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Living with cancer·Standard of care

Biochemical recurrence of prostate cancer: the decisions you may face

Cancer page →Second-opinion finder →

4 treatment settings, 3 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.

Other settings

After prostatectomy

3 options

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.

Guideline
NCCN Guidelines: Prostate Cancer
The options, in plain words
IMRT / IGRT (modern external beam)Standard of care

IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.

  • Conformal dose, fewer side effects
  • Hypofractionation saves visits
Androgen deprivation & AR pathway inhibitorsStandard of care

Androgen deprivation lowers testosterone or blocks its receptor, and has been the foundation of prostate cancer treatment since 1941 (Nobel Prize 1966).

  • Prolonged disease control
Decipher ProstateEstablishedGene-expression genomic classifier

A 22-gene test on the biopsy or surgical specimen that predicts spread and death, used to decide on surveillance or adding hormone therapy.

Also referenced:PSA (prostate-specific antigen)
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
IMRT / IGRT (modern external beam)
  • Low-dose bath to normal tissue
  • Motion management
Androgen deprivation & AR pathway inhibitors
  • Metabolic and bone toxicity; castration resistance inevitable in metastatic disease
Questions to ask about this decision
  1. Between IMRT / IGRT (modern external beam), Androgen deprivation & AR pathway inhibitors and Decipher Prostate, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. 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.
  6. 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.

Add these to your appointment list, or take the full question set for this cancer.

Second line

After radiotherapy, local recurrence

4 options

Salvage prostatectomy, brachytherapy, cryotherapy or high-intensity focused ultrasound in fit men with biopsy-proven local disease and no metastases on PSMA PET.

Guideline
NCCN Guidelines: Prostate Cancer
The options, in plain words
Robotic & minimally invasive surgeryStandard of care

Surgeons operate through small incisions using robotic arms with tremor-free precision and 3D vision.

  • Precision, shorter stay
  • Enables complex minimally invasive resections
BrachytherapyStandard of care

Brachytherapy places a radioactive source directly inside or next to the tumour.

  • Highest conformality
  • Short treatment
Focused ultrasound & histotripsyEstablished

Destroying tumours from outside the body with tightly focused sound waves, using either heat or microscopic bubbles.

  • Completely non-invasive
  • No ionising radiation
PSMA PETStandard of care

A prostate-cancer-specific PET scan that finds spread far earlier than CT or bone scan, and tells you whether a matched radioactive drug will work.

  • Detects recurrence at PSA <0.5 ng/mL
  • Theranostic gatekeeper
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
Robotic & minimally invasive surgery
  • Cost
  • Loss of haptic feedback
  • Not superior for every indication
Brachytherapy
  • Invasive
  • Declining expertise in some regions
Focused ultrasound & histotripsy
  • Acoustic window (ribs, bowel gas)
  • Long-term oncologic data limited
PSMA PET
  • PSMA-negative disease in ~10%
  • Uptake in ganglia, salivary glands
Questions to ask about this decision
  1. Between Robotic & minimally invasive surgery, Brachytherapy, Focused ultrasound & histotripsy and the other options, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. 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.

Add these to your appointment list, or take the full question set for this cancer.

Second line

High-risk biochemical recurrence (doubling time under 9 months)

3 optionsCompare side by side →

Enzalutamide with leuprolide, or enzalutamide alone (EMBARK); PSMA PET before starting; intermittent therapy with treatment suspension when PSA becomes undetectable.

Guideline
NCCN Guidelines: Prostate Cancer
The options, in plain words
EnzalutamideApprovedSmall-molecule AR antagonist

Enzalutamide is a second-generation androgen-receptor blocker that stops the receptor binding testosterone, entering the nucleus and switching on genes. It is approved at every stage of advanced prostate cancer, from rising PSA after surgery to castration-resistant disease, and fatigue, falls and memory problems are its main drawbacks.

Leuprolide (leuprorelin) and GnRH agonistsApprovedGnRH agonist depot

Leuprolide is the injectable that shuts off testosterone production, the foundation of hormone therapy for prostate cancer since the 1980s; it is also used for ovarian suppression in premenopausal breast cancer.

PSMA PETStandard of care

A prostate-cancer-specific PET scan that finds spread far earlier than CT or bone scan, and tells you whether a matched radioactive drug will work.

  • Detects recurrence at PSA <0.5 ng/mL
  • Theranostic gatekeeper
The evidence behind it
  • EMBARKPhase 3NCT0231983720231,068 peopleevidence 79
    Tests Enzalutamide
    High-risk biochemical recurrence (PSA doubling time ≤9 months) after local therapy: enzalutamide + leuprolide, enzalutamide alone, or leuprolide alone

    MFS HR 0.42 (combination).

    Metastasis-free survival, enzalutamide + leuprolide vs leuprolide (%): Enzalutamide + leuprolide, 5-year MFS 87.3 (n=355) vs Leuprolide alone, 5-year MFS 71.4 (n=358) · HR 0.42 · source
The main trade-offs on record
Enzalutamideall recorded rates →
  • Seizure risk: caution with drugs that lower the seizure threshold.
PSMA PET
  • PSMA-negative disease in ~10%
  • Uptake in ganglia, salivary glands
Questions to ask about this decision
  1. Between Enzalutamide, Leuprolide (leuprorelin) and GnRH agonists and PSMA PET, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in EMBARK, and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. 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.
  7. 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.
  8. How do the results of EMBARK apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

Second line

PSMA PET-detected oligorecurrence

One path named

Stereotactic radiotherapy to the visible metastases, usually within trials or with hormone therapy; the survival benefit is unproven.

The path, in plain words
SBRT / SABR (stereotactic radiotherapy)Standard of care

Stereotactic body radiotherapy converges multiple beams with sub-millimetre accuracy to deliver tumour-destroying doses in one to five outpatient sessions, doing the job of surgery for inoperable early lung cancer and for metastases in liver, spine and brain. Tumour size and location limit its use, and late toxicity is a concern near the central airways.

  • Ablative doses with minimal recovery
  • Outpatient
Also referenced:Oligometastatic diseasePSMA-PET-guided metastasis-directed therapy as a curative strategy in oligorecurrent prostate cancer
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
SBRT / SABR (stereotactic radiotherapy)
  • Size and location limits
  • Late toxicity near central airways
Questions to ask about this decision
  1. Is SBRT / SABR (stereotactic radiotherapy) the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
    Why: A single standard does not mean a single choice; timing and trials are decisions too.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. 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.

Add these to your appointment list, or take the full question set for this cancer.

How to read this page. Options and results come from OnCo records with their sources; the settings are the standard-of-care rows on the cancer page, and the lines of therapy are on the sequencing grid. Where a setting names one path, the choice is usually about timing, trials and where to be treated: see expert centres. OnCo is orientation, not medical advice.