Expert consensus recommendations for the management of biochemical recurrence in prostate cancer: a Delphi study across clinical scenarios

PURPOSE: To develop expert consensus recommendations in Spain for the management of biochemical recurrence (BCR) in prostate cancer across different clinical scenarios using a modified Delphi methodology, and to provide a multidisciplinary, evidence-based framework to inform clinical decision-making regarding definition, risk stratification, imaging, and treatment after radical prostatectomy (RP), radiotherapy (RT), and RP followed by salvage RT. METHODS: A multidisciplinary scientific committee formulated 51 clinical statements based on a narrative literature review and expert experience. A panel of 49 specialists, including urologists, radiation oncologists, and nuclear medicine physicians, independently rated these statements through two rounds of an online Delphi survey. RESULTS: Forty-two Spanish panelists completed both rounds. Consensus was reached for 38 of 51 statements (75%): 33 in the first round and 5 in the second. Key agreements included defining BCR after RP as a confirmed PSA rise ≥ 0.2 ng/mL; strong endorsement of next-generation imaging (NGI) for disease assessment, particularly in high-risk patients; and recommending salvage RT with or without androgen deprivation therapy (ADT) as the standard, reserving systemic therapy including androgen receptor pathway inhibitors (ARPI) for patients unsuitable for local salvage. The panel emphasized individualized ADT duration and risk-adapted imaging and treatment approaches. Additional areas of ongoing debate and future research needs were identified. CONCLUSIONS: These expert-driven recommendations provide a structured clinical framework integrating current evidence and consensus guidance to optimize BCR management in prostate cancer. The findings support personalized decision-making and highlight areas requiring further prospective validation.