What if My PSA Comes Back After Surgery?

Making Sense of PSA After Treatment

What do you do if PSA comes back, or never goes away, after prostatectomy or radiation therapy? 

I recently interviewed Weill Cornell Medicine urologist Jim C. Hu, M.D., M.P.H., on this topic for the Prostate Cancer Foundation’s website.  Jim Hu’s expert advice also appears in our book.

            Before we get started, please hear these words:  “If your PSA does go up after surgery or radiation therapy, don’t panic!” says Hu.  “It’s not a death sentence.  You just need to do something.”  And the first thing to do, he says, is to find out exactly what’s going on.

            Also:  If you have had a prostatectomy and your PSA is undetectable, that’s wonderful – but don’t stop getting it checked.  “Some men may think, ‘my surgery’s done, I got my path report, there are negative margins, so that means there’s no cancer left,’” says Hu.  And often, this is true.  “I’ve seen instances where men go ‘off the wagon,’ don’t get their follow-up PSAs for a couple of years.”  But they may not be out of the woods.  Of the men who do develop a recurrence of PSA after prostatectomy, 50 percent experience it more than three years after surgery, and 70 percent have it within five years.  In other words, most recurrences happen within 5 years after surgery.  After 10 years, the risk of a PSA recurrence becomes very low – but it’s still possible, and this is why many urologists advise their patients to keep getting the PSA checked for decades.

            Brief note:  If you have had focal therapy, and your PSA is going up, now is the time get a surveillance biopsy and to consider whole-gland treatment.  This is determined on a case-by-case basis; consult your doctor.

After Surgery, How Often Should You Get Your PSA Checked? 

This varies.  Your urologist may recommend getting it checked every three months for the first five years if you are at higher risk (of recurrence):  if you had positive surgical margins, or seminal vesicle invasion or N1 lymph node involvement, or high-grade (Grade Group 4 or 5; Gleason 8, 9, or 10) cancer, or a pathologic stage of T3b.

If you are not at high risk, your urologist may recommend the three-month check for the first two years after surgery, then move to every six months, and then yearly.   “The guidelines have been to check it every six months in the first five years, and then annually thereafter,” notes Hu, but some doctors move to a yearly PSA sooner.

Why not get PSA checked right after surgery?

Like a bad party guest, PSA doesn’t leave when you want it to.  It hangs around in the bloodstream for a while, even after the prostate is removed.  “It usually takes about two months for PSA to wash out of the bloodstream,” says Hu. “So you should never get that first PSA earlier than two months.  There can be a false positive,” because some PSA is still just lingering, taking its sweet time to fade away.  That PSA is an artifact; a marker of something that no longer exists – but it can be upsetting to see.  Thus, “three months is typically the soonest you should get it checked.”

 Should you get an ultra-sensitive PSA test?

Again, this depends on your doctor – and on you, as well.  Some national labs, such as Quest, run tests that can detect PSA at 0.02 ng/ml, and others, such as Labcorp, can show PSA below 0.006 ng/ml.  “Some men just want to know as precisely as possible,” says Hu.  “I know physicians who don’t like to order ultrasensitive tests because that first test may be a little higher, and that causes patient anxiety.  Also, if the PSA is less than 0.1 but not lower than 0.02 or 0.006, the patient may be worried.”  The very low number is actually too low to be actionable.  “The ultra-sensitive PSAs can be a double-edged sword,” Hu continues.  “There’s research to suggest that if your first PSA after surgery is less than 0.03, then there’s a decreased risk of recurrence.  Some people get the ultra-sensitive test because they want that reassurance.”

Next, Part 2:  What PSA Number Should Sound the Call to Action?