When to Consider Salvage XRT in Delayed BCR

How to cite: Frizzell BA. When to consider salvage XRT in delayed BCR. October 2025. Accessed January 2026. https://grandroundsinurology.com/when-to-consider-salvage-xrt-in-delayed-bcr/

Summary

Bart A. Frizzell, MD, Clinical Associate Professor, Radiation Oncology and Urology, Wake Forest University, Winston-Salem, North Carolina, provides a practical, PSA-driven framework for counseling men with delayed biochemical recurrence, focusing on timing, diminishing returns, and evidence-based thresholds.

Dr. Frizzell defines delayed biochemical recurrence as occurring more than five years after surgery, noting that this definition is arbitrary but allows internal consistency in clinical decision-making. While treatment nuances differ between early and late recurrence, his criteria for when to consider salvage radiation are based primarily on absolute prostate-specific antigen (PSA) values rather than time alone.

Using a “road sign” analogy, Dr. Frizzell outlines four key PSA thresholds that guide patient counseling. A PSA of 0.2 ng/mL is defined as biochemical recurrence, based on consensus guidelines, with a carefully applied exception informed by RADICALS-RT. The range of 0.2 to 0.5 ng/mL represents the “green” or “golden hour,” when salvage radiation is most likely to achieve durable biochemical control and reduce the risk of distant metastasis.

As PSA rises above 0.5 ng/mL, salvage radiation may still be effective, but outcomes progressively worsen. A PSA of 2.0 ng/mL serves as a cautionary threshold, supported by nomogram data and by enrollment limits used in trials evaluating androgen deprivation therapy and pelvic nodal irradiation. Beyond this level, clinicians begin to move outside the strongest evidence base.

Finally, Dr. Frizzell discusses PSA ≥ 4.0 ng/mL as a practical stopping point where the potential benefit of salvage radiation may be outweighed by treatment-related risk. He emphasizes that recognizing the optimal PSA window is the most crucial factor in maximizing the likelihood of successful salvage therapy.

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