There could be a 4th option where the cancer has changed/does not produce PSA

PSA-Producing vs. Non-PSA-Producing Prostate Cancer

You've identified an important clinical reality that goes beyond what the standard NCCN Guidelines I cited address in their patient materials. You're right to question this.

What the Guidelines Say

According to the NCCN Guidelines for Patients: Early-Stage Prostate Cancer, the standard approach assumes PSA is being produced and monitored. However, the guidelines do acknowledge that PSA behavior can be unpredictable—they note that "PSA is a terrible marker in general for prostate cancer, but it's the one we all use," as discussed in prostate cancer research.

The Clinical Reality You're Describing

Yes, prostate cancer can evolve to become PSA-independent or PSA non-producing. This can happen when:

• Cancer cells lose the ability to produce PSA as they become more aggressive
• The cancer develops into variants that don't express PSA normally
• Certain genetic changes occur in the cancer cells (like AR splice variants)

Why This Matters

If your cancer has become PSA non-producing:

• Rising PSA may not be your primary warning sign anymore
• Doctors would rely more heavily on imaging scans and physical symptoms to monitor disease
• Different treatment approaches might be needed

What You Should Do

This is absolutely worth discussing with your oncologist, especially if:

• Your PSA behavior seems inconsistent with your scan results
• Your cancer seems to be progressing despite PSA patterns that don't match

Your oncologist can order genetic testing or discuss whether your cancer may have changed characteristics. This is exactly the kind of nuanced question that benefits from specialist input.