# Biochemical recurrence of prostate cancer

Source: https://onco.cc/cancers/prostate-bcr/  
OnCo record `prostate-bcr` (Cancer). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Biochemical recurrence of prostate cancer is a rising PSA after surgery or radiotherapy with nothing yet visible on scans. Salvage radiotherapy can still cure it after surgery, and for a fast-doubling PSA the EMBARK trial showed that enzalutamide with or without hormone therapy delays spread.

## Summary

Biochemical recurrence is defined as a PSA of 0.2 ng/mL or more, confirmed, after radical prostatectomy, or a rise of 2 ng/mL above the nadir after radiotherapy (the Phoenix definition). It is found by routine PSA follow-up; PSMA PET now locates the recurrence in most men once PSA passes about 0.5 ng/mL, and often shows disease that conventional imaging misses. After prostatectomy, early salvage radiotherapy to the prostate bed, started before PSA reaches 0.5, cures many men, with short-term hormone therapy added for higher-risk features. After radiotherapy, local salvage by surgery, brachytherapy, cryotherapy or high-intensity focused ultrasound is possible for confirmed local recurrence. Men with a PSA doubling time under nine months are at high risk of metastasis: EMBARK randomised 1,068 such men and showed enzalutamide with leuprolide, or enzalutamide alone, cut metastasis or death by about half compared with leuprolide alone, and the FDA approved enzalutamide for this setting in 2023. Slowly rising PSA can be watched, and PSMA PET-directed stereotactic radiotherapy to a few metastases is under study.

## Fields

- Kind: Cancer
- Last checked: 2026-09-25
- Also known as: Biochemically recurrent prostate cancer; PSA recurrence; Rising PSA after local therapy; nmHSPC; Hormone-relapsed prostate cancer, PSA-only; Rising PSA after treatment
- Tags: subtype-page
- Group: genitourinary
- Burden: A rising PSA follows a quarter to a third of prostatectomies and radiotherapy courses; only a minority of these men develop metastases on scans within ten years, and the PSA doubling time tells the two apart.
- Subtypes: Biochemical recurrence after prostatectomy (PSA 0.2 or more); Biochemical recurrence after radiotherapy (nadir plus 2); High-risk biochemical recurrence (PSA doubling time under 9 months, non-metastatic hormone-sensitive); PSMA PET-detected oligorecurrence
- Biomarkers: PSA and PSA doubling time; PSMA PET (positive in most men above 0.5 ng/mL); Decipher on the prostatectomy specimen; Interval from local therapy to recurrence

## Sections of this record

The page is a hub with ten sections in reading order; large sections have their own page. The same plan as JSON: https://onco.cc/api/v1/cancers/prostate-bcr/sections.json

- Overview (on the hub): The TL;DR, the family this cancer belongs to, the organ, who gets it and what the state of the art is. https://onco.cc/cancers/prostate-bcr/#overview [3 state-of-the-art points]
- Types and stages (on the hub): Anatomy, the subtypes and how they differ, how it is staged, and where advanced disease spreads. https://onco.cc/cancers/prostate-bcr/#what-it-is [4 subtypes]
- Symptoms and diagnosis (on the hub): How this cancer shows itself, how the diagnosis is confirmed, and the biomarkers clinicians test for. https://onco.cc/cancers/prostate-bcr/#finding-it [4 biomarkers]
- Treatment (on the hub): The standard of care by setting, the medicines, surgery and radiotherapy named in it, and the regimens behind them. https://onco.cc/cancers/prostate-bcr/#treating-it [4 settings, 3 decisions with options]
- Trials and papers (on the hub): Trials recruiting now, the landmark trials, the trials held by this cancer's subtypes, the key papers and what they mean, the latest literature, and the milestones year by year. https://onco.cc/cancers/prostate-bcr/#evidence [19 trials, 3 key papers, 5 milestones]
- Biology and targets (on the hub): The molecular landscape: the targets and how often each appears, the pathways, the mechanics stages and the preclinical models. https://onco.cc/cancers/prostate-bcr/#science [1 target]
- Countries and centres (own page): Cases by country, the UK and NHS pathway and other country lenses, the expert centres with trials on record, and the centres named on this cancer's subtypes. https://onco.cc/cancers/prostate-bcr/where-you-are/ [26 UK centres]
- Decisions and support (on the hub): The decisions you may face, the aids that walk through them, the warnings on record, the first sixty days and the questions to ask. https://onco.cc/cancers/prostate-bcr/#living-with-it [16 questions, 2 red cards]
- Pipeline and open problems (own page): Everything in development, the medicines held by this cancer's subtypes, the open problems and what is being done about them, the roadmaps, and what changed on this record. https://onco.cc/cancers/prostate-bcr/coming/ [4 medicines, 19 trials, 1 idea, 3 open problems]
- Data (own page): Every connected record, the notes, the JSON, Markdown and RDF twins, and where the record came from and when it was checked. https://onco.cc/cancers/prostate-bcr/data/ [60 connected records, 1 note]

## Standard of care

- After prostatectomy: Early salvage radiotherapy to the prostate bed, with or without pelvic nodes and four to six months of androgen deprivation for adverse features; observation for slow doubling times. ([IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [Androgen deprivation & AR pathway inhibitors](https://onco.cc/technologies/androgen-deprivation/), [PSA (prostate-specific antigen)](https://onco.cc/terms/psa/), [Decipher Prostate](https://onco.cc/drugs/decipher-prostate/))
- After radiotherapy, local recurrence: Salvage prostatectomy, brachytherapy, cryotherapy or high-intensity focused ultrasound in fit men with biopsy-proven local disease and no metastases on PSMA PET. ([Robotic & minimally invasive surgery](https://onco.cc/technologies/robotic-surgery/), [Brachytherapy](https://onco.cc/technologies/brachytherapy/), [Focused ultrasound & histotripsy](https://onco.cc/technologies/hifu-histotripsy/), [PSMA PET](https://onco.cc/technologies/psma-pet/))
- High-risk biochemical recurrence (doubling time under 9 months): Enzalutamide with leuprolide, or enzalutamide alone (EMBARK); PSMA PET before starting; intermittent therapy with treatment suspension when PSA becomes undetectable. ([Enzalutamide](https://onco.cc/drugs/enzalutamide/), [Leuprolide (leuprorelin) and GnRH agonists](https://onco.cc/drugs/leuprolide/), [EMBARK](https://onco.cc/trials/embark/), [PSMA PET](https://onco.cc/technologies/psma-pet/))
- PSMA PET-detected oligorecurrence: Stereotactic radiotherapy to the visible metastases, usually within trials or with hormone therapy; the survival benefit is unproven. ([SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/), [Oligometastatic disease](https://onco.cc/terms/oligometastatic/), [PSMA-PET-guided metastasis-directed therapy as a curative strategy in oligorecurrent prostate cancer](https://onco.cc/ideas/idea-psma-pet-guided-mdt/))

## State of the art

- PSMA PET has turned biochemical recurrence from an invisible number into a map, though it also finds disease the trials never saw.
- EMBARK is the first trial to show that treating a fast-rising PSA with an androgen receptor inhibitor delays metastasis.
- Intermittent therapy with a treatment holiday is built into the approved EMBARK regimen.

## Open problems

- Whether treating PSMA PET-detected metastases early lengthens life or only lowers PSA.
- How to spare men with slow doubling times from years of hormone therapy.
- The trials that defined recurrence used conventional imaging; PSMA PET restages many of these men as metastatic.

## Notes

- The findings on the prostatectomy report that raise the chance of arriving here are extraprostatic extension (pT3a), seminal vesicle invasion (pT3b) and a positive surgical margin, which are three different things: the first two say how far the cancer grew, the third says whether the surgeon's cut passed through cancer, and a man can have one without the others.

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Biochemical_recurrence
- Wikipedia: https://en.wikipedia.org/wiki/Biochemical_recurrence
- NCCN Guidelines: Prostate Cancer: https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1459
- NICE NG131: prostate cancer, diagnosis and management (recommendations, including the Cambridge Prognostic Group table at 1.2.15): https://www.nice.org.uk/guidance/ng131/chapter/Recommendations

## Connected records

- cancers: [Localised prostate cancer, high and very high risk](https://onco.cc/cancers/prostate-high-risk/), [Localised prostate cancer, intermediate risk](https://onco.cc/cancers/prostate-intermediate-risk/), [Localised prostate cancer, very low and low risk](https://onco.cc/cancers/prostate-low-risk/), [Metastatic castration-resistant prostate cancer](https://onco.cc/cancers/prostate-mcrpc/), [Metastatic hormone-sensitive prostate cancer](https://onco.cc/cancers/prostate-mhspc/), [Non-metastatic castration-resistant prostate cancer](https://onco.cc/cancers/prostate-nmcrpc/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- terms: [Cambridge Prognostic Group (CPG 1 to 5)](https://onco.cc/terms/cambridge-prognostic-group/), [Extraprostatic extension and seminal vesicle invasion](https://onco.cc/terms/extraprostatic-extension/), [Intermittent androgen deprivation (IAD)](https://onco.cc/terms/intermittent-androgen-deprivation/), [Metastasis-free survival (MFS)](https://onco.cc/terms/metastasis-free-survival/), [Oligometastatic disease](https://onco.cc/terms/oligometastatic/), [PSA (prostate-specific antigen)](https://onco.cc/terms/psa/), [PSA density](https://onco.cc/terms/psa-density/), [PSA kinetics: PSA doubling time and PSA density](https://onco.cc/terms/psa-kinetics/), [TNM staging for prostate cancer, and what changed in the 9th edition](https://onco.cc/terms/tnm-prostate-cancer/)
- key papers: [EMBARK: enzalutamide with or without leuprolide in high-risk biochemically recurrent prostate cancer](https://onco.cc/key-papers/paper-embark-nejm-2023/), [proPSMA: PSMA PET-CT versus conventional imaging for staging high-risk prostate cancer](https://onco.cc/key-papers/paper-propsma-hofman-lancet-2020/), [RADICALS-RT: timing of radiotherapy after radical prostatectomy](https://onco.cc/key-papers/paper-radicals-rt-lancet-2020/)
- drugs: [Bicalutamide](https://onco.cc/drugs/bicalutamide/), [Decipher Prostate](https://onco.cc/drugs/decipher-prostate/), [Enzalutamide](https://onco.cc/drugs/enzalutamide/), [Leuprolide (leuprorelin) and GnRH agonists](https://onco.cc/drugs/leuprolide/)
- technologies: [Androgen deprivation & AR pathway inhibitors](https://onco.cc/technologies/androgen-deprivation/), [Brachytherapy](https://onco.cc/technologies/brachytherapy/), [Focused ultrasound & histotripsy](https://onco.cc/technologies/hifu-histotripsy/), [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [PSMA PET](https://onco.cc/technologies/psma-pet/), [Robotic & minimally invasive surgery](https://onco.cc/technologies/robotic-surgery/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/)
- trials: [64Cu-SAR-bisPSMA Positron Emission Tomography: A Phase 3 Study of Participants With Biochemical Recurrence of Prostate Cancer](https://onco.cc/trials/nct06970847/), [A Study to Compare Darolutamide Given With Androgen Deprivation Therapy (ADT) and Placebo Given With ADT in Men With Hormone Sensitive Prostate Cancer](https://onco.cc/trials/nct05794906/), [ARTISTIC meta-analysis](https://onco.cc/trials/artistic-meta-analysis/), [Biodistribution and Dosimetry of Ga-68 P16-093 in Prostate Cancer](https://onco.cc/trials/nct03444844/), [Cinacalcet Hydrochloride in Treating Men With Recurrent Prostate Cancer](https://onco.cc/trials/nct01054079/), [EMBARK](https://onco.cc/trials/embark/), [EORTC 22911](https://onco.cc/trials/eortc-22911/), [GETUG-AFU 16](https://onco.cc/trials/getug-afu-16/), [GETUG-AFU 17](https://onco.cc/trials/getug-afu-17/), [Hormone Therapy in Treating Patients With Rising PSA Levels Following Radiation Therapy for Prostate Cancer](https://onco.cc/trials/nct00003653/), [ORIOLE](https://onco.cc/trials/oriole/), [PET Scan Study to Detect Prostate Cancer in Patients with Early PSA Recurrence](https://onco.cc/trials/nct06617481/), [Prostate Radiation Therapy or Short-Term Androgen Deprivation Therapy and Pelvic Lymph Node Radiation Therapy With or Without Prostate Radiation Therapy in Treating Patients With a Rising Prostate Specific Antigen (PSA) After Surgery for Prostate Cancer](https://onco.cc/trials/nct00567580/), [RADICALS-HD](https://onco.cc/trials/radicals-hd/), [RADICALS-RT](https://onco.cc/trials/radicals-rt/), [RAVES (TROG 08.03/ANZUP)](https://onco.cc/trials/raves/), [STOMP](https://onco.cc/trials/stomp-oligorecurrence/), [SWOG 8794](https://onco.cc/trials/swog-8794/), [Treating Prostate Cancer That Has Come Back After Surgery With Apalutamide and Targeted Radiation Based on PET Imaging](https://onco.cc/trials/nct04423211/)
- ideas: [PSMA-PET-guided metastasis-directed therapy as a curative strategy in oligorecurrent prostate cancer](https://onco.cc/ideas/idea-psma-pet-guided-mdt/)
- roadmaps: [Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch](https://onco.cc/roadmaps/prostate-roadmap/)
- people: [Chris C. Parker](https://onco.cc/people/chris-parker/), [Stephen J. Freedland](https://onco.cc/people/stephen-freedland/)
- biomarkers: [PSMA expression by PET (PSMA-positive)](https://onco.cc/biomarkers/psma-pet-expression/)

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JSON: https://onco.cc/api/v1/entities/prostate-bcr.json