How do you approach rising PSA following radical prostatectomy and early salvage radiation therapy?

There are several factors that I will take into consideration, including the patient's overall health, the interval from treatment to relapse, the PSA doubling time (rather than a PSA threshold), whether or not they're castrate resistant and whether or not they now have overt metastatic disease. Patients generally fall into 3 categories: those that have rapidly progressing disease biochemically who are at high risk for overt metastases, those with slowing progressing disease who may never need treatment, and those in between.

Patients who relapse shortly after salvage treatment (i.e., <1 year), or while still on ADT if that was part of the regimen, and/or who have short PSA doubling times (<10 months, but especially if it's <3 months) are a...

In setting of patient s/p RALP and s/p salvage RT:

PSA > 0.2 - PSMA PET/CT

If negative, follow q3 months until PSA > 0.5, then repeat PET/CT

Presumably negative, continue q3 month PSAs until PSA > 1, repeat PET/CT. If still negative, refer to Med Onc for discussion.

Continue q3 month PSAs until PSA > 2 for shared decision-making on potentially starting ADT. Part of this depends on the patient as well as the medical oncologist.

Evaluate anything on each PET/CT that can be treated with some level of confidence. If you treated fossa and a LN pops up, make a repeat attempt at that. A single bony lesion, consider SBRTing. I've sent a patient for biopsies of this or that to r/o oligometastatic disease.

Be OK to be wrong (like SBRTing a new PSMA a...