At what PSA level do you offer early salvage radiotherapy?

For a patient with pT3 disease or positive margins, once the PSA is confirmed detectable, rising, and the patient is well-healed, it is appropriate to treat. Given the results from the now 7 adjuvant vs. salvage trials, delaying well past a PSA of 0.2 is associated with the need for more aggressive ...

In general, my interpretation of the trials on this point is as follows:

• If post-op PSA ≤0.1 ng/mL, OK to wait until PSA=0.2, even if positive margins or pT3b. Check PSA q3-6 months.
• The above does not hold if first post-op PSA >0.1 or if the patient is cN1 or pN1.
• Moderate caution if Gleason ≥8 (...

I think the best evidence that exists for this is this large multinational database study:

Tilki et al., PMID 36857638

It suggests that all-cause mortality might be increased when treating above a PSA of 0.25 for patients having at most, one of two risk factors: pT3/4 or Gleason 8-10.

For patients with...

Getting a PSMA or Axumin PET to help decide which patients to offer salvage RT to (i.e. no distant mets) is becoming more routine. The trigger point to be able to order these is a PSA >/= PSA 0.2.

I don't treat PSA alone. Delayed salvage is appropriate if favorable especially if low decipher.
High decipher I treat at any PSA or undet with high risk. Recent MGH data supports RT with undet PSA and 2 high risk features and that did not include Decipher.

If using serial increases in serum PSA already reaching 0.1ng/mL as criteria with no imaging or symptomatic findings, would you still wait until reaching 0.2ng/mL, or would you consider treating earlier?

There’s good data that if Decipher is high there is no safe low psa threshold. Negative PSMA is not sensitive enough in the nodes or VUA for me to observe a detectable PSA with a high decipher.

It depends. If the patient had a positive margin, etc. at surgery to where I felt the disease was likely in the prostatic fossa, I'd treat as soon as I had a couple of increasing PSAs.

OTOH, if the surgical margins were good, and I was concerned the disease could be outside of the fossa region (in a...