PSA Recurrence - how fast do I need to act?

I had a prostatectomy in Feb 2019 and then my PSA was undetectable for over 4 years. In June 2023 my PSA became detectable for the first time since pre-surgery. My recent PSA has been:

6/26/24: 0.15
5/22/24: 0.13
12/27/23: 0.08
9/7/23: 0.05
6/5/23: 0.04
2/25/19 - 7/27/22: <0.03 (undetectable)
2/25/19: Prostatectomy

I have some high risk factors so I know I probably shouldn't wait until official recurrence at .20 for treatment. I recently did a PSMA PET on 6-17-24 and I was told there was no obvious metastatic lesions. My medical oncologist mentioned possibly doing another PSMA before long but I'm not sure I can even wait that long.

Here are some of my risk considerations.

High risk factors from surgery pathology:
-- Gleason 9: Primary 4 + Secondary 5 + Tertiary 3 = Total: 9 (% Gleason 4/5: % of 4 was 50% , % of 5 was 10% )
-- Extraprostatic extension: Focal (pT3a). The tumor was present in extraprostatic location was close to, but not at the surgical margin.

Other high risk factors:
-- BRCA-2 mutation positive
-- PSA doubling rate over the last year is about 6 months.

Possible risk-lowering factors:
-- PSA was undetectable for over 4 years post-prostatectomy.
-- 30 lymph nodes removed during RP, all negative for cancer.
-- Seminal vesicles were clean on RP
-- Surgical margins were negative - no tumor not found outside the surgical margin.

I really want to have a chance to kill this for good. I figure there might only be once chance and it's not guaranteed. How quickly do I need to act? My medical oncologist and I discussed taking a little more time to try to figure out where the cancer is versus acting quickly. Do we radiate the prostate bed soon even though there is a good chance it's not there? That treatment would of course have hormone therapy too.

Also as a Gleason 9, I'm not really sure of the significance of being undetectable for over 4 years. Does that make me even a little lower risk? The 6 month PSA doubling rate so far is making me think it's back and means business. I'm not sure if doubling rate as meaningful when you're below .20 though.

I've only seen my medical oncologist once so more discussion is needed but I would really like to cross-check it with the vast experience of this group.

Hate to see that! But something is surely going on. Looks like your next step is to see a radiation oncologist to talk about the various options.

DjinTonic said...
Hi Bob.
Didn't your doctors discuss adjuvant RT with you following your surgery?
Djin

I don't recall that we discussed adjuvant RT back then but I may have forgotten about it. I did however receive a trial of Olaparib, a PARP inhibitor, for 90 days leading right up to surgery. Some studies have shown it to have effect for BRCA-2 positive folks. In the surgery pathology report they couldn't notice any effect although while on that drug my PSA dropped twice. That is the only time my PSA has ever dropped outside of surgery itself.

Well I definitely hear what you are saying that is now is the time to meet with a radiation oncologist. I don't have an appointment until July 30th but I'm looking to move it up as well as possibly start on hormone therapy beforehand.

Hello Bob,

You appear to have a difficult pathology with genetic stuff mixed in. You also have a low PSA which is not helping a PSMA scan find anything. I don’t know where your current doctors are but getting with a top cancer organization that will aggressively scan and treat you soon might be a good idea as there are some other scans to try. The BRCA gene is a wild card and would need to be addressed by someone who knows about such things like the PARP inhibitors that you apparently had some PSA success with.

If you start ADT soon, that will probably stop another PSMA scan from finding anything so that tends to push you right to salvage radiation and hope for the best not knowing anything more. However, SRT works best at low PSA so it is important to get going as you get near 0.20. There can be some insurance pushback at low PSA so you want aggressive doctors that will advocate for you.

A team of a MO and RO should be helping you figure this out.

you should have already been treated -- BCR has been confirmed for at least six months and you are G9!. someone has dropped the ball here

i would be demanding a shot of lupron at this point while you are arranging SRT. good luck to you man!

EDIT:Edit: Ed, I deleted your comment about surgery. No disrespect meant. We are all entitled to our opinions, but there is no point in second guessing a members decision, especially after it's been acted upon. Thanks for your understanding.

Hi Bob
I was diagnosed in 6/19 PSA 4.7
Gl 7. RP in 9/19
Clear for 3 years then PSA started to creep up
Had to wait til it hit .2. Actually went to .24 and PSMA was done as well as prostate bed mri. Both clear. But due to rising PSA started 25 radiation treatments to prostate bed and hormone therapy. Assumption was it must be coming from surgical site. Originally contained within organ. Being treated at MSK Have treatment 22 today and have had no significant side effects. PSA went to .12 after first week of treatment. Repeat PSA after final treatment. Dr wants 6 months of hormone therapy but I’m looking at doing 3 if PSA is undetectable. Good luck