worth doubling your odds of not having to face recurrence later.”

I also then tried this: "okay how about this......wait until it is about .25, do psma to see if it shows itself for a direct radiation hit but otherwise proceed with what you outlined a
ChatGPT said:

Yep — that’s a very logical “middle ground strategy.” Let’s lay it out clearly:

🕰 Wait-and-Image Strategy
Step 1: Watch PSA Until ~0.20–0.25

Why that number?

Many docs (and NCCN guidelines) use ≥0.2 ng/mL, confirmed as the official definition of biochemical recurrence.

Waiting until 0.25 gives a better chance that PSMA PET will light something up. At 0.15, the detection rate is maybe 30–40%; at 0.25 it jumps closer to 50% or more, depending on the tracer.

Step 2: Do a PSMA PET

Best case: PET shows a single node or spot → direct, targeted RT (“stereotactic body radiation therapy”) or focused boost on top of prostate bed RT.

If negative: You still know recurrence risk is high → proceed with prostate bed ± nodes + short ADT (the aggressive plan we walked through).

✅ Pros of Waiting

Better chance to catch disease on imaging, guiding treatment more precisely.

Possibly avoids overtreating with whole-pelvis RT if just one rogue node lights up.

Gives a little more time for sexual recovery after surgery before adding RT/ADT.

⚠️ Cons of Waiting

Risk that microscopic disease is growing while PSA inches up. The lower the PSA when you zap it, the better the long-term control odds.

If you wait too long (say >0.5–1.0), salvage radiation is less effective overall.

For stage 3b + persistent PSA, you already know biology is aggressive → waiting is a calculated gamble.

🎯 Bottom Line

Your version of the plan could be stated as:

“I’ll ride PSA monitoring until it hits ~0.25. Then I’ll get a PSMA PET. If it shows a specific lesion, I’ll consider targeted RT. If not, I’ll go forward with aggressive salvage RT (bed + nodes + 6 mo ADT).”

That approach buys time, maximizes imaging yield, but doesn’t walk away from the aggressive safety net.

One problem is You have not said what your Gleason score is. That is a major factor in deciding how aggressive one should be. It’s also a major factor in whether you should be on ADT and how long. The question is do you want to have progression free survival (PFS), if yourGleason is higher than 7 Then the more extensive radiation really makes sense as well as ADT.

The more extensive radiation gives you that longer PFS, And that radiation is not likely to affect your erections. All the spots that it would affect are already gone after surgery.. It’s the Orgovyx (Relugolix) (ADT) that will cause the ED problems as you probably know, Due to loss of desire,. I had 7 1/2 weeks of radiation and it had no side effects at all, Some people have fatigue some people have temporary urinary tract problems. I did have a six month Lupron shot shortly before radiation, I didn’t realize it had side effects back then and didn’t notice any.

I’m not sure you’ve heard about bimix or Trimix, You inject it into the penis in order to get a good erection. I know that in my case I still had some desire, even though I was on ADT.

What type of medical centers did you go to, to get those two different sets of Advice? Was one of them a center of excellence? If you did not go to a center of excellence that may be the best option getting a third opinion from experts.

Another thing you could do is get a decipher test, It will tell you how likely it is you will have a reoccurrence. If you get a very low number, then you can probably avoid ADT.

Yes, ADT has a number of side effects. I’ve never had a problem gaining weight even though I’ve been on it for nine years. I weigh myself every morning and base what I eat on what I weigh. I go to the gym three times a week (usually) and walk on the track (Or around the neighborhood) At least a mile twice a day every day. It keeps one healthy, Which is very important for prostate cancer. I also get bone strengthening agents. I was on Fosamax for six years and I’m now I’m getting Zometa infusions every three months. A bone specialist that a recent conference said that everybody on ADC should be on bone strengthers.

Damage to the bladder, colon, and nerves is not normally a big problem for most people with the radiation you’re talking about. Those are problems that can occur more often if you have radiation to the prostate initially. I’m not saying it won’t cause problems, but they are not usually a big deal for the majority of people and the problems are usually for a short time.