What are my options?

Here is my prostate cancer history

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Jan 2011 PSA 3.4
Biopsy Feb 2011: 2 out 12 cores cancerous with about 10% involved. Gleason 3 + 3
June 2011: Brachytherapy
PSA nadir: Jun 2012: 0.1
PSA bounce between Dec 2012 to Dec 2013 with high 0.2 June 2013
PSA rising: Jun 2014: 0.2, Dec 2014: 0.3, July 2015: 0.4, July 2016:1.5, Oct 2016: 1.8

Biopsy Sept 2016: No cancer inside prostate, cancerous extra-prostatic mass. No Gleason scale assigned because of radiation damage.
MRI finds mass to be about 1 inch in diameter
ADT: Firmagon Oct, Nov, Dec 2016
Cyberknife of cancerous mass Jan 2017
Lupron: Jan 2017 and Apr 2017
PSA undetectable (<0.1) from Jan 2017 to Jan 2018
PSA rising: Apr 6, 2018: 0.2, July13, 2018: 0.9, Aug 28,2018: 1.3
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The latest PSA rise is quite rapid with doubling time less than 6 months. The latest PSA of 1.3 is very close to the PSA I had before second biopsy. Current prostate size is around 20 cc and second biopsy found only brachytherapy seeds, no cancer. My guess is that the prostate is not responsible for the rapid rise in PSA. The extra-prostatic mass treated with ADT and cyberknife is not expected to produce much PSA rise. Bone scan and CT results were negative. My guess is most of the PSA is coming from some hidden prostate cancer. Where is the PSA producing cancer? if it is in the bone and elsewhere, it must be too small to be picked up by bone scan.

At this point should I wait and see how the PSA rises further? How high should the PSA rise before I hit the panic button? Have another biopsy? Start ADT without further delay? What other options are open to me?

I have good possibility of getting into a NIH clinical study to detect small recurrent and metastatic cancer. If it happens it would in October or later.

My testosterone was 40 in January 2018 and it is 332 in August 2018.

Just WOW.. I don't know $hit from shinola but I think I would sign up for the NIH scans.. it's hiding somewhere.. hoping for the best outcome for you.. Ed

I don't think that waiting a few more months to start ADT will be problematic, although I'm not sure what you'd do differently about it if the PET scan finds something or nothing. Either way, you'd probably start ADT.

Which brachy did you have?

I am not an expert but can PC hide in SV?

Going for brachy said...
My testosterone was 40 in January 2018 and it is 332 in August 2018

No wonder your PSA value is rising. All cancer cells were not killed by radiation yet. I would wait if the PSA value stabilizes within the next six months. A value below 2 ng/ml is a good result for radiation therapy.

George