Table 2. APCCC 2022 questions concerning PSA persistence and biochemical recurrence after definitive treatment that have reached a consensus.

Question	Answers	-Voting results, % (n)
34. In the majority of patients with PSA persistence 4–8 wk after radical prostatectomy (pN0) and M0 on preoperative imaging, do you recommend PSMA PET?	1. Yes	91 (90), strong consensus
	2. No	9(9)
36. What do you recommend for a patient with PSA persistence 4–8 wk after radical prostatectomy (pN0 and ≥2 risk factors: R1, pT3, ISUP grade group 4–5), M0 on preoperative imaging, and negative postoperative PSMA PET, provided that the patient has regained continence?	1. Salvage radiation therapy	10 (10)
	2. Salvage radiation therapy plus systemic hormonal treatment	77 (76), consensus
	3. Systemic hormonal treatment alone	1 (1)
	4. No immediate active treatment, PSA surveillance	12 (12)
42. For the majority of patients with rising PSA after radical prostatectomy and PSA-DT <1 yr or pathological ISUP grade group 4–5 (EAU high risk), at what confirmed rising PSA level do you recommend PSMA PET imaging?	1. PSA below 0.2 ng/ml	11 (11)
	2. PSA >0.2–0.5 ng/ml	80 (78), consensus
	3. PSA >0.5 ng/ml	9(9)
	4. No imaging	0(0)
44. For the majority of patients with rapidly rising PSA (eg, PSA-DT <3 mo) after radical prostatectomy (ISUP grade group 4–5 and/or pT3/4) with negative PSMA PET or no PSMA PET imaging available, what is your management recommendation?	1. Active monitoring and treat only in case of a positive lesion on follow-up imaging	8 (8)
	2. Salvage RT alone	6(6)
	3. Salvage RT plus systemic therapy	75 (75), consensus
	4. Systemic therapy alone	11 (11)
49. In the majority of patients with a PSA rise after radical prostatectomy (±salvage RT of the prostate bed) and 1–3 positive lymph nodes in the pelvis alone on PSMA PET, what is your treatment recommendation?	1. Locoregional treatment alone	10 (10)
	2. Systemic therapy alone	5(5)
	3. Locoregional treatment plus systemic therapy	85 (84), consensus
50. If you voted for locoregional treatment in the previous question in the majority of patients with a PSA rise after radical prostatectomy (±salvage RT of the prostate bed) and 1–3 positive lymph nodes in the pelvis alone on PSMA PET, what is your preferred strategy?	1. Radiation therapy	92 (85), strong consensus
	2. Surgery	8(7)
51. Outside of clinical trials, do you recommend the use of a molecular classifier (eg, Decipher) for patients with undetectable postoperative PSA after radical prostatectomy but subsequently rising PSA?	1. Yes	18(17)
	2. No	82 (78), consensus
52. Outside of clinical trials, do you recommend the use of a molecular classifier (eg, Decipher) for patients with PSA persistence (never achieved undetectable postoperative PSA) after radical prostatectomy?	1. Yes	20 (19)
	2. No	80 (75), consensus
54. If you recommend systemic therapy in combination with salvage radiation therapy in the majority of patients with rising PSA after radical prostatectomy and negative PSMA PET, what do you recommend?	1. ADT (LHRH agonist or antagonist)	85 (80), consensus
	2. ADT plus AR pathway inhibitor	10(9)
	3. Bicalutamide monotherapy	5(5)
55. If you recommend systemic hormonal treatment in combination with salvage radiation therapy in the majority of patients with rising PSA after radical prostatectomy and negative PSMA PET, which duration of AR blockade do you recommend for the majority of patients?	1. Short term (eg, 6 mo)	80 (76), consensus
	2. Long term (eg, 18–24 mo)	20 (19)
57. Which imaging modality do you recommend as a first imaging step for patients with rising PSA after radical radiation therapy of the prostate with an interval to biochemical failure of >18 mo and biopsy ISUP grade group <4 (EAU low risk), assuming that all imaging modalities are available?	1. MRI of the pelvis alone	11 (12)
	2. CT and/or bone scintigraphy	9(9)
	3. Whole-body MRI alone/choline/ fluciclovine PET/CT	1 (1)
	4. PSMA PET	78 (80), consensus
	5.1 do not recommend imaging in this situation	1 (1)
60. Which imaging modality do you recommend as a first imaging step for patients with rising PSA after radical radiation therapy of the prostate with an interval to biochemical failure of <18 mo or biopsy ISUP grade group 4–5 (EAU high risk), assuming that all imaging modalities are available?	1. MRI of the pelvis alone	5 (5)
	2. CT and/or bone scintigraphy	10 (10)
	3. Whole-body MRI alone/choline/ fluciclovine PET	1 (1)
	4. PSMA PET	84 (87), consensus
	5.1 do not recommend imaging in this situation	0(0)
65. What do you recommend in patients with rising PSA after definitive local therapy (RP ± salvage RT, RT of the prostate), with no local salvage therapy options available and no detectable metastases on imaging, and in a lower-risk setting (PSA-DT ≥12 mo and/or ISUP grade group ≤3)?	1. Start immediate systemic therapy for the majority of patients	11 (11)
	2. Monitor by PSA and imaging until detection of metastases	89 (89), consensus
69. In the majority of patients with PSA rise after radical local radiation of the prostate alone (no pelvic RT) and 1–3 positive lymph nodes in the pelvis alone on PSMA PET, what is your treatment recommendation?	1. Locoregional treatment alone	19 (19)
	2. Systemic therapy alone	6(6)
	3. Locoregional treatment plus systemic therapy	75 (73), consensus
70. If you voted for locoregional treatment in the majority of patients with PSA rise after radical local radiation of the prostate alone (no pelvic RT) and 1–3 positive lymph nodes in the pelvis alone on PSMA PET, what is your preferred strategy?	1. Radiation therapy	82 (74), consensus
	2. Surgery	18 (16)

ADT = androgen deprivation therapy; APCCC = Advanced Prostate Cancer Consensus Conference; AR = androgen receptor; CT = computed tomography; EAU = European Association of Urology; ISUP = International Society of Urological Pathology; LHRH = luteinising hormone-releasing hormone; MRI = magnetic resonance imaging; PET = positron emission tomography; PSA = prostate-specific antigen; PSA-DT = prostate-specific antigen doubling time; PSMA = prostatespecific membrane antigen; RP = radical prostatectomy; RT = radiation therapy.