Prostate Cancer BCR After Prostatectomy: When Salvage Radiotherapy and Hormonal Therapy Have Not Controlled PSA Rise

In men with prostate cancer who develop biochemical recurrence after radical prostatectomy — defined as two consecutive PSA rises above an undetectable level — salvage radiotherapy with hormonal therapy is the established first response. When that treatment fails to achieve its intended goals, a subsequent, structured escalation protocol is indicated.

Clinical Scenario

Male patient with prostate cancer biochemical recurrence following radical prostatectomy: two consecutive PSA rises above the undetectable threshold, with no distant metastases identified on imaging.

Prior Treatment Line — Goals Not Reached

Early salvage IMRT/VMAT plus image-guided radiotherapy (IGRT) to the prostate bed, delivered together with hormonal therapy, was the initial response to biochemical recurrence. The goals of that line — undetectable serum PSA and no radiological progression — were not achieved, which triggers escalation to this next protocol.

Next-Step Approach (Partial Overview)

The structured protocol for this situation involves androgen deprivation therapy (ADT) combined with an additional targeted hormonal agent. The clinical goals pursued at this stage include PSA decline and metastasis-free survival. The complete regimen — including specific agents, eligibility criteria, and sequencing — is available in the full protocol.

Instant Access to Structured Evidence-Based Regimens

References

Offer early salvage intensity-modulated radiotherapy/volumetric arc radiation therapy plus image-guided radiotherapy to men with two consecutive prostate-specific antigen (PSA) rises.

Once the decision for salvage radiotherapy (SRT) has been made, SRT (at least 64 Gy) should be given as soon as possible.

Offer enzalutamide with ADT to EMBARK-like patients (M0 patients on conventional imaging and PSA doubling time of ≤ 9 months).

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