View the full panel discussion video here.
A regional roundtable discussion, moderated by Alan Tan, MD, Vanderbilt-Ingram Cancer Center, explored the evolving treatment landscape of prostate cancer, from hormone-sensitive to castration-resistant disease, including systemic therapy selection, the role of radiation and surgery, novel targeted therapies, and more. Dr. Tan was joined by other practitioners in the greater Knoxville area, including Nilesh S. Patel, MD, Tennova Healthcare; Wesley M. White, MD, University of Tennessee; Saikrishna Gadde, MD, University of Tennessee; David Chism, MD, Tennessee Oncology; and James Bienvenu, MD, University of Tennessee.
In the first segment, the panel begins with a discussion on the diagnostic workup of a patient with elevated PSA, highlighting the roles of repeat testing, multiparametric MRI, and biopsy strategies. They also explore the expanding use of PSMA PET imaging, its advantages and limitations compared with conventional scans, and how results influence treatment decisions in high-risk prostate cancer.
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Dr. Tan: Welcome everyone. I am Dr. Alan Tan from the Vanderbilt-Ingram Cancer Center in Nashville. I am a medical oncologist, and I specialize in genitourinary cancers. I am very pleased to be here today for this prostate cancer roundtable discussion with my colleagues from the greater Knoxville area. Before we begin, let us go around the table and have each of you introduce yourselves.
Dr. Patel: Thank you, Alan. My name is Dr. Nilesh Patel. I am a urologist, and I practice with Tennova Healthcare in Knoxville. My focus is on urologic oncology, but I see the full spectrum of general urology as well.
Dr. White: I am Dr. Wesley White. I am a urologist at the University of Tennessee Medical Center in Knoxville. My practice includes both general urology and urologic oncology, and I also have a particular interest in minimally invasive surgery.
Dr. Gadde: My name is Dr. Saikrishna Gadde. I am a radiation oncologist at the University of Tennessee Medical Center. I see patients with all types of cancers, but I have a strong interest in treating patients with prostate cancer, including the use of newer imaging techniques and advanced radiation delivery.
Dr. Chism: I am Dr. David Chism. I am a medical oncologist with Tennessee Oncology in Knoxville. I focus primarily on genitourinary cancers, including prostate, bladder, and kidney cancer.
Dr. Bienvenu: My name is Dr. James Bienvenu. I am a radiation oncologist at the University of Tennessee Medical Center. I treat a wide range of patients, but a significant portion of my practice is dedicated to prostate cancer, both localized and metastatic.
Dr. Tan: Thank you all for those introductions. To begin our discussion, I want to present a case. This is a 65-year-old man who comes in with an elevated PSA level of 10. He does not have any significant past medical history. A repeat PSA confirms that the level is again 10. In this situation, what are your next steps in the evaluation?
Dr. Patel: For a patient like this, the first step I take is to repeat the PSA test to confirm that the value is truly elevated, which has already been done here. After that, I would typically order a prostate MRI to look for any suspicious lesions. If the MRI shows an area of concern, such as a PI-RADS 4 or 5 lesion, I would recommend proceeding with a targeted biopsy of that lesion, along with a systematic biopsy to make sure we are not missing any clinically significant cancer.
Dr. White: I agree with that approach. Multiparametric MRI has become very valuable in these situations. When we see a PI-RADS 4 or 5 lesion, that gives us a clear target for biopsy and increases our diagnostic accuracy. At the same time, if the MRI is negative or only shows PI-RADS 1 or 2 lesions, that can sometimes help us avoid unnecessary biopsies and provide some reassurance to the patient.
Dr. Tan: That is a very important point. Are you seeing a shift toward incorporating MRI earlier in the diagnostic process compared with how you practiced in the past?
Dr. White: Yes, there has definitely been a shift. In the past, we relied much more heavily on systematic biopsies without imaging guidance. Now, with MRI being more available and widely accepted, it has become much more common to use it as part of the initial workup.
Dr. Patel: I agree. I think the increased access to MRI has made it easier to obtain, and patients themselves are often aware of it and will ask about it. It adds another layer of reassurance when the findings are negative, and when there is a suspicious lesion, it allows us to have more confidence that we are identifying clinically significant disease.
Dr. Tan: Excellent points. Let us move on to the next step in the case. Suppose this patient undergoes biopsy and is found to have high-risk features. At that point, how are you incorporating PSMA PET scans into your practice for staging?
Dr. Gadde: PSMA PET has become increasingly important for us in staging patients with high-risk prostate cancer. It is much more sensitive than conventional imaging and often identifies disease that we would not otherwise see. For example, we sometimes detect very small lymph node metastases or early bone lesions that are not apparent on CT or bone scans. That information can change the way we approach treatment.
Dr. Chism: I completely agree. I have had several cases where PSMA PET findings have directly altered management. In some patients, the scan revealed metastatic disease that we would not have suspected, and in others, it helped clarify equivocal findings on conventional imaging. That can make a big difference in guiding decisions about whether to treat with curative intent or with systemic therapy.
Dr. Bienvenu: I would also add that PSMA PET has become very useful in radiation oncology. When we are planning treatment fields, it is critical to know the full extent of disease. If the PSMA PET shows involvement of pelvic lymph nodes or distant metastases, we can adjust our fields or our treatment approach accordingly. It gives us a level of precision that we did not have before.
Dr. Tan: These are excellent insights. It sounds like PSMA PET is rapidly becoming an integral part of how we stage and manage patients with high-risk prostate cancer.
View the next segment on Managing Post-Prostatectomy PSA Persistence and BCR.