Managing Rising PSA Levels and PSMA-Detected Recurrence in Prostate Cancer

Up to a third of men treated for prostate cancer experience rising PSA levels after surgery or radiation. If imaging scans show no evidence of cancer, this is known as biochemical recurrence (BCR). In this case, PSA—a biochemical marker—indicates the presence of cancer cells that doctors cannot yet see. BCR is asymptomatic and can take years to develop visible metastases; some men may never develop metastases despite rising PSA.

PSMA Scanning and (PSMA)+BCR

An ultra-sensitive scanning technology called PSMA scanning illuminates a protein on cancer cells (prostate-specific membrane antigen), revealing small tumors that conventional imaging (bone scans, MRI) cannot detect. When BCR is detected by PSMA scanning, doctors refer to it as (PSMA)+BCR.

Treatment Approaches for Biochemical Recurrence

• Traditional BCR: Treatment decisions are based on PSA velocity. Options include delaying treatment or initiating androgen-deprivation therapy (drugs that block testosterone).
• (PSMA)+BCR: Visible metastases on PSMA scans often prompt many doctors to treat aggressively with powerful hormonal combinations that have significant side effects.

A Nuanced Approach

Experts like Dr. David Einstein emphasize a more measured strategy. “We’ve encountered situations where patients have small cancerous lesions on a PSMA scan that don’t necessarily grow,” he says. While metastatic cancer visible on conventional imaging is serious, biochemical recurrence can be associated with a decade or more of survival—likely true for some PSMA-detected recurrences as well. “Many, if not most, men with PSMA-detected recurrence face no imminent threat of morbidity or mortality from their prostate cancer,” write Dr. Einstein and colleagues.

Aggressive treatment may simply add years of toxic side effects without proven survival benefit. Although treating BCR can delay progression and control PSA, no evidence shows it improves overall survival.

Ongoing Research

Researchers are studying the natural history of PSMA-detected recurrences to understand disease spread and behavior over time, as well as developing clinical trials for novel treatments with longer-lasting benefits than hormonal therapies.

Expert Perspectives

“The advanced technology of PSMA scanning that detects very small deposits of cancer has raised important treatment questions that are now being actively studied,” says Dr. Marc B. Garnick. “Delaying or postponing treatments that would in the past have been given immediately is a strategy that is often embraced by our patients.”