Biochemical recurrence of prostate cancer
Biochemical recurrence 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.
Overview
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.
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.
Red cards
From the labels and guidelines behind the standard of care. Your team's thresholds win.- Emergency services nowBlood clot (tamoxifen and others)
A swollen painful calf, or sudden breathlessness with chest pain; the tamoxifen boxed warning covers pulmonary embolism and stroke.
- Check before combiningFood and drink: Enzalutamide
Seizure risk: caution with drugs that lower the seizure threshold.
See all on the product pages:EnzalutamideLeuprolide (leuprorelin) and GnRH agonists·Printable cards in the navigator
Anatomy and lymph node drainage
- Peripheral zone (most cancers)
- Transition zone (BPH)
- Ducts (ductal, intraductal, neuroendocrine)
- Seminal vesicle (T3b)
- Nodes: obturator
- Nodes: internal iliac
- Nodes: external iliac
- Nodes: presacral
About three quarters of cancers arise in the peripheral zone at the back of the gland, the part a finger or a biopsy needle reaches; drainage is to the obturator and iliac nodes.
- Peripheral zone (most cancers)High-risk biochemical recurrence (PSA doubling time under 9 months, non-metastatic hormone-sensitive)
- Transition zone (BPH)
- Ducts (ductal, intraductal, neuroendocrine)
- Seminal vesicle (T3b)
- obturator
- internal iliac
- external iliac
- presacral
Same organ: Prostate cancer, Localised prostate cancer, very low and low risk, Localised prostate cancer, intermediate risk, Localised prostate cancer, high and very high risk, Metastatic hormone-sensitive prostate cancer, Non-metastatic castration-resistant prostate cancer, Metastatic castration-resistant prostate cancer, Neuroendocrine and small-cell prostate cancer
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.
Cases by country
No country-level case numbers. This cancer is not mapped to a GLOBOCAN site.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
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.
Salvage prostatectomy, brachytherapy, cryotherapy or high-intensity focused ultrasound in fit men with biopsy-proven local disease and no metastases on PSMA PET.
Enzalutamide with leuprolide, or enzalutamide alone (EMBARK); PSMA PET before starting; intermittent therapy with treatment suspension when PSA becomes undetectable.
Stereotactic radiotherapy to the visible metastases, usually within trials or with hormone therapy; the survival benefit is unproven.
Subtypes & biomarkers
top- 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
- 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
How often this target appears
- 1997ASTRO consensus defines PSA failure after radiotherapy
- 2005Phoenix definition: nadir plus 2 ng/mL
- 2017RTOG 9601: bicalutamide with salvage radiotherapy improves survival
- 2020PSMA PET approved for recurrence
- 2023EMBARK: enzalutamide delays metastasis in high-risk biochemical recurrence
Dated changes read from the records linked to this cancer: approvals, regulatory steps, reported trials, guideline versions and milestones. Newest first; no date is inferred.
All 7 changes by month →- 2026-09-17This recordBiochemical recurrence of prostate cancerFacts on this page last checked
When this page itself was last checked or edited.
- 2023Trial resultEMBARKEMBARK reported
MFS HR 0.
- 2023MilestoneEMBARKEMBARK: enzalutamide delays metastasis in high-risk biochemical recurrence
A milestone in how this cancer is treated.
- 2020MilestonePSMA PETPSMA PET approved for recurrence
A milestone in how this cancer is treated.
- 2017MilestoneBicalutamideRTOG 9601: bicalutamide with salvage radiotherapy improves survival
A milestone in how this cancer is treated.
- 2005MilestonePSA (prostate-specific antigen)Phoenix definition: nadir plus 2 ng/mL
A milestone in how this cancer is treated.
What is in development for Biochemical recurrence of prostate cancer, drawn from the whole corpus: 2 items. Drugs are grouped by the most advanced trial phase they have reached anywhere; approved treatments sit under standard of care. Technologies are the methods being tested for this cancer, trials are the studies recorded here, and ideas are proposals not yet in a trial.
Trials reported · 1
- EMBARK · phase 3 · 2023 · positive
Ideas not yet in a trial · 1
Open problems and what is being done
Whether treating PSMA PET-detected metastases early lengthens life or only lowers PSA.
and how the field plans to fix it →What is being done about thisAdvanced and metastatic diseaseAvailable now- Decipher ProstateEstablished
- IMRT / IGRT (modern external beam)Standard of care
- PSMA PETStandard of care
- SBRT / SABR (stereotactic radiotherapy)Standard of care
In trials- EMBARKPositive
Background: Oligometastatic disease. Also on OnCo: Atlas of advanced disease · Invasion and metastasis.
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.
Trials
topTrials recruiting now
Country and place are remembered in this browser only. A postcode is sent to OpenStreetMap's Nominatim service to find coordinates when you press the button; nothing else leaves your device.
Landmark trials
Expert centres
topExpert centres
Melbourne · cancer center | Australia | none recorded | 0 | 1,547 | 24,196 | #14 | |
Seoul · hospital | South Korea | none recorded | 0 | 464 | 3,248 | #22 | |
Stanford · university | United States | 0 | 3,000 | 50,162 | #30 | ||
Munich · university | Germany | none recorded | 0 | 1,937 | 23,450 | #31 | |
San Francisco · cancer center | United States | 0 | 2,800 | 46,704 | #33 | ||
Shanghai · hospital | China | none recorded | 0 | 2,872 | 31,534 | - | |
London · hospital | United Kingdom | none recorded | 0 | 2,376 | 28,940 | - | |
Sydney · cancer center | Australia | none recorded | 0 | 2,222 | 33,278 | - | |
Los Angeles · cancer center | United States | 0 | 2,019 | 32,934 | - | ||
Beijing · hospital | China | none recorded | 0 | 1,784 | 18,230 | - | |
Dallas, TX · cancer center | United States | 0 | 1,744 | 19,757 | - | ||
Utrecht · cancer center | Netherlands | none recorded | 0 | 1,422 | 20,323 | - | |
Guangzhou · hospital | China | none recorded | 0 | 1,245 | 12,931 | - | |
Tianjin · cancer center | China | none recorded | 0 | 1,219 | 11,455 | - | |
Hangzhou · cancer center | China | none recorded | 0 | 1,219 | 17,635 | - |
These are the things we can measure; they are not a ranking of quality. Each column is a field on the institution record or a count over what OnCo has linked; a centre that treats many patients with Biochemical recurrence of prostate cancer but is thinly recorded here will look small.
Not known: OnCo holds no case-volume or outcome figures for centres, so none are shown. Where a national audit or registry publishes them, the centre's page links to it. Default order: Newsweek rank, then trials for this cancer, then research output.
Questions to ask
topQuestions to ask your oncologist about Biochemical recurrence of prostate cancer
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Why: Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example PSA and PSA doubling time, PSMA PET, Decipher on the prostatectomy specimen, Interval from local therapy to recurrence), and what were the results?Why: These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Why: Recognised subtypes for this cancer include Biochemical recurrence after prostatectomy, Biochemical recurrence after radiotherapy, High-risk biochemical recurrence.
- Is germline (inherited) genetic testing recommended for me or my family?Why: Inherited variants can change treatment and matter for relatives.
After prostatectomy
- For my situation (after prostatectomy), which of the standard options do you recommend and why?Why: Guideline options include: 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.
- Am I a candidate for Decipher Prostate, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
After radiotherapy, local recurrence
- For my situation (after radiotherapy, local recurrence), which of the standard options do you recommend and why?Why: Guideline options include: Salvage prostatectomy, brachytherapy, cryotherapy or high-intensity focused ultrasound in fit men with biopsy-proven local disease and no metastases on PSMA PET.
High-risk biochemical recurrence (doubling time under 9 months)
- For my situation (high-risk biochemical recurrence (doubling time under 9 months)), which of the standard options do you recommend and why?Why: Guideline options include: Enzalutamide with leuprolide, or enzalutamide alone (EMBARK); PSMA PET before starting; intermittent therapy with treatment suspension when PSA becomes undetectable.
- Am I a candidate for Enzalutamide, Leuprolide (leuprorelin) and GnRH agonists, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of EMBARK apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
PSMA PET-detected oligorecurrence
- For my situation (psma pet-detected oligorecurrence), which of the standard options do you recommend and why?Why: Guideline options include: Stereotactic radiotherapy to the visible metastases, usually within trials or with hormone therapy; the survival benefit is unproven.
Any stage
- Are there clinical trials I could join, for example of PSMA PET, Enzalutamide, SBRT / SABR (stereotactic radiotherapy), PSMA-PET-guided metastasis-directed therapy as a curative strategy in oligorecurrent prostate cancer?Why: Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Why: Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Why: Supportive care improves quality of life and helps patients complete treatment.
- I read that “Whether treating PSMA PET-detected metastases early lengthens life or only lowers PSA”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
- I read that “How to spare men with slow doubling times from years of hormone therapy”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
Newly diagnosed? Read the first 60 days with Biochemical recurrence of prostate cancer, then print the one-page appointment sheet with room for the answers.
Print this page for your appointment (your browser's print command). These prompts are for discussion; your clinical team knows your case.
Direct links plus the targets, companies, and technologies of this cancer's products.
technologies
10targets
1drugs
4companies
9terms
2trials
1ideas
1Latest papers
topQuery for this cancer: (TITLE:"Biochemical recurrence of prostate cancer" OR ABSTRACT:"Biochemical recurrence of prostate cancer" OR TITLE:"Biochemically recurrent prostate cancer" OR ABSTRACT:"Biochemically recurrent prostate cancer" OR TITLE:"PSA recurrence" OR ABSTRACT:"PSA recurrence" OR TITLE:"Rising PSA after local therapy" OR ABSTRACT:"Rising PSA after local therapy" OR TITLE:"nmHSPC" OR ABSTRACT:"nmHSPC") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Biochemical recurrence of prostate cancer, not a curated reading list.
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