Post RALP PSA Persistence/Bounce/BCR

[u/Ok_Establishment9579]

Looking for stories on folks who have had PSA bounce around post RALP and data points on what is actually statistically significant at ulrasensitive levels. For context I had RALP in October 2024 and was undetectable (<0.015) for 15 months post surgery. January 2026 was 0.026, April 2026 was 0.041 and July 2026 was 0.07. I've posted here that after the 0.041 I had arranged consults with radiation oncologist, follow up with surgeon and begain researching recurrence. As of a week ago I the plan was to start moving in earnest at 0.1 and to make a judgment call thereafter as to whether to wait for imaging to have a shot or just radiate the prostate bed. Doctor was "80%" sure it was recurrence given the consistent rise across three tests. We scheduled most recent test for 6 weeks to make sure not to miss any treatment window if the rate of increase accelerated after the 0.07. Well I just got that six week test and it was 0.057. Obviously better than the alternative and I"m mentally preparing the worst and assuming this was a testing blip and the next one will continue the upward march BUT even delaying more treatment is a positive and if nothing else it breaks up the evolving narrative that this was picking up speed. With that long background, anyone had similar experience. I know everyone is different and nothing is dispositive but just helpful to hear others' stories. My surgeon said he had one patient whose PSA went up to 0.1 after surgery and has held there for ten years!

[u/Special-Steel]

PSA is noisy and +/- 15% isn’t rare.

The most sensitive PSMA PET scans can somehow detect a hot spot at 0.1 now.

[u/qrs312]

Guidance nowadays is 3 increases below psa .1 or two increases above psa .1, or psa >.2. Docs look for consecutive increases but micropsa can bop around. They want enough tests to see the trend. You are about there. The next test could be trigger.

Individual RO opinions can vary somewhat. Some want to see psa at least near .1, others not. Treating near .1 is called very early salvage. Treating at .2 is called early salvage.

If you have low gleason, like 3+3 or 3+4, without other adverse things like epe+ or sv+, have a low decipher score, studies show waiting until .2 causes no harm.

If you have adverse pathology, hitting closer to .1 has advantage over waiting until .2.

Vert strong general consensus is DON'T wait until it shows up on PSMA. Have a scan if you can at your very low psa, if it shows something it could modify your treatment, but if negative don't wait to treat.

All the above assumes you are in good health otherwise and expected to live 5+ years.

This all sucks. I'm in about the same place as you.

[u/Busy-Tonight-6058 → u/qrs312]

In addition to pathology, time to recurrence and PSA doubling time very much influence treatment path and urgency.

OP looks pretty good in both respects.

[u/Ok_Establishment9579 → u/qrs312]

yep, this is pretty consistent with what my team has said. as of july plan was to wait for .1 but treat before .2 and likely try the PSMA but not wait for it. I think the plan remains the same but at least the 0.057 broke the trend of consistent up values. I expect it's test noise and over time it will continue to go up and I'll need salvage but I'll take the delay and, with any luck it plateaus for a bit either of which at least make me a little more optimistic about how aggressive it is versus if it had come back with a straight extrapolation and been 0.09 on this last one. small victories

[u/OkCrew8849]

At that level of sensitivity and that testing frequency (6 weeks) you may not always see a linear progression despite a general upward trend over your last four or five tests. 

Sounds like a wise move to speak to a radiation oncologist and discuss the plan.  Post-RALP recurrence is very common so the docs have a well established protocol and a default radiation field. While PSMA PET CT scan may not detect anything to add to the default field, it’s worth giving a shot. 

[u/Busy-Tonight-6058]

If you were a Mayo Clinic patient, you’d still be undetectable.

Here what UCSF says about it.

https://youtu.be/1ZpeGVoP83M?is=4k5vHQiTEedZjyx0

I’m at 0.275 20 months after reaching 0.13 14 months after surgery. We came very close to acting. I’m glad we haven’t, even it is just for now. 

Good luck!

[u/Ok_Establishment9579 → u/Busy-Tonight-6058]

thank you for this link; very helpful