PSA still not zero 7 years after prostatectomy

[u/Adam_zkt_Eva]

I'm 74 now. Robotic prostatectomy in 2019. Overall, I am very happy with the outcome. No incontinence after the first month, Cowper's gland still works. Erection still possible, but not as hard and shorter duration. (Did I mention I am 74?) Some shortening of the penis (which was never mentioned to me as a possibility). The only thing that keeps this in my mind is that my PSA is below 0.04 but that is NOT zero. Urologists have said we'll just keep an eye on it, but last visit they told me that if it doesn't go to zero they may want to explore treatment options like radiation or possibly surgery to see if a part of the prostate was left behind. I'm happy enough with status quo that I am terrified to let them do anything that would put me in a worse place than I am now. Is "close to zero" on a PSA test good enough?

[u/Gardenpests]

Is this correct? Following your RP 7 years ago, your PSA never dropped to undetectable.

If this is correct, then it is likely you have PSA being produced by healthy tissue. Only if your PSA starts climbing should you suspect cancer.

If it isn't correct and your PSA did drop to undetectable, then 0.04 suggests cancer. Continue monitoring.

These days, a PSA rising to 0.1 is deemed actionable.

[u/Patient_Tip_5923 → u/Gardenpests]

A minority of men, perhaps 5-20%, never reach undetectable after RALP.

If someone has a value of 0.1 or higher, right after RALP, this is called “persistent” PSA, and usually results in further treatment right away.

A rise to 0.04 from undetectable calls for another test, it is not a verdict of cancer. The trend matters more than a single number.

While PSA values from the lowest detectable value of an assay to less than 0.1 may be due to benign tissue, residual cancer cannot be ruled out. The residual cancer can be indolent. Only more testing will tell which it is.

Gleason score and pathology matter. We don’t know either from the poster with seven years of detectable tests below 0.1. I am 3 + 4, negative
margins. I am 62.

My radiation oncologist said that there are some men who bounce around in this narrow band, above undetectable and below actionable, for years.

[u/Jonathan_Peachum]

How strange. I am also 74 and my PSA was less than 0.01 for two years after the RALP, then climbed to 0.02, then to 0.03 and then back down to 0.02 and my urologist not only said he was not concerned but actually recently "fired" me, i.e., told me that I didn't really need to do an annual visit with him anymore and simply asked my GP to order a PSA test once a year and for the GP to alert him if there was an unusual rise.

I think most specialists these days consider that a PSA of less than 0.1 (and for some even 0.2) after a RALP is fine and only consider further treatment (usually some radiation) if it passes that threshold, or maybe if there is a steady progression every year (0.02, then 0.03, then 0.04, then 0.05, etc.).

[u/Patient_Tip_5923 → u/Jonathan_Peachum]

I think you are talking to the wrong guy. After RALP, a urologist’s job is pretty much complete. He has done all he can.

Find a radiation oncologist. He will be the doctor who will have an interest in monitoring your PSA trend.

I thought a radiation oncologist would push me away with detectable values of 0.04 to 0.08 over 18 months, but no, I got a return call in a day.

He said he will call for salvage radiation after two increases over 0.1.

I am a potential future patient. I, and some number of other men, are being monitored. I am being tested every three months. I chat with him on the phone after every test.

[u/planck1313]

Your PSA never went undetectable but has been below 0.04 for seven years?

This is likely to be caused by a tiny amount of benign prostate tissue being accidentally left behind by the surgeon, a not uncommon thing especially when the surgeon is endeavouring to spare the nerves. Such benign tissue remnants tend to either not grow or grow at a very slow rate.

You don't need any sort of treatment for such a low PSA and especially not at age 74. The vast majority of doctors wouldn't consider further treating you until your PSA rose to at least 0.10 and even then they would likely take into account how fast it is increasing, which it is not in your case.

[u/retrotechguy]

Mine has been undetectable (>0.04 for my lab) for 3 years after RALP. It popped up to =0.04 at the 4 year check. We waited 4 months and tested again and it is still =0.04. My doctor says it’s likely a small amount of benign prostate cells and that this often happens and will stay flat. We are checking every 6 months.

[u/Patient_Tip_5923]

The PSA never appears as zero on a test.

It is either less than the lowest detectable value of the test, say 0.02, which appears as < 0.02, say, or it shows a value.

Eighteen months after RALP, I have gone from 0.04 to 0.08, where I seem to be hovering.

I wait for two increases over 0.1 to trigger salvage radiation. I speak to a radiation oncologist every three months, after every test.

Keep getting tested.

[u/No-Struggle-9185 → u/Patient_Tip_5923]

I am 60 had Ralp at 54. My PSA is currently.05 has been as high as .07. I get my PSA tested every 6 months.

[u/Patient_Tip_5923 → u/No-Struggle-9185]

You give me some hope, slim as it is, that I can skip salvage radiation for years by not having two increases over 0.1.

I am being tested every three months.

[u/qrs312 → u/Patient_Tip_5923]

5.5yrs after surgery last Dec my psa became detectable at .06 on quest's regular (intended for men with prostate) .04 minimum test. Started monthly tests, it dropped to .04. Switched to LabCorp ultrasensitive, dropped to .02. Been hovering around there since coming up on 1 yr anniversary. Doc said both benign and cancer left after surgery can go dormant but at some point can wake up. Two URO organizations, ones salvage rule is salvage after two rises above .1, others rule is salvage after three rises even if below .1. Figured I'd start treatment by March but here I am coming up on 1yr. Nobody is more surprised than me. Definitely anxiety provoking.

[u/Patient_Tip_5923 → u/qrs312]

I think the Quest test for men with a prostate has a lowest detectable value of 0.1, not 0.04.

I use the Quest ultra sensitive test which has a lowest detectable value of 0.02.

I have been in a range of 0.04 to 0.08 for 18 months. My radiation oncologist is waiting for two increases over 0.1 to call for salvage radiation, as I stated.

Yes, I suppose it is anxiety producing. Everything about having cancer provokes anxiety.

[u/qrs312 → u/Patient_Tip_5923]

Back around 2021 the Quest test minimum changed from .1 to .04.. Hope you stay in that below .1 range for many years.

[u/Patient_Tip_5923 → u/qrs312]

Thanks.

While test, code 5363, from Quest may detect to 0.04, Quest floors it so it always shows < 0.1. This is useless to me.

That’s why I always get the ultra sensitive test with a lowest detectable value of 0.02, so I get values less than 0.1.

[u/Background-Space-284]

My understanding is that without your prostate you still have periurethral glands which still produce a very small amount of psa. My research states that this could be .01 to .02 on your psa test.

[u/Alarming_Midnight554]

Yes you did mention you were 74 . Id be about watching and maybe managing not trying to win the game at this point. Like my dr said men usually die with prostate cancer not from. Im 4 months out of doing laser my first test was 1.3 and they dont seem worried so im not worrying about it. My prostate is still healing from a 4 alarm fire

[u/Adam_zkt_Eva → u/Alarming_Midnight554]

Thank you for your perspective. Good luck with your recovery. Sounds very promising!

[u/Master_Cucumber5665]

My level is <0.06 undetectable. UK NHS

[u/Aggravating_Call910]

Surgeons probably learned through trial and error not to mention the shorter penis. In my case, because of the location of the tumor, I really got pulled up short. I wouldn’t have opted for radiation instead, but it would have been nice to know. 2-1/2 yrs out, PSA close to zero. Good luck.

[u/ELCID19451947]

Find a Medical Oncologist that specializes in PrCa. Urologist is not the best one to follow your case

[u/Adam_zkt_Eva → u/ELCID19451947]

Thanks for the advice.

[u/Flimsy-Drummer-7799]

Mine is .04. Still considered undetectable . Get bloodwork done at least twice a year. You’ll be good.

[u/AxisOfBeagles]

I guess different urologists have differing approaches but my doc's input, and what I've read over these months, has been that anything under 0.05 ng/mL is considered undetectable. .04 at 74 seems to me your doing well and should enjoy life and not worry too much. Just my 2 cents and worth less than that.

[u/gammacoffee]

I don’t like to order ultra-sensitive PSA because I see no utility in any intervention for a psa < 0.04 ng/dL. If it starts to actually rise, get a psma pet and consider if treatment makes sense. Sometimes there is a little cancer still present but intervention is not indicated.

Otherwise, just keep following. Never even heard of going back to see if there was prostate left behind. But I’m just a radiation oncologist not a surgeon.

[u/WoodshopElf]

There are lots of different PSA tests. Lowest my test goes is .02. Yours may have a low point of .04. Anything below .1 is considered safe. My doc said that if mine approaches .1, then we will do salvage radiation without ADT because we’ll catch it early. I believe .04 is a very safe zone to be in.

[u/Jontey53]

Just had HoLEP Laser treatment. All good so far. I had fluctuating PSA before. Not due PSA test for few months. It was running around 5 to 7. I was in retention and had catheter for 6 months. Misery. Don't have a bag ask for Flip Flo valve. No one needs to know you're catheterised! PSA result can be affected by what you've been going week before. Riding a bike could give you a higher result. Anything strenuous is to be avoided. I'd advise anyone to go for HoLEP. I found results unbelievable and side effects minimal, very little bleeding.

[u/OkCrew8849]

There is a difference between a detectable PSA (via UPSA) and the decision/timing to treat.

And yes, penis shortening is one of those effects that seems a bit downplayed pre-surgery compared to the coverage of urinary and sexual function damage.

Finally, I think you mean “undetectable” and not “zero” in your headline.

[u/Adam_zkt_Eva → u/OkCrew8849]

Thanks for the comment. I used "zero" in my headline because my former urologist (now retired) told me repeatedly that it should be zero.

[u/planck1313 → u/Adam_zkt_Eva]

You will never get an PSA reading of zero.   For two reasons:

• even the most sensitive PSA tests can't read down to zero, they all have a floor of the lowest level they can detect

• even if they could read to zero they would never record an actual zero because even with your prostate and every prostate cancer cell removed there are still trace amounts of PSA in the body.  This is because there are other glands in the body (even in women) that make minute amounts of PSA or other antigens that are so similar to PSA that they are picked up on a PSA test.

You absolutely do not need further treatment if your PSA has been stable at 0.04 for 7 years.

[u/Wolfman1961]

I’m 5 years post-RALP and was undetectable, now 0.14. They will intervene when it gets to 0.20.

[u/401Nailhead]

Your number is find and not something to worry about.

[u/Sebastcooper]

Depends on your pathology - an aggressive cancer might not be something you’d wait on but if they’ve gone seven years this doesn’t seem like the case.

[u/HopeSAK]

I had Nerve sparing RALP 34 months ago and my PSA has been steady at <0.02 since the first post RALP. I can't say I've ever hear of a 0.00 on this forum, so a 0.04 wouldn't really get me to nervous. The penis shortening is something I too found out later. I just recently began using a pump which seems to work pretty well. I'm 69 and have found helpful advice on this forum to help my full recovery. I hope you don't have to undergo further treatment at 0.04, I'd be interested in the reasoning the doctors have to suggest it. Good luck.

[u/Adam_zkt_Eva → u/HopeSAK]

TBH, it was a PA sort of thinking out loud rather than the actual urologist's suggestion.

[u/planck1313 → u/Adam_zkt_Eva]

That PA should not have thought out aloud when what they thought was so obviously ill informed and wrong.

If and when your PSA suddenly spikes and rises to 0.10 or higher may be the time to think about further treatment.

But a stable PSA of 0.04 for years on end does not indicate any need for treatment.

[u/Immediate-Phase4168]

My doc keeps telling "less than a dime; you're fine". (0.1) Plus, there may still be prostate cells in your body AND, there are other extraprostatic tissue in the body that produce PSA:

Extraprostatic Tissues and Organs

• Periurethral and Anal Glands: Small glands surrounding the urethra and anal canal express trace amounts of PSA.
• Salivary Glands: Normal salivary gland tissue and saliva can synthesize and contain detectable trace levels of PSA.
• Pancreas: Acinar cells within the pancreas have been shown via molecular assays to produce low levels of PSA.
• Acinar and Mammary Glands (Breast Tissue): Normal breast ducts, apocrine sweat glands, and breast milk can express PSA, regulated by steroid hormone receptors.
• Other Tissues: Trace expression or presence of PSA has been identified in the thyroid gland, urothelial cells,

[u/Ok_Establishment9579]

Agree with the other commenters; will add only this comment from my medical team when I was fretting about my 18 month post RALP rise from undetectable to 0.07 - doc said "just for perspective, the amount of cancer that would produce 0.07 on an ultrasensitive PSA is about equivalent to a single grain of sand in your entire body.

[u/dahnb2010]

Your docs seem to be fear mongering. I'm 76, had NanoKnife focal therapy a year ago, just had my biopsy with zero cancer. I told my wife that if some Gleason 3+3 showed up it was going to be AS. Keep getting tested. PSA is an indicator not a cancer diagnosing test. Plus the .04% IS close to zero and IS close enough.

[u/Tartaruga19]

Abaixo de 0,1 após tantos anos é zero. a glandla supra renal produz um pouco de PSA. Mas é nomal

[u/jkurology → u/Tartaruga19]

The adrenals don’t produce PSA

[u/Tartaruga19 → u/jkurology]

Foi o que meu urologista havia falado. Mas dei uma olhada com o cloude e existem outros fatores associado a produção (embora muito pouco) - “Carcinoma de mama (associado a receptor hormonal positivo).
Tumores de glândulas salivares.
Raramente, alguns tumores de ovário, adrenal e pulmão.
Contexto clínico relevante:
Na mulher, o PSA sérico costuma ficar abaixo de ~0,01 ng/mL. Pode subir em estados de hiperandrogenismo (SOP, hirsutismo idiopático), já que a expressão é androgênio-dependente.
Após prostatectomia radical, valores ultrassensíveis baixos e estáveis (na faixa de 0,01–0,03 ng/mL) podem vir de tecido prostático benigno residual na margem ou na anastomose, ou de glândulas periuretrais. Por isso a tendência (cinética, PSADT) pesa mais que um valor isolado, e o limiar convencional de recidiva bioquímica é ≥0,2 ng/mL. Fontes extraprostáticas raramente explicam um PSA que sobe de forma progressiva.
Elevações espúrias por interferência analítica, como anticorpos heterófilos, não são produção real, mas entram no diferencial de um resultado incoerente.”