PSA Screening Protocol After Prostatectomy
Physicians should monitor PSA every 6-12 months for the first 5 years after radical prostatectomy, then annually thereafter indefinitely, with biochemical recurrence defined as PSA ≥0.2 ng/mL confirmed on two successive measurements. 1, 2
Initial Post-Operative Testing
- Obtain the first PSA measurement at 6-8 weeks after surgery to allow adequate washout time and avoid falsely elevated results from surgical inflammation 1, 2
- PSA should become undetectable (< 0.2 ng/mL) within several weeks of surgery; any detectable or rising PSA indicates residual or recurrent disease 1, 3
- If PSA is detectable on initial testing, repeat in 1-3 months to confirm elevation and calculate PSA doubling time 2
Standard Surveillance Schedule
Years 1-5 Post-Surgery
- Standard-risk patients: PSA testing every 6-12 months 1, 2
- High-risk patients (seminal vesicle invasion, positive margins, extraprostatic extension): PSA testing every 3 months for the first 2 years, then every 6 months until year 5 1, 2
After Year 5
- PSA should be measured annually, continuing indefinitely 1, 2
- Annual digital rectal examination is recommended, though may be omitted if PSA remains undetectable 1
Definition of Biochemical Recurrence
Biochemical recurrence is defined as PSA ≥0.2 ng/mL confirmed on a second successive measurement. 4, 1, 2 This threshold represents the optimal balance between detecting true recurrence and avoiding false positives from benign remnant tissue 2. This definition is endorsed by ASCO and used in 35 of 145 reviewed studies 2.
Management of Detectable PSA
- Any confirmed detectable or rising PSA requires immediate referral to the primary treating specialist, as it suggests residual or recurrent disease 2
- Salvage radiotherapy should be offered when PSA is rising without evidence of distant metastases, with effectiveness greatest when PSA is low (ideally <2.0 ng/mL) 4, 2
- Calculate PSA doubling time from serial measurements; PSADT <6 months indicates higher risk and need for intervention 1
Imaging Considerations
- Imaging is generally not indicated unless PSA becomes detectable and rising (≥0.2 ng/mL on two occasions) 1
- Bone scans are rarely positive with PSA <20-30 ng/mL 1
- Multiparametric MRI is most accurate for detecting local recurrence when salvage therapy is being considered 1, 2
Key Clinical Principles
Regular PSA monitoring after radical prostatectomy is necessary because PSA recurrence is associated with higher risk of metastatic prostate cancer or death from disease. 4 Early detection enables timely administration of salvage therapies, which are most effective at lower PSA levels 4. The 45% of recurrences occur within 2 years, 77% within 5 years, and 96% by 10 years, but 4% manifest after 10 years, justifying indefinite surveillance 5.