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BackTable / Urology / Article
Biochemical Recurrence in Prostate Cancer: How to Assess Risk Before & After Prostatectomy
Kaitlin Sheppard • Updated Feb 24, 2025 • 37 hits
Biochemical recurrence (BCR) of prostate cancer—defined as a rising PSA after definitive treatment—poses a clinical challenge in determining when and how to intervene. While some cases remain indolent, others signal the need for early salvage therapy. Advances in imaging and risk stratification have refined surveillance strategies, yet treatment decisions remain nuanced, balancing oncologic outcomes with patient preferences.
In this article, urologic oncologist Dr. James Eastham discusses his approach to counseling patients on recurrence risk before and after surgery, the role of nomograms in risk assessment, and evolving thresholds for PSA monitoring. He also elaborates on how recurrence risk and other patient parameters inform his treatment decisions.
This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Urology Brief
• Radical prostatectomy is not always a standalone intervention; high-risk patients often require adjuvant or salvage therapy.
• While nomograms provide statistical estimates, clinical judgement remains essential in counseling patients on recurrence risk.
• Biochemical recurrence does not equate to treatment failure but may indicate the need for additional therapy.
• The first postoperative PSA test is typically performed at 6-8 weeks, followed by semiannual testing for high-risk patients and annual testing for lower-risk cases after three years.
• Current practice favors a PSA threshold of 0.2 ng/mL for defining biochemical recurrence, reflecting advances in imaging and treatment selection.
• Advances in imaging have improved detection of recurrent disease, refining the decision-making process for initiating salvage therapy.
• Not all node-positive patients have the same recurrence risk; treatment decisions should be individualized based on tumor burden, Gleason score, and pathological findings.
• While adjuvant radiation is not standard for all node-positive cases, high-risk features (e.g. multiple positive nodes, seminal vesicle invasion, Gleason 9 disease) may warrant earlier intervention.
• Avoiding unnecessary radiation in low-risk patients while ensuring timely therapy for high-risk cases remains a key challenge in optimizing long-term outcomes.
Table of Contents
(1) Preoperative Counseling & Risk Assessment in High-Risk Prostate Cancer
(2) Postoperative PSA Monitoring & Thresholds for Biochemical Recurrence
(3) Assessing Risk in Node-Positive Post-Prostatectomy Cases
Preoperative Counseling & Risk Assessment in High-Risk Prostate Cancer
Preoperative counseling for prostate cancer has shifted alongside advancements in risk stratification, treatment, and outcomes. Dr. Eastham highlights the increasing focus on high-risk patients, where surgery is often part of a multimodal strategy rather than a standalone intervention. Given the likelihood of biochemical recurrence in these cases, early discussions about potential adjuvant or salvage therapies are essential. While nomograms provide statistical estimates of recurrence risk, many clinicians rely on clinical experience and judgment to guide treatment expectations.
Rather than framing recurrence as a failure, the contemporary approach emphasizes comprehensive planning, ensuring patients understand the evolving role of surgery, radiation, and systemic therapy in optimizing long-term outcomes.
[Dr. Aditya Bagrodia]:
I thought we could actually kick off with the preoperative counseling. When you see a patient that comes in, their cancer merits treatment, and you're advising them, "Let's focus on the oncologic outcomes." What does that look like, James?
[Dr. James Eastham]:
It is changing, and it has changed over the years. We've transitioned from operating on folks who had relatively low or favorable intermediate risk, and now we're operating on patients with much higher-risk cancers. The need for salvage treatment or even adjuvant treatment has increased. I have a conversation based on the patient's risk, first letting them know that if they do require treatment after surgery, it's not necessarily a failure, it's part of their treatment paradigm.
Especially in high-risk situations, in many other cancers, we routinely use combinations of surgery and radiation therapy. I approach it that way, that surgery is potentially curative, but it's also potentially part of a multidimensional strategy that may involve radiation, that may involve systemic therapy, and we will go through the process of how those might be incorporated.
[Dr. Aditya Bagrodia]:
That's super helpful. Are you actually going through the Sloan Kettering nomograms, the Partin tables, any type of predictive model with their specific characteristics, or is it a gestalt after doing this for a while?
[Dr. James Eastham]:
Yes, it's a gestalt. I do not give a patient you have an X percent chance of biochemical recurrence within so many months of surgery. I just give them a gestalt that patients with your risk prostate cancer are more or less likely or there is a chance that you will need additional treatment down the road. Most of that will be guided by your postoperative PSA testing. Pathology can help guide the type of treatment, but whether or not treatment is given is usually determined by whether or not their PSA is detectable and rising.
[Dr. Aditya Bagrodia]:
Perfect. I think you're absolutely right. These days, it's not grade group 1 or even small volume grade group 2 with the small pattern 4. These are real cancers and we have so many more tools now, MRI and PSMA PET scan and maybe we'll touch base on that. I would say it's like I also go with the gestalt early on. I use the Sloan Kettering nomograms, but I feel like they can be a little bit of a source of consternation for patients when you look at these biochemical recurrence-free survival rates that can be relatively low.
Even when you shift to your overall survival at 10 and 15 years being 99% and 99% respectively, on the one hand, I think it manages expectations, on the other hand, I think it can be a little bit dejecting out of the gates. Any comment on that?
[Dr. James Eastham]:
I think like anything, a nomogram as a tool, and not all tools need to be utilized. Many of our patients will have gone on the website and the nomograms are available. If they're interested in chatting about that, that's fine. I'll go through what they mean and what they don't mean, that biochemical recurrence is not death, that it oftentimes initiates an evaluation and potentially treatment.
Surgery is still a very effective part of the management strategy. Hopefully, the only management strategy, but part of the management strategy for many patients with higher-risk disease. We don't know whether surgery upfront or typically in the higher risk setting radiation plus hormones up front is the best course. It's a discussion with the patient about which of those strategies might be best for them.
I do not believe that surgery should be used in every single patient and I don't believe radiation therapy is appropriate for every single patient. It is getting a sense of what the patient is interested in accomplishing, what they're trying to do. Those types of factors come into what is recommended for a given patient. It's not one size fit all, and it's utilizing the tools we have. Hopefully, we don't need all of the tools, but in a given patient utilizing as few of the tools that we have to try to get them to where they want to be. That can vary from patient to patient.
[Dr. Aditya Bagrodia]:
I think that's perfect. As a part of the counseling, I try to get a sense of does this patient prefer things to be a little bit more black and white, PSA detectable, undetectable. If that resonates with a given person and they're a good candidate for both, sometimes I feel like that could be reason enough to tip them in one way or the other. I also think it'll be exciting to see the output of the Scandinavian trial, which is a difficult trial to execute surgery and possible post-operative radiation versus upfront radiation. It's been in the works for-- Gosh, 10, 15 years now. Any thoughts on that James, how that's going to enlighten us?
[Dr. James Eastham]:
It'll be like any clinical trial in non-metastatic prostate cancer. To get a meaningful endpoint will take a decade unless you select really high-risk patients, and then you'll get an outcome a little sooner. For most patients, it's always going to be "We don't know the exact right strategy. For you, these are the things you'll have to weigh." I just was in clinic and I was chatting with a gentleman with unfavorable intermediate-risk prostate cancer.
I said, "I could have your prostate twins sitting next to you, give you both the exact same information. One of you may opt for a radiation-based strategy, the other may opt for a surgery-based strategy, and you're both right because there will be something about a treatment that is either appealing or so unappealing that you'll go with the direction that it guides you to." That's the state right now. We've done lots of randomized trials and we say, "Yes, that was a good randomized trial," and we still don't follow the results. We still don't let it guide treatment.
I'm not sure a randomized trial will convince the biased to change what they do, but it's good to get information. Hopefully, the trials will be successful, and ultimately, we're trying to improve how we take care of our patients.
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Postoperative PSA Monitoring & Thresholds for Biochemical Recurrence
PSA monitoring after radical prostatectomy is not governed by strict guidelines but instead relies on clinical judgment and evolving evidence. Dr. Eastham describes his preferred surveillance strategy, beginning with an initial PSA test at six to eight weeks postoperatively, followed by routine assessments every six months for high-risk patients. The threshold for defining biochemical recurrence has shifted over time, moving from early intervention at 0.06 ng/mL to a more conservative 0.2 ng/mL, largely due to improvements in PSMA PET imaging. While most patients are observed until PSA reaches 0.2 ng/mL before initiating salvage therapy, certain high-risk cases—such as those with positive lymph nodes or large positive margins—may warrant earlier intervention. Despite the availability of ultra-sensitive PSA assays, excessively low thresholds can introduce unnecessary patient anxiety without clear clinical benefit.
[Dr. Aditya Bagrodia]:
First postoperative PSA, when is that coming, typically?
[Dr. James Eastham]:
You mean in terms of testing or what value or both?
[Dr. Aditya Bagrodia]:
Timing, what test, and what value. How about all three?
[Dr. James Eastham]:
Sure. Again, there's no science. It's preference. I usually get a PSA at about six to eight weeks after surgery, usually get one at six months after surgery, and then every six months. If they were a pathologically confined Gleason 3+4=7, at three years I'll convert to just checking a PSA once a year. If they were at higher risk than that, I'll continue doing PSAs every six months for the first five years. That is purely Eastham's brain. No science behind that, it's just what I prefer. There's no rationale for that, but that's just what I do.
The PSAs, what triggers salvage treatment has changed. Certainly in my career, it used to be that as soon as the PSA became detectable and it was confirmed that it was rising, and this was with ultra-sensitive values, at least at Memorial it's down around .05. When it reached .06 and it was confirmed, we would very frequently send to radiation therapy at that point. Then the whole concept of maybe there's a benign component, we should probably wait a little bit longer, then it became we'll call a recurrence at 0.1 and then we would send to radiation therapy.
Then now with PSMA scanning and the 0.2 cutoff, it's typically I'm waiting now until the PSA gets to 0.2, except in selected patients. Obviously, if they had positive lymph nodes, a large positive margin that was more than a couple millimeters, then I'll send early. For the majority of patients, typically waiting until their PSA is 0.2 would do imaging with both an MRI and a PSMA PET scan at that point, and refer typically to radiation oncology, letting the patient know that even in the setting of negative imaging, we likely will still recommend treatment, usually radiation therapy to the prostatic fossa.
[Dr. Aditya Bagrodia]:
Largely that sounds very similar to the way I practice, not surprising, since Memorial is where I train. I generally don't get the-- I guess I'll call it ultra-ultra PSAs, less than 0.06.
[Dr. James Eastham]:
No, I don't get those either. It's .05 at Memorial.
[Dr. Aditya Bagrodia]:
I generally find that they cause consternation. We'll talk a little bit about convalescence timing and how all that plays in. Six to eight weeks is exactly what I do, especially in the high-risk patients, and it's more to be a conversation starter necessarily than to pull the trigger, at least the way I think about it. We talk about timing, ultra-sensitive, and then value. For you, high-risk patient, multifocal positive nodes, node-positive disease, detectable has got your attention, garden variety, things are still not entirely clear. You're monitoring that, and 0.1, 0.2 is your threshold for defining a biochemical recurrence.
Assessing Risk in Node-Positive Post-Prostatectomy Cases
The presence of positive lymph nodes after radical prostatectomy represents a distinct risk category that requires individualized treatment decisions. Not all node-positive patients carry the same recurrence risk, and management should be risk-adjusted rather than dictated by generalized guidelines. Patients with low-volume nodal involvement, such as a solitary Gleason 3+4=7 node-positive lesion, may never develop biochemical recurrence. In contrast, those with high-risk features—such as multiple positive nodes, Gleason 9 disease, or seminal vesicle invasion—have an almost certain likelihood of recurrence and may require earlier intervention.
[Dr. James Eastham]:
I think most of the radiation therapy trials that looked at adjuvant versus early salvage, they didn't focus on node-positive patients. I think we can't apply a weight for the salvage setting in the node-positive patients. I think node-positive is a different risk category, and I have a low threshold to send node-positive patients to radiation oncology. I'm telling someone who knows, but node-positive patients aren't all the same. There's a risk of recurrence or a spectrum of recurrence even within node-positive.
A patient who had a 3+4=7 confined to the prostate with a solitary positive lymph node is very different than someone with a Gleason 9 with six positive nodes, extra-prostatic extension, and seminal vesicle invasion. Those patients are both node-positive, but they're going to have a very different likelihood of recurrence. Half of the former, the lower-risk node-positive, won't ever experience BCR, whereas I would venture to say 99.9% of the high-risk patients will.
It's difficult to talk in generalities about oh, salvage radiation. It still becomes risk-adjusted. While we tend not to think about adjuvant radiation therapy per se, I think in the node-positive, very high-risk group, I talk to those patients when I discuss their pathology that you're likely going to need radiation therapy, and we may not wait until your PSA reaches 0.2. We'll have you heal up from the operation, get your continence back, but I'm going to have you meet with a radiation oncologist sooner rather than later, so that's all in place. Whereas someone who had a regular non-node-positive radical prostatectomy with modest risk of recurrence, I won't send them to radiation therapy. I'll monitor their PSA test.
Podcast Contributors
Dr. James Eastham
Dr. James Eastham is a urologic surgeon at Memorial Sloan-Kettering Cancer Center in New York City.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2024, March 5). Ep. 155 – Managing Biochemical Recurrence After Prostatectomy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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