Understanding Biochemical Recurrence in Prostate Cancer
Prostate cancer cells make a protein called Prostate Specific Antigen (PSA). The term biochemical recurrence (BCR) refers to a rise in PSA levels after primary treatment for prostate cancer, such as surgery or radiation. It may be an indicator of potential cancer return. While BCR does not always signify clinical recurrence (the reappearance of visible tumors), it is a critical marker that prompts further investigation and discussion with the care team. Understanding what BCR means, how it's monitored, and the available management options are crucial for informed decision-making and proactive prostate cancer care.
What is Biochemical Recurrence in Prostate Cancer?
The concept of BCR is most applicable to patients who have undergone prostate cancer surgery or radiation. In patients who have undergone open or robotic radical prostatectomy, for example, the PSA should be undetectable in the bloodstream because the prostate gland has been removed. So, in theory, any level of PSA detection may indicate prostate cancer recurrence in those who have undergone processed cancer surgery. However, with the advent of highly sensitive PSAs or super sensitive PSA testing, it is possible for a man to have extremely low levels of PSA detected in their bloodstream and, indeed, not have a reoccurrence of prostate cancer. In general, any level of PSA more than 0.3ng/ml is considered a biochemical recurrence of prostate cancer in men who have undergone radical prostatectomy.
In men who have undergone radiation for prostate cancer, the indication of BCR is more controversial than those who have undergone surgery. The strictest definition of BCR in those who have undergone radiation is a PSA greater than 0.5 ng/mL. However, some prostate cancer experts suggest that one should not rely on a specific number as the definition for BCR. Instead, it is recommended that three consecutive rises in PSA checked every three months from its lowest level post radiation should be considered as PSA failure or BCR.
What is the Significance of BCR?
The significance of BCR is that it may indicate the recurrence of prostate cancer in some men who have previously undergone treatment. Therefore, elevations in PSA after primary prostate cancer treatment can be related to the recurrence of prostate cancer. However, like many other concepts in medicine, not every man with rising PSA or detectable PSA post-treatment has cancer recurrence. Besides the prostate, other tissues in the body can make PSA. For instance, men who have developed inflammation of their gums or salivary glands may exhibit slight increases in their PSA levels.
Furthermore, in men who have undergone surgery, if some normal processed cancer cells are still residing in the body (such as the bladder neck), then those normal prostate cells may also secrete some PSA into the bloodstream. In men who have undergone radiation and still have an intact prostate in their body, the gland may intermittently produce some PSA, which will enter the bloodstream. If the radiated prostate becomes inflamed, such as during infection, then this can also cause a temporary increase in the PSA post-radiation.
It is important to note that in the early phases of BCR when the PSA levels are only slightly detectable or slightly elevated over expected baselines, there may be no other physical or radiographic (as might be found in imaging studies such as MRI) signs of a prostate cancer recurrence. Therefore, BCR can be used in many cases as an early warning sign for further potential prostate cancer regrowth in the future.
The knowledge that BCR brings offers some advantages and disadvantages. On the one hand, early warning signals can help providers initiate treatment protocols earlier and more successfully to control or mitigate the propagation of prostate cancer. On the other hand, these early signals may increase the level of distress and anxiety in a man who otherwise is feeling very well and has no related symptoms associated with prostate cancer recurrence. However, open and honest conversations about BCR in prostate cancer are an essential element of the doctor-patient relationship. Your provider is there to support you, and every man should feel comfortable sharing his thoughts on the matter with a trusted provider.
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Dr. Ramin’s email answers provided on 3/19/25
