Positive Margins, Rising PSA, and Salvage Treatment: What Happens Next?
This article forms part of Dr Deanne Soares’ urologic cancer education series, providing evidence-based guidance on treatment, recovery and life after urological cancer surgery.
For many men and people with prostates, prostate cancer surgery feels like the end of the most difficult part of the journey. The prostate has been removed, recovery is underway, and attention turns to healing and moving forward.
Then a pathology report shows a positive margin.
Or the PSA does not fall to undetectable.
Or the PSA begins to rise months or years later.
These moments can be deeply unsettling. Patients often interpret them as evidence that surgery has failed or that the cancer is inevitably progressing. GPs frequently field urgent questions, and surgeons are asked to explain what this means — and what happens next.
This article explains how positive margins and rising PSA are interpreted after prostate cancer surgery, how decisions about salvage treatment are made, and why uncertainty does not automatically signal poor outcomes.
Patient summary
Key points to know:
A positive margin does not automatically mean the cancer will return
PSA changes after surgery are common and often slow
Not all PSA rises require immediate treatment
Salvage treatment can be effective when used selectively
Decisions are individualised and often made over time
What a “positive margin” actually means
After a radical prostatectomy, the removed prostate is examined by a pathologist. If cancer cells are present at the edge of the specimen, this is reported as a positive surgical margin.
In practical terms, this means cancer was present close to where the prostate was separated from surrounding tissue. It does not mean cancer was deliberately left behind, and it does not mean recurrence is inevitable.
Margin status must always be interpreted in context.
Why margin details matter
Not all positive margins carry the same risk. Important factors include:
the length of the margin
the location (for example, apex or posterolateral)
the grade of cancer at the margin
whether there is extraprostatic extension
A small, focal margin in otherwise favourable disease carries a very different implication from an extensive margin associated with high-grade or locally advanced cancer. This nuance is often lost when margins are discussed in binary terms.
PSA after surgery: what is expected — and what varies
After prostatectomy, PSA is expected to fall to very low or undetectable levels because the prostate — the main source of PSA — has been removed.
However, PSA behaviour after surgery is variable. Common patterns include:
PSA becomes undetectable and remains so
PSA becomes undetectable and then rises slowly over time
PSA never quite reaches undetectable
PSA fluctuates at very low levels
Not all of these patterns require immediate action.
What is biochemical recurrence?
Biochemical recurrence refers to a PSA rise after surgery that meets defined thresholds. In Australia, this is commonly considered a PSA of ≥0.2 ng/mL with a confirmatory rise, though definitions vary slightly.
Importantly, biochemical recurrence:
is a laboratory finding, not a symptom
does not necessarily indicate clinical progression
often evolves slowly
Many patients live for years with biochemical recurrence while remaining well and active.
Why observation can be appropriate
One of the most difficult aspects of post-operative prostate cancer care is tolerating uncertainty.
There is a natural urge — from patients and sometimes clinicians — to act immediately when PSA changes. In practice, early intervention does not always improve outcomes and can expose patients to unnecessary side effects.
Careful observation may be appropriate when:
PSA is rising very slowly
pathology suggests lower-risk disease
imaging does not show clear recurrence
patient priorities favour caution
Watching closely is not inaction. It is a deliberate, monitored strategy.
Salvage treatment: what it is and when it is considered
Salvage treatment refers to additional therapy given after surgery when there is evidence of persistent or recurrent cancer. The most common form is salvage radiotherapy, sometimes combined with hormone therapy in selected situations.
When salvage radiotherapy is used
Salvage radiotherapy may be recommended when:
PSA rises beyond accepted thresholds
PSA kinetics (such as doubling time) suggest higher risk
pathology indicates likely benefit
imaging supports local recurrence
Timing matters. Evidence suggests salvage radiotherapy is most effective when PSA levels are still low — but that does not mean every PSA rise requires immediate treatment.
What salvage treatment aims to achieve
The goals of salvage therapy are to:
control residual or recurrent local disease
reduce the risk of progression
delay or avoid systemic treatment
When used thoughtfully, salvage radiotherapy can be effective and well tolerated for many patients.
Understanding the trade-offs
Salvage treatment is not without consequences. Radiotherapy after prostatectomy can affect:
urinary control
bowel function
sexual function
These potential effects must be weighed against the expected oncological benefit. For some patients, the balance clearly favours treatment. For others, continued surveillance or delayed intervention is appropriate.
There is no single pathway that suits everyone.
Imaging and multidisciplinary care
Advances in imaging, including modern PET scans, have improved the ability to localise recurrence at low PSA levels. However, imaging is not perfect, and a negative scan does not exclude microscopic disease.
Decisions about salvage treatment are often best made through a multidisciplinary team (MDT) approach involving urologists, radiation oncologists, medical oncologists and radiologists. This allows pathology, PSA behaviour, imaging and patient priorities to be considered together.
Surgical judgement and experience
Managing positive margins and rising PSA benefits from experience across the full prostate cancer pathway — including surgery, surveillance, salvage treatment and long-term functional outcomes. Familiarity with these phases allows treatment to be timed and tailored rather than reflexive.
For patients: how to approach this phase
If you are navigating a positive margin or rising PSA, helpful questions include:
How quickly is the PSA changing?
What does my pathology suggest about risk?
Is treatment needed now, or can we monitor safely?
What are the likely benefits and side effects of salvage treatment for me?
Anxiety is understandable. Urgency is not always required.
For GPs and referring clinicians
GPs play a key role during this phase by:
normalising PSA-related anxiety
reinforcing that biochemical recurrence is not a crisis
supporting shared decision-making
monitoring general health and mental wellbeing
Clear communication between primary care and specialist teams reduces distress and improves continuity of care.
A note on individual decision-making
This information is intended to help patients understand the landscape after prostate cancer surgery, but it cannot replace an individual consultation. Decisions about margins, PSA changes and salvage treatment depend on pathology, PSA behaviour over time, imaging and personal priorities, and are best made through discussion with the treating team.
Conclusion
Positive margins and rising PSA are unsettling, but they are not uncommon and they are not the end of the story.
Modern prostate cancer care recognises that surgery is one step in a longer pathway. Salvage treatment, when used appropriately, can be highly effective. Equally, careful observation is often the right choice.
Good outcomes are not defined by eliminating uncertainty, but by managing it with experience, evidence and clear communication. For many men and people with prostates, this phase is about staying informed, supported and engaged — rather than rushing toward the next intervention.
About the author:
Dr Deanne Soares is a Melbourne-based urologist with a subspecialty focus in robotic prostate, kidney and bladder cancer surgery, offering advanced minimally invasive cancer care.
