In general, a patient whose volume of cancer is out of proportion to their PSA makes me nervous. So, I'm much more worried about the patient with a PSA of 5 and multiple cores positive for high volumes of Grade Group 4-5 cancer than I am about the patient with a PSA of 5 and a single positive core s...

It is always a concern when the PSA does not represent the severity of the disease. It probably means more dedifferentiated histology. I am usually concerned with only following the PSA on these patients. Generally, I would get an MRI and a bone scan yearly in addition to their 6-month PSA. 

I do not change my surveillance strategy per se other than I check PSA q3-4m until testosterone recovery for all high risk patients other than ECE only risk feature. If PSA becomes detectable, I lower my thresholds for PSMA PET for patients that have a low secretory profile which is almost always gr...

I know the Harvard group was trying to define a high-risk low secreting subset. I’m not sure where that data stands now, but it might be patients we escalate in the future, novel anti androgens, maybe systemic therapy, etc.