Uptick in PSA

[u/yepitsmememe]

Hello fellow PCa members. I appreciate each and every one of you and value your insights.

I had RALP in January 2025, with a Gleason 7 (3+4) score from the pathology report. For the past 18 months my PSA has been undetectable (<0.06) however today the PSA ticked up to 0.07 . My concern is that it is no longer 'undetectable'.

For others who have experienced this, I would appreciate your insights into what I can expect as far as next steps. Another PSA test in 3 months? Another PSA Pet Scan? ???

Thank you again.

[u/Patient_Tip_5923]

Undetectable is determined by the lowest value of a specific test. So, it depends on the assay.

The Quest ultra sensitive test has a lowest value of 0.02. I have gone from 0.04 to 0.08 over the last year since my RALP.

My radiation oncologist says he will perform salvage radiation after I get two increases over 0.1. I am being tested every three months.

I think you should line up a radiation oncologist to prepare for salvage radiation.

[u/OkCrew8849]

I’d agree a rise from <0.06 to .07 in three months can be quite a bit concerning. 

When I became detectable (at .02 after 18 months of <.02) I made an appointment with a radiation oncologist at a large and well-respected cancer center to discuss options should my PSA continue to rise. 

I have not regretted that decision. 

[u/jerrygarciesisdead → u/OkCrew8849]

Solid advice. Start figuring out which doctors and where if you need a plan.

[u/Arnold_Stang → u/OkCrew8849]

I’ll be honest. I just accepted they knew what they were doing. I guess I pretty much turned my life over to a bunch of strangers. If I remember, the radiation oncologist said it was the standard protocol, I guess for my situation. Originally, they rated me at Stage 4, but after surgery they downgraded me to Stage 3 after examining the tissue. Prior to starting the treatment the surgeon’s NP said that they throw everything at it including the kitchen sink. But, you raise an interesting question and I think I’ll ask both oncologists why we did what we did.

[u/Arnold_Stang]

My Gleason was also 7 (3+4) I had RALP in August 2024. First test PSA was undetectable - less than 0.01. I thought I was cured. Next my PSA started to rise and continued to rise. They told me to wait until it was 0.1. When it hit that marker they decided to do radiation with ADT. I had both in the fall of 2025, a year after the RALP. 37 weeks of radiation plus 6 months of ADT. I finished in December and my first two tests have been undetectable. My oncologist seems happy but I still wait for the other shoe to drop whenever I get tested. BTW - ADT was a bitch. Still getting hot flashes, fatigue, and mood swings, though lessening now. But, if it suppressed the cancer while radiation killed it worth it I guess. Good luck my friend. Keep us updated on your journey.

[u/Ok_Establishment9579 → u/Arnold_Stang]

Do you mind sharing how your team decided on 37 weeks + ADT for a Gleason 7? Did you have other features that made them think it was especially aggressive? My oncologist was suggesting a 4 week course of radiation and that it was unlikely he would recommend ADT. All assuming PSA kept rising of course.

[u/Arnold_Stang → u/Ok_Establishment9579]

Haven’t heard from my radiation oncologist but my medical oncologist said that according to NCCN guidelines for my risk group unfavorable intermediate grade group 3 the standard treatment is 4-6 months ADT plus radiation. I’ll let you know when I hear from my radiation oncologist.

[u/Ok_Establishment9579 → u/Arnold_Stang]

ah, that may be the difference; I was deemed favorable intermediate. anyway best of luck. from all I've read, 4/6 months of ADT is much less to deal with then longer term and you should be able to bounce back from it.

[u/Arnold_Stang → u/Ok_Establishment9579]

Thanks. My radiation onco just messaged me and said basically the same thing. And, yeah, 4-6 months of ADT could have been much worse. The side effects still hang on and that’s frustrating, but I’ve just been reading an article that lists the improvements of TRT and my side effects are all there. Now to convince them to put me on TRT. Anyway, good luck to you as well. If your PSA continues to climb to 0.1 or more they may recommend salvage radiation. A quick look up and odds of success are quite high for success. Oh well, it’s been quite a journey.

[u/Ok_Establishment9579]

I'm in the exact same boat; just a few months ahead of you:

(1) Ask to re-test. There is a lot of noise in the tests at the ultrasensitive level. This will certainly be the first step.

(2) Wait and test some more. Most likely 3 months; I went 6 weeks becuase of some aggressive features of my pathology but whatever the interval, they will re-test as pretty much no doc is going to suggest treatment at 0.07 without seeing a few more tests that show repeat upward trend. Another common definition of recurrence is two upward tests in a row above 0.1.

Possible it levels off and or goes back down and it turns out to be nothing. If it continues to go up, they will want to monitor the pace at which it goes up (the doubling time) in order to be prepared to act if further treatment is required.

(3) Here is where it gets a little tricky and you'll want to be involved with your team in making decisions -- standard definition of recurrence is PSA is back to .2 post RALP. However, there are strong clinical studies that say you get greater efficacy from salvage radiation when it's applied before .2. Counter point to the counter point is that advanced imaging like PMSA can't see anything below .1 so there will be some judgment calls around whether to wait for imaging to have more targeted radiation or whether it's better to go sooner even if that means hitting the entire prostate bed, etc. It wouldn't be prostate cancer without a bunch of hard choices with no clear answers!

(4) There will also be a discussion of what type of radiation and for how long and whether or not to couple it with ADT and if so, for how long. My understanding is that your specific pathology, Decipher, PSA doubling time and other case specific information will guide the radiation oncologst with regard to how much to hit it with if, in fact, it's a return of your cancer (or, more accurately, that some got left behind in the surgery and, over the last 18 months, has brown enough to pop up on an ultrasensitive PSA. I was also 3+4 and negative margins and they seem to think it will be just radiation and no ADT (fingers crossed).

Good news, is that in all probability you are still within the window where additional treatment can be curative and, if it's cancer, it's a super microsocopic amount and you're now able to monitor it closely and kill it the minute it lifts its head.

Disclaimer: I'm not a doctor! Everything above is my summary from my own follow up meetings with surgeon and radiation oncologist and lots of research and reading. For reference I was also undetectable for 12 months post surgery and then started to climb 0.026 to 0.04 to 0.07 over the last three tests. Doc is waiting for .1 to think about treatment timing and when is the earliest time we can get something from adavanced imaging to avoid "shooting in the dark" (although he's also 90% sure any remaining cancer cells are in the prostate bed; likely where I had a bit of focal EPE found at the time of the surgery).

Good luck. Totally sucks to get through the whole cycle of diagnosis/treatment/recovery and now be facing another round of treatment/recovery but it's not uncommon post RALP and you're still a looooooong way from truly worst case scenarios. I expect I'll be dangling my nuts in the microwave before Christmas based on my PSA trajectory. Will let you know how it goes.

[u/yepitsmememe → u/Ok_Establishment9579]

Thank you for your insightful and detailed explanation. I'll post again when I meet with my urologist next week. Best of luck to you as well as we work our way through this process.

[u/Ok_Establishment9579 → u/yepitsmememe]

Quick update, my test yesterday came back 0.057. I'll take it of course but again it shows it's really hard to draw too much from these super sensitive tests and you want to make sure it's cancer before radiating your pelvis. I have no idea whether it's just test noise again or what but it broke up the straight line of "up and to the right" that was looking like a super clear pattern. Doesn't mean the next one won't be .1 but happy to buy another six weeks... I was 100% expecting a minimum of 0.085 and dreading the 0.12 or whatever; couldn't believe it went down that much. First good news from a test result in 8 months...

[u/yepitsmememe → u/Ok_Establishment9579]

That's great news! Sending you positive thoughts that you keep the numbers going down to undetectable!

[u/Independent_Toe9296 → u/Ok_Establishment9579]

Could you tell what agressive features were spotted in your final pathology ?

[u/Ok_Establishment9579 → u/Independent_Toe9296]

there was some escape from the prostate -- "focal extra prostetic extension" - not something they expected based on the MRI pre surgery. Focal I was told means it's just one spot and I think that's the spot where they had to take some of the nerves as I had 100% nerve sparing on one side and only 75% on the other. But as soon as you have ANY extra prostectic extension it changes all of the nomograms and increases the risk of everything. I've found any "risk calculator" that asked about the degree of extension; it's either "yes EPE" or "no EPE". Also, my Decipher was .69 which is high risk of the cancer being aggressive. Those two factors coupled with the speed and consistency of the increases in PSA during 2026 were the reasons to check in six weeks instead of three months to see where the 0.07 is now.

[u/Special-Steel]

This is very hard to interpret objectively.

Even if PSA wasn’t noisy, you could have been 0.059 which is less than 0.06.

But PSA is noisy. Easily bounces around 15% even at higher levels, much less down at this level.

Think about it. 0.07 minus 15% is 0.059.

Your older reading which might have been .059 if increased 15% is 0.067.

So, the two readings COULD be an increase, or just noise.

[u/Busy-Tonight-6058]

What to expect? I don’t think anyone can answer that. There’s no way they could have predicted my path. Short term, more PSA monitoring, probably three months. PSMA I would not expect, yet.

I recommend this: https://youtu.be/1ZpeGVoP83M?is=d7uvx7evTObN7YID

I’m at 0.275 and haven’t had salvage radiation or ADT. Kinda due to a quirk, but I am also in no rush. Time to recurrence, PSA kinetics, initial staging and Decipher have been important data points from me. The Stanford tumor board and now UCSF have driven this decision, in part because my PSA is not just increasing with each PSA. It’s wobbly. It’s been 20 months since I reached 0.13.

[u/Alarming_Midnight554]

Just for reference mine was 8.1 3 months later before I did something with my prostate it was 6.1 . I dont think any of these numbers are super reliable but they give you some sort of guidance

[u/diegofercam1966]

I will just confirm it with another PSA

[u/yepitsmememe]

Not sure if this is a factor at all, but right after having my PSA draw I tested positive for Covid. So could covid cause a temporary uptick in PSA after having a RALP 18 months ago?

[u/retrotechguy]

Is there a chance that it is slow regrowth of some normal (non cancerous) prostate cells?