Management of high-risk biochemical recurrence in prostate cancer: A GCC Delphi consensus (BEAM Panel)

BACKGROUND: High-risk biochemical recurrence (HR-BCR) of prostate cancer (PC) is a prostate-specific antigen (PSA)-only relapse state in which rapid PSA kinetics predict early metastatic progression. Variation in care pathways across Gulf Cooperation Council (GCC) systems supports the need for shared guidance. METHODS: The HR-BCR Expert Alignment Meeting (BEAM) convened 11 GCC-based senior clinicians with expertise in genitourinary oncology, including medical oncology, urologic oncology, and radiation oncology representation. A writing committee reviewed evidence up to December 2025 and drafted 19 statements. A modified two-round Delphi process used an anonymous online survey in Round 1 and live QR code-enabled voting in Round 2. Consensus was predefined as ≥80% Agree, with abstentions included in the denominator. RESULTS: Of 19 initial statements, 17 reached final consensus after two Delphi rounds. The panel standardized BCR definitions after radical prostatectomy (PSA ≥0.2 ng/mL confirmed) and radiotherapy (PSA rise ≥2 ng/mL above nadir), and defined HR-BCR primarily by PSA doubling time ≤9 months. Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) was endorsed as preferred restaging modality and considered sufficient for routine staging in EMBARK-aligned HR-BCR, where available. Management recommendations supported androgen receptor pathway inhibitors (ARPIs) plus androgen deprivation therapy (ADT) intensification for eligible patients, intermittent strategies with defined treatment-holiday and restart triggers, and proactive cardiovascular and bone protection. Enzalutamide plus ADT was endorsed as standard for eligible patients, with enzalutamide monotherapy as an evidence-based alternative for selected men. CONCLUSIONS: This expert-based consensus provides an evidence-aligned, GCC-relevant pathway to harmonize definition, staging, and management of HR-BCR and to facilitate timely, equitable implementation of contemporary care.