What is the expected PSA timeline in the first year after radical prostatectomy?
Executive summary
After radical prostatectomy (RP) PSA typically falls to a very low or undetectable level within about 2 months, but recent large-cohort research and several specialist bodies argue for waiting at least 3 months before declaring a persistent (non‑undetectable) PSA to avoid unnecessary salvage treatment [1] [2] [3] [4]. Longer-term surveillance after the first year shifts to routine intervals (every 3–12 months initially, then every 6–12 months up to 5 years and yearly thereafter) depending on risk — clinicians disagree on exact timing and some recent data challenge the historical 1.5–2 month check [5] [2] [6] [7].
1. Early trajectory: PSA should drop quickly after surgery — usually by 2 months
After complete removal of the prostate, authoritative patient guides and guideline summaries state PSA “should fall to a very low or even undetectable level” and typically does so within roughly two months post‑RP (American Cancer Society; Canadian Cancer Society; EAU guideline summary) [1] [8] [2]. This is the baseline expectation clinicians tell patients: an undetectable PSA at the early postoperative check is the sign that surgery removed the PSA‑producing tissue [1] [2].
2. When to perform the first postoperative PSA: traditional practice vs. new evidence
Traditional practice has often scheduled the first post‑op PSA at roughly 6 weeks to 2 months (about 1.5–2 months) (health information sites and guideline citations) [9] [2] [5]. However, a multi‑center cohort analysis of >43,000 men published recently (reported widely in March–June 2025 coverage) argues the 1.5–2 month window is too short and that waiting at least 3 months reduces mislabeling of “persistent PSA” and thus potential overtreatment with radiation or androgen‑deprivation therapies [3] [7] [4]. Mass General Brigham and other outlets explicitly recommend measuring PSA for at least three months after surgery to avoid premature salvage therapy [3] [4].
3. What counts as “persistent” vs. “biochemical recurrence” and why timing matters
Studies distinguish an immediately detectable or persistent PSA shortly after surgery from a biochemical recurrence occurring later. Declaring persistence too early risks treating men whose PSA would have fallen with more time; the recent JAMA Oncology cohort showed some men labeled persistent at 1.5–2 months would likely have reached undetectable levels by ~3.4 months (median undetectable time reported in the analysis) [10] [4]. Guideline language notes PSA is “expected to be undetectable two months after RP” but acknowledges evidence on optimal timing is limited — leaving room for interpretation and revision [2].
4. Surveillance schedule through year one: common patterns and variability
After the initial postoperative measurement, common follow‑up schedules used in practice include PSA testing every 3 months for the first 1–2 years for higher‑risk patients, while lower‑risk patients often move to testing every 6–12 months; many guideline sources recommend every 6–12 months for the first 3–5 years and annually thereafter [5] [6] [2]. Health sites advise repeat tests every 3 months if recurrence risk is high, otherwise once every 6–12 months for about 5 years [5] [9] [6].
5. Balancing early detection with the risk of overtreatment — competing perspectives
Proponents of the traditional earlier check emphasize rapid detection to allow timely salvage therapy when needed; proponents of delaying to 3 months emphasize avoiding unnecessary radiation/ADT prompted by transient or slow‑falling PSA [5] [3] [7]. Large new observational data favor the latter, but guideline committees (EAU) still reference a two‑month expectation while acknowledging low evidence for exact intervals [2] [4]. Both perspectives share the goal of optimizing oncologic outcomes while minimizing harm; they differ on the acceptable tradeoff between earlier intervention and false‑positive persistent PSA labels [7] [3].
6. What patients should ask and expect in year one
Ask your surgeon/urologist: when will my first PSA be measured, what threshold they use for “detectable” or “persistent” PSA, and how often they intend to test over the first year (sources recommend individualized schedules based on risk) [5] [2]. If told a detectable PSA at ~6–8 weeks would prompt immediate salvage therapy, discuss whether the team follows the emerging evidence recommending at least 3 months of observation to confirm persistence [3] [4].
Limitations: available sources do not give a single universal protocol; recommendations differ across patient‑facing sites, institutional press releases, and guidelines, and the new large cohort published in JAMA Oncology has prompted reappraisal but not yet universal guideline change [2] [4] [3].