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BackTable / Urology / Article
Prostate Cancer Recurrence Diagnosis & Treatment: Focus on Shared Decision-Making
Kaitlin Sheppard • Updated Apr 1, 2025 • 36 hits
As cancer management becomes more complex, effective patient communication and shared decision-making is becoming more important at all stages of care. In the context of prostate cancer, preoperative counseling enhances patient understanding of recurrence risks, prepares them for potential salvage treatments, and reduces psychological distress. Educating patients about outcomes, such as the likelihood of biochemical recurrence, possible adjuvant therapies, and the multidisciplinary nature of prostate cancer treatment ensures that recurrence or retreatment discussions are not met with surprise or distress. By the same token, clear communication about the risks of incontinence, potency loss, and systemic therapy empowers patients to voice their preferences and enhances trust between patients and providers.
With guidance from urologic oncologists Dr. James Eastham and Dr. Aditya Bagrodia, this article focuses on how to effectively involve prostate cancer patients and multidisciplinary cancer specialists in diagnostic and treatment decisions, particularly in the case of biochemical recurrence.This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Urology Brief
• Pre-treatment counseling reduces patient distress by setting clear expectations about biochemical recurrence and salvage treatment options.
• Shared decision-making fosters a collaborative approach, ensuring treatment aligns with clinical evidence and patient values.
• Multidisciplinary coordination improves treatment planning, integrating urology, radiation oncology, and systemic therapy teams.
• PSA kinetics, particularly doubling time, assist in recurrence risk stratification but should not delay early referral to radiation oncology.
• Preoperative education on continence and potency recovery timelines ensures patients have realistic expectations.
• MRI is the preferred modality for evaluating local recurrence at the anastomosis due to its superior soft tissue contrast. PSMA PET is more effective in detecting distant metastases and nodal involvement.
• The first postoperative PSA test is typically performed 6-8 weeks after surgery, with subsequent monitoring based on patient risk level.
Table of Contents
(1) Identifying Biochemical Recurrence with MRI & PSMA PET
(2) Persistent PSA After Prostatectomy: Risk Assessment & Early Intervention
(3) Postoperative PSA Surveillance & Treatment Escalation in Biochemical Recurrence
(4) Setting the Right Patient Expectations Around Biochemical Recurrence
Identifying Biochemical Recurrence with MRI & PSMA PET
Postoperative imaging plays a critical role in assessing biochemical recurrence, with MRI and PSMA PET scans serving complementary purposes. MRI is particularly valuable for evaluating local recurrence at the anastomosis, offering superior soft tissue contrast compared to PET scans, which may be limited by tracer accumulation in the bladder. PSMA PET, on the other hand, is more effective for detecting distant metastatic disease and nodal involvement. Given these distinct advantages, a dual-imaging approach can provide a more comprehensive assessment of disease recurrence.
While routine digital rectal examinations (DREs) are less common in the postoperative setting, particularly in telemedicine-based follow-ups, imaging advancements have largely supplanted their role in recurrence detection. The decision to proceed with salvage treatment, whether surgical or radiation-based, benefits from detailed anatomical information that both MRI and PSMA PET can provide.
[Dr. Aditya Bagrodia]:
I think it actually is a fairly common theme in prostate cancer. It's either very little monitoring or it's kitchen sink. I hear you. A 52-year-old with T3b, grade group 5, 1, maybe even 2 out of 20 nodes positive, I'm worried that might be a radiation-heavy ADT patient, whereas the first patient you described, 3+4=7, maybe a T3a, negative margins, positive single node, good lymph node density, perhaps we just monitor that.
I do think it's shared decision-making. Here's your risk of recurrence. Here's what postoperative treatment, systemic therapy, radiation looks like. Fantastic. I also get MRIs and PSMA PET scans in the biochemical recurrence setting just to get an updated lay of the land. Actually, one of the [unintelligible 00:16:04] asked me, why do I get MRIs? I'd be curious from your perspective, and are you doing rectal exams as well? How that influences what comes next.
[Dr. James Eastham]:
I don't frequently do rectal examinations solely because many of my patients, I'm on the computer screen with them. It's a telemedicine chat. Not many folks we operate on are-- Even Jersey is considered a long way away from Manhattan, so we do a lot of this by phone, by telemedicine. They're not in person. In reality, whether I feel a little bit of something or don't feel a little bit of something, I think our imaging is so much better these days that if we don't do routine postoperative digital rectal examinations, I think it's okay, especially if the PSA is undetectable.
The reason I still use MRI is because on some of the PET scanning, the bladder can be full of tracer, and if there's a small area of abnormality within the prostatic fossa, it may simply be missed, which I've seen. Not all cancers, recurrent cancers in this case, are PSMA avid. I think they're complementary imaging studies. With radiation therapy today, sometimes they use MRI guidance.
If there's something one can see on an MRI, I think it provides information in terms of is there a recurrence or not. I think the MRI shows the area of the anastomosis better than what a PSMA PET scan does. I think both imaging studies are complementary. I use the MRI for local evaluation. I use the PSMA more for-- You'll get some local information, but more for distant disease, nodal, et cetera.
[Dr. Aditya Bagrodia]:
That's way more sophisticated than my answer, which is if I'm going to go in and do any type of salvage treatment after primary treatment to the prostate, I want to know what the anatomy is like, and I would imagine that an astute radiation oncologist can derive something beneficial.
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Persistent PSA After Prostatectomy: Risk Assessment & Early Intervention
A persistently detectable PSA after radical prostatectomy is a challenging scenario that often signals undiagnosed metastatic disease rather than incomplete surgical resection. While advances in PSMA PET imaging have improved preoperative staging, some metastases—such as rectal or atypical nodal involvement—may still be missed. For high-risk patients, PSMA PET scans are prioritized over MRI, though accessibility and insurance coverage remain barriers.
When persistent PSA is detected, early systemic therapy with androgen deprivation therapy (ADT) may be considered, particularly for patients who experience significant anxiety about recurrence. However, in most cases, radiation therapy is deferred for at least six months postoperatively to allow for recovery of continence and potency. Establishing realistic expectations during preoperative counseling can prevent undue distress and ensure patients understand the structured, stepwise approach to postoperative treatment.
[Dr. Aditya Bagrodia]:
Can you tell me a little bit about how you think about a persistently detectable PSA? We'll talk about a biochemical recurrence, but that's obviously overall disappointing for the patient, disappointing for us as their surgeon. What does that counseling session look like?
[Dr. James Eastham]:
Obviously, it's very disappointing for the patient and their family, of course. As a surgeon, we want to cure everybody, but that's unfortunately not reality. It typically represents metastatic disease unless the surgeon grossly left behind tumor, which is infrequent these days. With imaging technology, the robots, and all of that good stuff, we can see a lot better than what we could many years ago.
I think leaving gross tumor behind is rare. I think if surgery fails immediately, it's typically related to undiagnosed metastatic disease. That is becoming less frequent because we're now using better preoperative imaging to help assess extent of disease. With PSMA, we're finding lymph nodes in areas where we wouldn't even think. These are rectal nodes, you find them in all sorts of locations that we wouldn't typically even think to look that are now showing up on these scans.
I think imaging will help because it'll help guide how we initially counsel and manage the patients. We should have fewer of these persistently detectable PSAs after surgery, but I think it tends to represent metastatic disease. It will be systemic therapy, plus if we see an area of abnormality, likely radiation therapy to that side as well.
[Dr. Aditya Bagrodia]:
Perfect. That sounds very consistent with what I've found anecdotally, it would be a patient that really probably didn't meet criteria to get staged with a PSMA PET scan. The pathology was a bit more ominous on final prostatectomy and their six, eight-week PSA is a little bit higher. Real quick, when you're staging broad strokes, who are you getting PSMA PET scans in versus is the MRI sufficient? Can you talk a little bit on pre-op staging?
[Dr. James Eastham]:
Typically if they're high risk, PSAs over 20, Gleason 8 or higher, bulky disease on an MRI even, all have a low threshold to try to get a PSMA scan. Now they're not always paid for. Then the dilemma is, will the patient cover the costs out of pocket or will we just do without a PSMA scan? Certainly in the high-risk setting, we've been fairly successful to get PSMAs covered.
The question then is, what about unfavorable intermediate-risk disease? It tends to be on the unfavorable side, 90% pattern, four plus three, that's 90% pattern. Four compared to 55% pattern four in one biopsy. Higher volume Gleason 4 disease basically, higher PSAs. Favorable intermediate risk don't do it. Certainly in low-risk patients don't do anything, but high-risk patients and selected unfavorable intermediate-risk patients for PSMA scanning.
[Dr. Aditya Bagrodia]:
Perfect. Exactly consistent with what we do. I promise we're going to get to biochemical recurrence, but I typically will tell patients even when they're high risk that have met with our multi-D folks and they've elected for surgery that if anything's going to be required, and it's a little bit of an exaggeration that nearly certainly we won't be doing anything for six months.
Obviously, if they're content and potent 10 days after their catheter comes out, that's wonderful for them. It allows us to intervene whenever we think is necessary. I feel like sometimes patients, if they develop a recurrence or if it's persistently positive, understandably want to start doing something like yesterday. I want to help decrease some of the anxiety, allow them to heal. We can talk about that before we jump into whatever comes next. Can you maybe just talk about timing of radiation and functional status and how you think about this?
[Dr. James Eastham]:
If someone declares themselves early, the persistently detectable PSA patient, that's about the only setting where you're thinking about doing radiation therapy within six months. One can always start hormonal therapy because typically they're going to be on hormonal therapy if they're really nervous about things and they want to get something done, they want their PSA checked every hour, that type of situation. You can always start the hormonal therapy sooner rather than later.
They're going to need that and starting it in a neoadjuvant concurrent setting is not unreasonable. If you have that type of situation, they're still not continence yet. They're going to need hormonal therapy down the road anyway. Whether or not they recovered potency, that probably becomes less of an issue. In that particular setting, persistently detectable PSA level after surgery, someone that's very nervous or concerned about their PSA level, and they aren't willing to say we're going to wait a little bit until we reassess, add other treatment on, you can always start hormonal therapy. That's unusual these days.
As you have intimated, and certainly I follow, it's all about patient preparation. If you tell the patient ahead of time that "Look, even in the setting where you need additional therapy after surgery, we're not going to do it typically for about six months." There's always exceptions, but typically for about six months. Then they're prepared for that. I don't run into the situation very frequently where the patient is saying, "Why don't we radiate yesterday?"
Usually, they've already seen a radiation oncologist pre-decision making, so they have that relationship. They'll be able to contact the radiation oncologist. As you said, the multi-D clinics, we're all on the same page in terms of timing. We'd like their continence to get as good as possible. They're aware of why we're doing things in a particular stepwise fashion. It's all about preparation.
Not to open Pandora's box, but there's this huge debate about whether to call Gleason 6 cancer or not. I think if we prepared patients before their biopsy for what the possibilities are, there would be no debate at all. You could call Gleason 6 whatever you want, cancer, non-cancer, but if you have a conversation with a patient, "Look, if you are diagnosed with a Gleason 6 prostate cancer on your biopsy, this is something we're going to perform active surveillance on", there wouldn't be a controversy.
The controversy is after the fact, people hear the diagnosis of cancer. If you've prepped them, then it's not a problem. The problem is on us and not prepping the patients before their biopsy. Anyway, that's a sidelight, but a conversation for another day.
Postoperative PSA Surveillance & Treatment Escalation in Biochemical Recurrence
The management of biochemical recurrence following prostatectomy requires careful consideration of pathologic risk factors, PSA kinetics, and imaging findings. Positive surgical margins are often associated with local recurrence, while seminal vesicle invasion or early recurrence within two years may indicate micrometastatic disease. Confirming a rising PSA trend is essential before initiating treatment, as transient elevations may result from lab variability.
While PSA doubling time is a useful prognostic marker, absolute PSA levels and clinical variables often dictate the timing of salvage radiation therapy. The improved side effect profile of modern radiation therapy has lowered the threshold for treatment, but observation remains an option for select patients with slow PSA kinetics and limited life expectancy. The evolving multimodal approach to high-risk recurrence integrates radiation, androgen deprivation therapy (ADT), and novel systemic therapies, requiring close collaboration between urologists, radiation oncologists, medical oncologists, and the patient to optimize outcomes.
[Dr. Aditya Bagrodia]:
All right, so we've got our patient. They're in the office, they had their PSA drawn a couple days prior. For some period of time, it's been undetectable. Now it's detectable. When you're digging into that patient's chart and trying to sort out what comes next, what are the critical elements? Let's say they're functional and all of that. What are the critical elements of their history, physical, pathology, et cetera, that to you are the most important drivers here?
[Dr. James Eastham]:
Pathology I think can help. Positive margins are more likely to be a local issue. Seminal vesicle invasion can be a local issue, perhaps a little more likely to be metastatic. Obviously, if they had node-positive disease, that suggests node positivity, but it doesn't preclude local recurrence either. Pathology can give a little bit of information. How far they are out from their surgery? Two years before or after?
That's a general landmark. If they're more than two years, more likely local recurrence. If it's before two years, more likely distant recurrence. Then imaging. I don't rely just on one PSA level, of course. We've had several situations where a PSA has been checked, it's been detectable, and then you simply repeat the PSA test and it's gone back to undetectable, and it's just a lab error. It happens.
Always confirm the test, if not just once, twice. I don't necessarily do it immediately. Depending upon the value, I usually wait a few weeks and say, "Look, sometimes there's just these blips and things we don't understand, but we're not going to treat until there's an obvious trend going upwards, and then we will be guided by all the information that we have." Pathology reports, time from surgery, what imaging shows.
[Dr. Aditya Bagrodia]:
I think these are the tried and true risk factors, grade, margins, nodes, obviously clinical factors, making sure that they've got some gas left in the tank, some years left. Doubling time, can you talk a little bit about that?
[Dr. James Eastham]:
We typically aren't getting so many PSAs unless it's someone who's rising very slowly, and then you know they have a long doubling time. In terms of is this a patient who's a candidate for salvage radiation therapy, should I get three to six PSA levels so I can calculate a doubling time? I'm not sure that's a practical way of doing things. I think in more advanced disease, sure, but I think in selecting a patient for consideration of salvage radiation, I think the absolute value of the PSA is far more important with other clinical variables than waiting for a doubling time.
I might be wrong about that, but I don't use doubling times in terms of I have a very low threshold to send folks to radiation therapy for the conversation. I'd rather refer too early than too late. As you have at your place, we have a great relationship with our radiation oncologist. It's not adversarial at all. No one's trying to have the patient and say, "The other treatment's awful. You shouldn't have surgery. You shouldn't have radiation therapy." It's a group effort. It's multidisciplinary.
I have no trouble sending them off to the radiation oncology folks who will give them very sound advice. It may be a little different advice than I might have given them, but no one's right. It's just different advice. Timing might be a little different, those types of things, but I have a low threshold to just send them to get another opinion.
[Dr. Aditya Bagrodia]:
Totally. I think there historically used to be this thought process that if they see a radiation oncologist, they're going to get radiated. I think that's historical interest only as long as you have good patient-centric care. I couldn't agree more with that assessment. I also think it's important for patients to really get a firsthand look at what does radiation look like, number of sessions, bladder filling, time per day as they're trying to sort this out in the context of their whole life.
For me, I would say that the doubling time really comes into play when I'm trying to talk patients off the ledge who've had a nice long interval undetectable PSA, it goes from .01 undetectable to 0.1, and they're freaking out. First of all, I go through my, "Here, you got 13 years, don't freak out." They want to do something. I'm like, "Let's just monitor this and we'll check it at three months." If it's barely creeping, we're obviously talking about the actual management here. Broad strokes, I'm thinking observation if they don't have a dangerous cancer, XRT, radiation therapy, monotherapy, or radiation therapy plus ADT, or systemic therapy only. Those are the four buckets I've organized things in.
Maybe we can start taking your input on that, starting with observation. Are there people that you're generally saying, "Yes, your PSA is detectable, but let's just hang tight"?
[Dr. James Eastham]:
One thing I think that has improved dramatically over the last several years anyway, maybe many years, is the side effect profile of salvage radiation therapy has markedly improved. The negatives about receiving radiation therapy after surgery are far less than what they were 15 or 20 years ago. It becomes much easier to recommend a treatment if the side effect profile is fairly bland. That's why I have a low threshold.
In terms of who might I observe following biochemical recurrence, someone with a limited life expectancy, if they're already, based on age or medical condition, probably not going to live much longer than five years, especially if their PSA is just trickling up, and their imaging is negative. I have several of those patients that were just watching, and they're content with that.
That's the main group that I do with observation. The other, there are some patients that they have a bias against receiving radiation therapy for some reason, and if their PSA is not going up very quickly, I'll still have them meet with the radiation oncologist, I'll even have them meet with a medical oncologist, even though they're probably not going to get systemic therapy, but just for patients like hearing from someone who doesn't have the infamous dog in the fight so to speak, to give them advice.
Medical oncologists aren't selling surgery or selling radiation therapy, and sometimes the medical oncologist can be a good arbiter of what comes next. There are selected patients, primarily older, less healthy patients, those with shorter life expectancy, patients who are averse to getting salvage anything, they're willing to monitor things. This is where I think you can look at doubling times because you'll have more time to get more PSA values and can get a better calculation of doubling time.
Systemic therapy, obviously if they have metastatic disease on their imaging, and if they have a local disease only, or they're being treated as if they're local recurrence only, and their PSA is a little higher than what we like to see, or they have some other risk factors, I leave that guidance to the radiation oncologist, whether or not hormonal therapy is included with prostatic fossa radiation therapy.
If there's any nodal disease or [unintelligible 00:41:38] disease, other types of metastatic disease, I get the medical oncology folks involved early, not because they're necessarily going to be continuously on hormonal therapy, but again, just to establish the relationship so that if that service is needed down the road, they at least know the person that will be delivering that care.
[Dr. Aditya Bagrodia]:
I think it's going to evolve and maybe become continually more complicated, true multi-D. Taking a walk down memory lane, it used to be like a node-positive patient, ADT for the rest of your life, messing trial, boom. Now I would say that that's largely fallen out of favor in a major way. We've got extrapolation from stampede, ADT, abiraterone radiation. We've got the EMBARK study of enzalutamide.
I think looping in the whole gang and hopefully, they've seen them in some form or fashion for their pre-treatment counseling makes a lot of sense and it goes back to nothing, i.e. observation or kitchen sink. Radiation, ADT, Enza or Abi, fossa plus nodes potentially are the gamut as I see it today. Is that fair?
[Dr. James Eastham]:
I think that's incredibly accurate and yes, we're getting better at detecting systemic disease and we're getting better at determining what therapies are useful in a particular systemic disease. I think yes, it's not all or none anymore. It's not we're going to do nothing versus we're going to do everything. This will happen as time goes on. I think we'll be better able to select what type of therapy is most appropriate for a given type of patient.
That'll involve genetics, that will involve targeted therapies, and as is the trend now, I'm not saying anything that's mind-boggling by any means, is we're going to, as we're doing, shift away from treating cancer by their cell of origin but by their genetic makeup. We won't treat prostate cancer, we won't treat bladder cancer, we won't treat kidney cancer. We'll treat a cancer of this type of genetic makeup is managed with this approach.
It may only be in the classic sense, that's only 5% of prostate cancers and you'll say that's great because, in these patients, this drug works wonderful. it's like olaparib, it's the PARP inhibitors. It's a very small percentage of patients that will benefit, but there is a benefit. Actually, I think surgery will probably be used more and not necessarily as they call it debulking. It's not just taking out or treating the primary perhaps with both surgery and radiation therapy, using appropriate systemic therapy guided by genetics, the clinical situation, et cetera.
I think surgery is not going to go away. I think it's going to be a critical part of a multi-D management to try to cure patients with metastatic disease. That's the goal. I think surgery will play a key role in that.
[Dr. Aditya Bagrodia]:
I couldn't have asked for a better plug. You all have a neoadjuvant PARP inhibitor trial, olaparib in high-risk patients with BRCA mutations. Yes, the incidence is only 5%, but you better believe for those 5%, it could be a total game changer. I totally love that. Of course, you spearheaded the CalGB trial of neoadjuvant docetaxel. I think we ought to keep looking and there's going to be the subsets that benefit. Since you mentioned personalized medicine, tailored medicine, are you using any genomic classifiers to help inform timing of radiation, PSA levels, and whether or not to use ADT as well like Decipher, for instance?
[Dr. James Eastham]:
Primarily an unfavorable intermediate risk, the 4+3s, typically they will get a Decipher test to help guide whether or not the patient will or won't benefit from the addition of ADT. Haven't used it much post-radical to say a patient should or should not receive early radiation therapy. I still use PSA testing and let that guide me. I have not used the Decipher testing post-radical to say, "Oh, your PSA is just detectable. We're going to give you radiation therapy early rather than waiting to 0.2."
I don't know if I'm right or wrong in that. I just don't think the data is convincing enough to say that particular use of genetic testing alters what I'm going to do with the patient. Where I think patients certainly, and some physicians, we use the term genetic testing. There's germline testing, there's somatic testing, there's the specific, you mentioned Decipher, Oncotype Prolaris, they all measure different things.
I think that we have to be very clear when we say, "Oh, we're going to get a genetic test." What genetic test, why are you getting it, and what's the purpose of it? What I try to teach the fellows, if you're going to order a test, is it going to change your management even if it's a hemoglobin? Why do you get a hemoglobin at eight hours? The guy's hemodynamically stable, you had one four hours ago, and it's normal. Why are you getting it? What are you going to do with that test? If it goes down, what are you going to do with it? If it goes up, what are you going to do with it? Why are you doing the test?
We have to have a reason to do the test. There's so many tests we have available today. It's why are you doing it and how are you going to react to the result? If it's not going to change management, don't do the test. All my low-risk patients, I don't get genetic testing on them, just the ones that are borderline. Even those patients, I'm really trying to convince them to have active surveillance, but I many times will get a genetic test if they're saying, "I want treatment", hoping the genetic test comes back favorable, so it gives me more reason to help them make a shared decision about choosing active surveillance.
[Dr. Aditya Bagrodia]:
I absolutely appreciate that. It's going to remain a dynamic process. The way I see it is we just need to stay up to date. There used to be the Stevenson paper where the Holy Grail magic number was 0.5, and there was the update of 0.2 to pull the trigger, so to speak. I think there's evolution in the management to get node-positive ADT for everybody. Now it's another way of thinking, as you described earlier.
[Dr. James Eastham]:
That's the exciting part of it. If everything stayed the same, it would get boring.
[Dr. Aditya Bagrodia]:
Absolutely.
[Dr. James Eastham]:
Heck, we're operating on seminoma now, my God.
[Dr. Aditya Bagrodia]:
There you go. It is exciting. We talked about observation. We talked about maybe the other end of the spectrum, the grade groups, 4s, 5s, high PSAs, persistently positive that are going to be more [unintelligible 00:48:52], Abi, ADT, plus radiation, [unintelligible 00:48:55]. Intermittent ADT, is that something that you're doing much in your practice?
[Dr. James Eastham]:
I have to punt because Memorial is a different place. I've not given ADT for the whole time I've been here. The reason for that is a bit historical. Back in the day, giving ADT may have made patients ineligible for clinical trials. The agreement at Memorial was that if someone had a biochemical recurrence after surgery or radiation therapy, we would not give ADT and have the medical oncologist evaluate the patient. That is perpetuated.
I have to back off a little bit in terms of whom I recommend radiation or hormonal therapy for because I don't give it. I know our medical oncologists use intermittent hormonal therapy in some situations. They use continuous in some situations. It just depends but I punt to the experts on systemic therapy. I don't give it.
[Dr. Aditya Bagrodia]:
I think that's totally fair. I personally think that even this clinical stage is getting increasingly complex. There's opportunity for clinical trials. There's opportunities for escalation, enzalutamide, abiraterone, et cetera. Perhaps in the community setting, a large urology group practice setting where there's not the support infrastructure to really run through everything. It makes sense for a urologist to say, "Hey, let me prescribe your ADT and your enzalutamide, which isn't rocket science and we'll get you well taken care of."
I would tend to agree, that's a patient in my hands that I want to loop in the team to make sure we're doing it perfectly. The baseline DEXA scans, the vitamin D, the calcium, all of it. It's not just here's your ADT, have a good time.
[Dr. James Eastham]:
I think there's many urologists who do that. It's just I'm not one of them. I realize my limitations and I do have the benefit of having folks around me who are interested and do it a lot better than I do. My bar for referral is very low. As you mentioned, there are some practices where there are urologists who focus on systemic therapy and they're great at it.
I think as long as one is comfortable doing all the things that you mentioned, pre-evaluation, DEXA scans, making sure patients get their vitamin D and calcium and do especially weight-bearing exercise, that they take their medications appropriately, they're monitored appropriately, then have at it. I don't care if a urologist is giving the right treatment or a medical oncologist is giving the right treatment, as long as it's the right treatment. I'm not the urologist that does that. I'm not comfortable doing it, so I refer. If there is a urologist that's comfortable doing it, great. That's fine. The patient just needs a good doctor. It doesn't matter what their moniker is.
Setting the Right Patient Expectations Around Biochemical Recurrence
Effective preoperative counseling and expectation management are essential for improving patient outcomes and satisfaction in prostate cancer care. Patients who are educated about potential outcomes before biopsy or surgery are better prepared for biochemical recurrence, treatment side effects, and ongoing monitoring, reducing anxiety and fostering informed decision-making.
Setting expectations early—such as the risks of incontinence after radical prostatectomy or the potential need for adjuvant therapy in high-risk cases—allows for more productive discussions if recurrence occurs. As recurrence management continues to evolve, integrating insights from urology, radiation oncology, and medical oncology ensures that treatment remains patient-centered and evidence-based.
[Dr. Aditya Bagrodia]:
I think the lifestyle elements of it, the diet, the exercise, the health, that's clearly outside of the typical oncology purview. I think it's incredibly important because it empowers patients to do something as things are being done to them. I couldn't agree more that this is becoming a team sport more so than it even was once upon a time. James, I've certainly learned a ton as we approach an hour here. As we're wrapping up, any parting thoughts for the listenership on this topic or prostate cancer or in general?
[Dr. James Eastham]:
I think that patients are getting more sophisticated. As we talked about on several fronts, I mentioned, before a biopsy, talking about what the possible outcomes of the biopsy are so that a Gleason 6 doesn't become this monumental Twitter X argument, talking about biochemical recurrence ahead of time. The prepared patient is the best patient and best, I mean from their overall own well-being. They've heard it before. It's not a surprise. They're potentially prepared for it.
It takes a lot less time doing it upfront than trying to explain it after the fact. I would never operate on someone and not tell them that incontinence is a risk factor after radical prostatectomy. The same thing, biochemical recurrence is a risk factor after radical prostatectomy but as you mentioned, it doesn't mean a death sentence. There's lots of ways to treat that. We're going to have to monitor you. All of those things, prepping patients for what the potential outcomes are, it takes a few minutes, it's time well spent, and you'll have a much happier patient population.
Podcast Contributors
Dr. James Eastham
Dr. James Eastham is a urologic surgeon at Memorial Sloan-Kettering Cancer Center in New York City.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2024, March 5). Ep. 155 – Managing Biochemical Recurrence After Prostatectomy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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