You may find this review paper (Shore and others, 2023) on treatment for BCR following either prostatectomy or radiation. It lists a range of approaches but clearly shows that risk stratification is a key factor, across the board. From all my readings, the various approaches seem rooted in trying to balance the risks of under-treatment against the risks of over-treatment.

My story: Robotic radical prostatectomy in 2015. Margins were positive, Gleason 3+4, Prolaris score of 1.7 with a 10-year risk of BCR at 53%. pT2c, Gleason Group 2, unfavorable intermediate. For ten years, my PSA was undetectable (< 0.1). In June 2025, my PSA was 0.11 and 0.12 on closely consecutive tests (lab error ruled out). A DRE detected a small nodule in my prostatic fossa. This was followed with a PET PSMA scan that showed high specific activity of the nodule, but no evidence of metastatic disease. A pelvic MRI with contrast further confirmed the lesion in the fossa and yielded no evidence of pelvic lymph node invasion, consistent with the PET scan. After conferring with two ROs, I will begin EBRT in a couple of weeks. No ADT at this point. Will also test PSA one more time just before beginning RT. So, my PSA is below 0.2 but because of the confirmed presence of a local recurrence, RT was recommended by both ROs. Surveillance was off the table. This seems consistent with most the treatment guidelines listed in the attached paper, including NCCN guidelines.

Best wishes for getting the treatment that you believe you need and that fits with your goals and values.