Salvage treatment depends on the previous treatment and where the recurrence appears to be.

Salvage radiotherapy after surgery

Salvage radiotherapy is one of the commonest salvage treatments after radical prostatectomy.

After surgery, the prostate has been removed. If the PSA becomes detectable or rises later, this may suggest cancer cells remain in the prostate bed, lymph nodes or elsewhere.

If there are no known distant metastases, radiotherapy may be offered to the prostate bed, sometimes with treatment to pelvic lymph nodes depending on risk and imaging.

Hormone therapy may also be added in selected cases.

Prostate Cancer UK explains that radiotherapy may be given to the prostate bed after prostate removal if there is concern cancer may return or was not completely removed, and that timing may depend partly on urinary recovery. (Prostate Cancer UK)

Salvage surgery after surgery

Surgery after surgery is less common, but it can be considered in selected cases.

This usually does not mean removing the prostate again, because the prostate has already been removed. It may mean surgery to remove suspicious or proven recurrent lymph nodes in the pelvis.

This is sometimes called salvage lymph node dissection.

It is not suitable for every patient. It depends on where the disease is seen, how many nodes are involved, PSA behaviour, previous treatment, surgical risk and whether other treatments such as radiotherapy or systemic therapy are more appropriate.

The aim may be to reduce visible disease, delay further treatment or help with local control, but the evidence and benefit vary between patients.

Surgery after radiotherapy

Surgery after radiotherapy is called salvage prostatectomy.

This means removing the prostate after previous radiotherapy when cancer appears to have returned within the prostate.

This is a difficult operation. Radiotherapy can cause scarring, altered tissue planes, reduced healing capacity and tissue fragility. This can increase the risk of urinary leakage, rectal injury, strictures, erectile dysfunction and other complications.

Surgery after radiotherapy may be considered only in carefully selected men, usually after imaging and biopsy confirmation of local recurrence.

It should be performed only in specialist hands and after detailed counselling.

Salvage treatment after focal therapy

If cancer persists or returns after focal therapy, options may include:

Repeat focal therapy
Radical prostatectomy
Radiotherapy
Hormone therapy
Active monitoring in selected cases

Recurrence after focal therapy may be:

In-field, meaning recurrence in the treated area
Out-of-field, meaning cancer elsewhere in the prostate

This matters because focal therapy treats a target, not necessarily the whole prostate.

MRI, PSA and repeat biopsy are usually important before deciding on further treatment.

Proton beam therapy

Proton beam therapy is a type of radiotherapy that uses protons rather than standard X-rays.

It may reduce radiation dose to some surrounding tissues in certain cancers and anatomical situations. However, for prostate cancer, its routine role is more limited and should be discussed with a clinical oncologist.

NHS England’s policy has stated that proton beam therapy for prostate cancer is not supported except within trials or registration studies because more evidence is needed. (NHS England)

That does not mean proton therapy is never discussed, but patients should understand whether it is being offered as standard care, trial treatment, private treatment or within a registry.

Focal salvage therapy

Focal therapy can sometimes be considered as salvage treatment, especially after radiotherapy if recurrence appears localised within the prostate.

Options may include HIFU, cryotherapy, irreversible electroporation or other focal approaches.

This requires careful imaging and usually biopsy confirmation. The key issue is whether the recurrence is genuinely localised and treatable.

Focal salvage treatment may reduce some side effects compared with whole-gland salvage treatment, but it also carries risks of persistent disease, recurrence and need for further treatment.