Despite significant technological advancements, radical prostatectomy (RP) and radiotherapy (RT) are not always effective in curing localised prostate cancer (PCa). Many patients experience a rise in prostate-specific antigen (PSA), known as biochemical recurrence (BCR), leading to considerable anxiety and a search for solutions. Various treatment options for BCR have been extensively discussed over the years. According to European Association of Urology (EAU) guidelines, men with two consecutive prostate specific antigen (PSA) rises after RP should be offered early salvage RT, and highly selected patients with biopsy-proven local recurrence after RT should be offered salvage local treatment. New imaging technologies like prostate-specific membrane antigen (PSMA) positron emission tomography (PET) have gained prominence, with the EAU recommending its use when PSA levels exceed 0.2ng/ml if it affects treatment decisions. Although small phase two trials support metastasis-targeted therapy, it lacks demonstrated overall survival (OS) or progression-free survival benefits, yet many view it as standard care. However, only one-third of BCR patients develop metastases, and one-fifth die from PCa. The RADICALS-HD trial confirms that BCR often follows an indolent course, with 10-year metastasis-free survival (MFS) rates of 79% and overall survival rates of 86% after salvage RT without androgen deprivation therapy (ADT). Identifying patients at higher risk of poor outcomes is crucial to prevent overtreatment. Weiner et al.’s systematic review examined risk stratification for recurrence after RP and RT, analysing 37 studies. The identified risk factors were supported by evidence of moderate or low strength due to variability in treatments and reliance on PSA-free survival rather than more robust endpoints like MFS. Key risk factors include pT3 stage, Gleason grade 4, negative surgical margins, and PSA levels above 0.5ng/ml. A shorter PSA doubling time and shorter time to BCR are also associated with poor outcomes. The review emphasises the importance of individualised treatment and prospective validation of emerging technologies. Ensuring that new techniques like PSMA PET scans or Decipher scores are used responsibly, without overreliance on technological advancements, is essential for improving BCR management and avoiding overtreatment.
