Given the biochemical failure definition of PSA nadir+2 ng/mL, how do you approach a PSA bounce of magnitude 2 ng/mL or higher?

If a PSA bounces >2 points then PSA decreases subsequently without any treatment, I do *not* consider these patients to have failed. This does occur in the clinic occasionally.

Thankfully, when patients have rising PSAs after RT, there usually is not an urgency to start salvage treatment. When a patient does reach nadir +2, I often will recheck the PSA in another 3 or 6 months. If it is a bounce (not a recurrence), usually the PSA will decrease at recheck.

ASTRO definition of biochemical failure has high specificity (about 80%) and high negative predictive value ( 90%) but lower sensitivity and positive predictive value (40% or so) . It is good for reporting to avoid incorrect reporting. A PSA bounce can effect the less than 2 years reporting numbers. A bounce can happen 1 in 4 patients and bounce can meet astro criteria for failure but one needs to be care to avoid incorrect reporting. Best way to manage is a repeat PSA at regular intervals as time would confirm bounce vs. failure (unless there are clinical signs of failure)