[Note: Dr. Peter Carroll's presentation contains some graphic images for the purposes of medical education]




Summary of the Transcript: Prostate Cancer Management and Evolving Practices

Overview
The speaker, a highly experienced urologist and surgeon, provides a comprehensive overview of the current landscape, challenges, and innovations in prostate cancer diagnosis and treatment. Drawing on extensive personal and institutional experience, the presentation covers the spectrum of disease, risk assessment, active surveillance, surgical outcomes, the role of imaging and AI, and the debate over terminology and overtreatment.

Key Points

Prostate Cancer as a Spectrum

Prostate cancer varies widely in aggressiveness and risk, making precise, nuanced risk assessment crucial.

Both over- and undertreatment remain significant issues, with historical trends toward overtreatment now being countered by more conservative approaches such as active surveillance.

Active Surveillance

UCSF has one of the largest active surveillance cohorts, with about 3,000 men.

For low-risk (grade group 1) or low-volume grade group 2 disease, about 50% of patients remain treatment-free at 10 years, with only about 1% risk of metastasis at 10–15 years.

Most disease progression is mild; major progression (to higher grade) occurs in about 17% over 10 years.

Surveillance intensity can be reduced over time for stable patients, but even after 5–10 years, a small risk of progression remains, justifying continued but less frequent monitoring.

Risk Factors for Progression

PSA density, genomic markers, MRI findings, disease volume, and histologic subtypes are all predictive of progression.

Younger patients tend to have more favorable outcomes and are good candidates for surveillance, even if they have not completed their families.

Debate on Terminology

There is ongoing debate about whether low-grade prostate cancer should be renamed to reduce patient anxiety and overtreatment.

The speaker opposes removing the term "cancer," arguing that it remains a spectrum and about 17% still progress significantly.

Focal Therapy and Imaging Advances

Focal therapy is increasingly popular, especially for well-localized, intermediate-risk tumors, though long-term outcomes are still lacking.

Advanced imaging (MRI, PSMA PET) and AI-driven pathology are revolutionizing diagnosis, risk stratification, and surgical planning.

Surgical Trends and Outcomes

Surgery is now primarily reserved for higher-risk patients at UCSF, with only about 6% of low-risk patients undergoing surgery.

Robotic surgery offers some advantages in recovery and potency, but both open and robotic approaches have similar long-term outcomes.

Positive surgical margins predict recurrence but not metastasis; factors like seminal vesicle invasion are more predictive of poor outcomes.

Lymph Node Dissection

The benefit of extended lymph node dissection is unclear and associated with increased morbidity.

PSMA PET imaging helps better localize disease and may reduce unnecessary dissections.

Radiation Therapy and Recurrence

Radiation after surgery should not be rushed; waiting for a rising PSA and using advanced imaging to localize recurrence can improve outcomes and reduce unnecessary toxicity.

Most recurrences after surgery are regional (lymph nodes), not local.

Future Directions

Multivariable risk models outperform traditional risk groupings (NCCN, AUA) for guiding management.

AI and novel imaging techniques will further refine diagnosis and treatment.

Treatment decisions should be individualized, data-driven, and transparent, with outcomes tracked and used to inform practice.

Conclusion
Prostate cancer management is rapidly evolving, with a shift toward individualized, risk-adapted strategies, greater use of surveillance and focal therapy, and integration of advanced imaging and AI. Ongoing debate continues around overtreatment and terminology, but the focus remains on optimizing outcomes while minimizing harm and unnecessary interventions.