Prostate cancer: shared team decisions

A 64-year-old man, a retired teacher, receives the result of his MRI-guided prostate biopsy: ISUP grade 2 adenocarcinoma, PSA of 7.8 ng/mL, disease confined to the gland on digital rectal exam. At the first visit, the urologist explains prostatectomy. Two weeks later, a friend mentions he had radiotherapy and "felt nothing". A video on the internet says you can "just monitor it". He arrives at the second visit with a sheet of questions: which option lives longer, which leaves incontinence, which takes away the erection, and who can answer all of that at once. The scene is fictional and was written for teaching.

This text uses the case as a setting for clinical reasoning for students and health professionals. The topic is the organization of care in prostate cancer: how urology, radiotherapy and oncology present the alternatives and build a shared decision, and when to bring in nuclear medicine, genetics and urinary and sexual rehabilitation. The text does not replace your country's guideline or your service's protocol. If you play the case of the day on NEXO, you will recognize the challenge: the clues seem to point to a single answer, but a good decision depends on weighing several.

Key points

• In localized low- and intermediate-risk disease, active surveillance, surgery and radiotherapy have similar mortality results in the 15-year follow-up of ProtecT.
• What changes between the options is the profile of urinary, bowel and sexual effects, and that is the center of the shared decision.
• The multidisciplinary visit reviews staging and the slide, and the review changes the risk classification of a portion of patients.
• PSMA PET has a clearer role in high risk than in intermediate risk, where guidelines disagree.
• Germline genetic testing has an impact on the patient and the family and needs its own pathway.
• Pelvic floor and sexual function rehabilitation is part of the plan from the start.

Why the prostate calls for a shared decision

In many tumors, the evidence points to a preferred treatment, and the conversation with the patient revolves around how to carry it out. In localized low- and intermediate-risk prostate cancer, the situation is different. There are several valid options, with similar oncological results and different adverse effects. The assessment by the Gustave Roussy multidisciplinary prostate clinic sums up the problem: the initial decision is complex, there are several valid approaches with no absolute consensus for each scenario, and expert opinion may vary.

This variation has a known origin. Each specialist tends to present best what they do. The urologist knows surgery in detail; the radiation oncologist, radiotherapy. The patient who sees only one of them receives a partial view, with no bad faith from anyone. The shared decision corrects this in two ways: it ensures the patient hears all eligible options and brings his values to the table, such as the importance he gives to continence, sexual function or the peace of mind of having treated it right away.

The three errors the team tries to avoid

Dr. Alexei's question for this tumor has two halves. The first is to avoid overtreatment of indolent disease, which exposes the man to permanent effects with no survival gain. The second is to avoid undertreatment of aggressive disease, which lets the window of control slip by. Between the two, there is a third, quieter error: choosing the treatment well, but not preparing the patient for the effects, which arrive with no rehabilitation plan.

What ProtecT teaches about the options

ProtecT is the study that underpins almost every discussion about localized prostate cancer. In the United Kingdom, between 1999 and 2009, 82,429 men aged 50 to 69 entered the study, and 1,643 with localized cancer were randomized among active monitoring, radical prostatectomy and radiotherapy, according to the commentary by Spohn and Grosu on the 15-year results. With a median follow-up of 15 years, the study showed no difference in mortality among the three strategies, and the commentary authors highlight the role of active surveillance, especially in low risk, in the same text.

Similar mortality does not mean the options are the same. The analysis of patient-reported outcomes from ProtecT showed that prostatectomy had the greatest negative effect on sexual function and urinary continence, with some recovery, but always worse than in the other groups. Pad use went from 1 in 100 men before diagnosis to 46 in 100 at 6 months in the surgery group, versus 4 in 100 with monitoring and 5 in 100 with radiotherapy, according to the NEJM article. In the sixth year, it was 17 in 100 with surgery, 8 with monitoring and 4 with radiotherapy.

Erectile function fell in all groups. Before diagnosis, 67 in 100 men reported erections sufficient for intercourse; at 6 months, it was 52 in 100 with monitoring, 22 with radiotherapy and 12 with prostatectomy, in ProtecT. Radiotherapy had the greatest sexual impact at 6 months, and there was partial recovery afterward; the same study reports a greater bowel effect with radiotherapy.

How to summarize the options for the patient

Option	What it involves	Most marked effect in ProtecT	Who takes part
Active surveillance	Periodic PSA, exam, MRI and biopsy; treatment if there is progression	Fewer initial effects; function declines gradually with age and if there is later treatment	Urology, radiology, pathology
Radical prostatectomy	Removal of the prostate, open or robotic	More frequent incontinence and erectile dysfunction	Urology, anesthesia, pelvic physiotherapy
Radiotherapy	External beam radiotherapy or brachytherapy, sometimes with hormonal blockade	Early sexual effect and bowel effect	Radiotherapy, oncology, urology
Associated systemic treatment	Hormonal blockade and, in high risk, intensification	Fatigue, hot flashes, loss of bone and muscle mass	Clinical oncology, radiotherapy

The multidisciplinary consultation in practice

There are several formats of multidisciplinary prostate care. The best known is the same-day clinic. In the Johns Hopkins model, from 2008 to 2012, 887 men with a recent diagnosis went through a process in which they were examined in the morning, had imaging and slides reviewed at midday by urology, radiotherapy, clinical oncology, pathology and radiology together, and in the afternoon talked with the specialists for each eligible option.

The review had a concrete effect. After pathological re-evaluation, the Gleason grade rose in 13.3 in 100 men and fell in 8.2 in 100, and 28.7 in 100 changed NCCN risk class, according to the article published in Prostate. The same study describes men referred with suspected metastatic disease who were reclassified as non-metastatic after the full evaluation. For the student, the lesson is that the meeting is not only for choosing treatment; it is for checking whether the diagnosis that arrived is correct.

Two consultations and a meeting

At Gustave Roussy, the prostate clinic consists of two consecutive consultations, one with the urologic surgeon and one with the radiation oncologist, and then a discussion at a tumor board. Among the patients who answered the questionnaire, 98 in 100 felt better informed, and the double consultation was considered useful by 96 in 100, according to the two-year evaluation of the clinic. In 55 in 100 patients, treatment options new compared with what they knew before were offered.

Why not every service has this model

The same Johns Hopkins experience shows what joint assessment corrects: taking the NCCN guidelines as a reference, many men had undergone tests without an indication before reaching the clinic, with unnecessary CT or MRI in about 47 out of every 100 and unnecessary bone scan in about 24 out of every 100, according to the report by Sundi and colleagues. In practice, many services adapt the model: instead of a same-day clinic, they hold sequential appointments and a weekly meeting with a record of the recommendation.

What the meeting needs to decide

• Is the risk classification correct after review of the slide and the imaging?
• Which options are eligible for this patient, considering age, comorbidities and baseline urinary and sexual function?
• Is there an indication for PSMA PET or another staging image?
• Is there a criterion for germline genetic testing?
• Who will present each option to the patient and who is his contact until the decision?
• What is the rehabilitation plan if the choice is surgery or radiotherapy?

Communicating uncertainty without frightening

Explaining that three options have similar mortality and different effects requires language that many professionals have not trained. Phrases such as "the choice is yours" can sound like abandonment, and phrases such as "I would have the surgery" can sound like an order. The middle path is to describe what happens to similar men with each option, ask what weighs most for him and only then say which option best matches what he has described. Radiotherapy, for example, had a greater bowel effect at 6 months in ProtecT, with partial recovery, but with a progressive increase in the frequency of blood in the stool; this detail matters for a man who has inflammatory bowel disease or who places great value on his bowel habit.

Decision support tools

Decision support tools are structured materials, printed or online, that present the options, risks and benefits and help the patient state what he values. In a Dutch randomized trial with 382 men with localized prostate cancer, active surveillance was an eligible option for 38 out of every 100 patients. Those who used the tool chose active surveillance more often than the usual care group, 29 versus 16 out of every 100, according to the article in World Journal of Urology.

This result does not mean the tool "pushes" toward surveillance. It suggests that, when the patient understands that surveillance has similar mortality and fewer immediate effects, some men prefer to postpone active treatment. The decision remains his.

Well-run active surveillance

Active surveillance is not absence of care. The Prostate Cancer UK consensus on good practice in active surveillance covers the follow-up protocol, the role of multiparametric MRI at the start and during monitoring and the information the man should receive. For the team, this means defining who orders the PSA, who reads the MRI, when to repeat the biopsy and which finding leads to discussing treatment.

• PSA and combined test schedule agreed in writing with the patient.
• Multiparametric MRI read by a radiologist with prostate experience.
• Explicit progression criteria that lead to a new discussion.
• A defined contact for questions and for anxiety, which is a frequent reason for dropping out of surveillance.
• A record of the reason for each change in management.

When to call nuclear medicine

PET with prostate-specific membrane antigen ligands, PSMA, changed staging. The joint procedure guideline from EANM and SNMMI lists as applications initial staging of unfavorable intermediate risk and high risk, biochemical recurrence after surgery or radiotherapy, persistent PSA after surgery and selection for radioligand therapy. The guideline cites as risk features ISUP grade 3 or higher, PSA above 20 ng/mL and clinical stage T2c to T3a.

The test has limits that the team needs to know. For pelvic lymph node metastasis, specificity in the studies cited by the guideline was high, 95 out of every 100 or more, but sensitivity was in the range of 40 out of every 100, so a negative PET does not rule out lymph node micrometastasis, according to the EANM and SNMMI guideline.

Intermediate risk still divides the guidelines

A guideline analysis published in BJU International compared the recommendations of EAU, AUA, NCCN, NICE, CUA, ASCO and SNMMI on PSMA PET in the staging of newly diagnosed intermediate risk. The authors found major disagreement in this group and stronger consensus in high risk, with generally weak recommendations. That is why the indication in intermediate risk is a good question for the meeting, and not an automatic request.

Biochemical recurrence: the team meets again

Shared decision making does not end with the first treatment. The EANM and SNMMI guideline defines biochemical recurrence as the return of cancer indicated by a rise in PSA after definitive surgery or radiotherapy, and biochemical persistence as PSA that remains high despite surgery. In both scenarios the question changes: is the tumor in the prostate bed, in the lymph nodes or at a distance, and what does each answer allow you to do. This is where nuclear medicine returns to the table, together with radiotherapy, which can offer salvage treatment, and with clinical oncology, which discusses hormonal blockade.

For the patient, this moment is usually more distressing than the diagnosis. He has already been through a treatment, has already lived with side effects and now hears that his PSA has risen. The team that agreed from the start who monitors PSA, how often and which value leads to a new discussion avoids two failures: delay, because nobody looked at the test, and the anxiety of someone who receives a number without explanation.

The effect of the unexpected finding

A more sensitive test finds more lesions. This can lead to stage migration, in which the patient comes to be classified as metastatic because of a small lesion that conventional tests did not see. Decisions made on the basis of these findings do not always have evidence of benefit. Nuclear medicine helps the team interpret the finding and decide whether it should change the treatment.

When to call in genetics

Germline genetic testing looks for inherited variants, such as BRCA2, ATM, CHEK2 and HOXB13, which can change the patient's treatment and the screening of relatives. In a cohort of 505 men tested according to NCCN criteria, pathogenic or likely pathogenic variants appeared in 7.6 out of every 100 with metastatic disease and in 11.2 out of every 100 with localized disease. The most frequent were CHEK2, BRCA2, ATM and HOXB13, in the Urology Practice article.

This finding contradicts a common intuition, that the test only matters in advanced disease. It shows that men with localized disease who meet the criteria also carry important variants. The result affects brothers, sons and daughters, and so the pathway needs to include genetic counseling before and after the test.

What the team agrees on about genetics

• Who checks the testing criteria, based on personal and family history.
• Who explains to the patient what the test can and cannot show.
• How the result reaches the oncologist who decides the treatment.
• How the family is guided when there is a pathogenic variant.
• What to do with a variant of uncertain significance, which should not change management on its own.

Urinary and sexual rehabilitation from the start

ProtecT made it clear that incontinence and erectile dysfunction are the side effects that weigh most after surgery. This puts pelvic physiotherapy and sexual medicine on the team from before the operation, and not only when the problem appears.

Pelvic floor muscle training is the basis of urinary rehabilitation. A scoping review of training protocols after prostatectomy included 24 studies and found frequent recommendations of three sessions a day, with 6 to 15 contractions per session, in lying, sitting and standing positions. There was no consensus on when to start, how long to continue and with what intensity to contract. In most protocols that reported who was responsible, the person giving the guidance was the physiotherapist, according to the same review.

In practice, the pelvic physiotherapist can see the patient before surgery to teach the correct contraction, and again after the catheter is removed. Nursing reinforces the guidance in writing, and the urologist follows the continence progress at follow-up visits. When urinary loss persists longer than expected, the team discusses specific tests and treatments, instead of asking the patient to simply wait.

Sexual rehabilitation

Penile rehabilitation aims to protect the cavernous tissue after surgery. An umbrella review of meta-analyses concluded that phosphodiesterase 5 inhibitors improve erectile function during use, but that the evidence that they promote spontaneous recovery is limited. Vacuum devices work for assisted intercourse, with little effect on the return of baseline function, and the penile prosthesis is the most reliable definitive treatment in refractory cases. Regenerative approaches, such as shock waves, platelet-rich plasma and stem cells, remain experimental.

The conversation about sexual function needs to start before treatment. Many men do not ask, and many professionals do not offer. When the team records baseline function and agrees on the rehabilitation plan, the patient knows what to expect and who to turn to.

How NEXO helps train this reasoning

NEXO uses fictional cases with realistic clinical presentation, with up to six clues, to train step-by-step decision-making. In prostate cancer, the skill is similar: separate what changes survival from what changes quality of life, check whether the diagnosis that arrived is correct before discussing treatment, and know when a new test deserves to change management. The texts on overdiagnosis and on retrospective bias and outcome bias help you think about why a good result does not prove that the decision was good, and vice versa.

The Researcher track goes deeper into the mechanisms behind the clues, the Closer profile helps you measure your own accuracy, Curator organizes case curation and Creators brings together those who produce medical content. The usage limits are at /economia. To train the conversation between professions, also see the post on interprofessional clinical reasoning.

Frequently asked questions

Which treatment makes people live longer in localized prostate cancer?

In ProtecT, with a median follow-up of 15 years, there was no difference in mortality between active monitoring, prostatectomy and radiotherapy. The choice depends on the risk of the disease, the effects of each option and the patient's values.

Is active surveillance leaving the cancer untreated?

No. It means monitoring with PSA, examination, MRI and biopsies, with defined criteria for treating if there is progression.

Should every patient have a PSMA PET scan?

No. It has a clearer role in high risk and in biochemical recurrence. In intermediate risk, guidelines disagree, and a negative scan does not rule out lymph node micrometastasis.

Who should have genetic testing?

Those who meet the criteria of the guideline adopted by the service, whether due to personal or family history or due to disease characteristics. Variants also appear in localized disease.

Can incontinence after surgery be prevented?

Pelvic floor training guided by a professional is the basis of rehabilitation. Protocols vary, and there is no consensus on the best time to start.

Do erection medications restore natural function?

They help during use, but the evidence that they promote spontaneous recovery is limited. The prosthesis is the most reliable definitive option in refractory cases.

Final checklist

• Slides and imaging reviewed before discussing treatment.
• All eligible options presented, with the side effect profile of each one.
• Baseline urinary, bowel and sexual function recorded.
• Indication for PSMA PET discussed according to risk.
• Genetic testing criteria checked and counseling planned.
• Pelvic and sexual rehabilitation plan defined before surgery or radiotherapy.
• Patient contact and re-evaluation criteria recorded.

Play the case of the day on NEXO and train weighing clues that point in different directions.

References

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2. Carll J, Shi W, Perera M, et al. Guideline of guidelines: PSMA PET in staging newly diagnosed intermediate-risk prostate cancer. BJU Int. 2025. PMID 40704877.
3. Donovan JL, Hamdy FC, Lane JA, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2016. PMID 27626365.
4. Fendler WP, Eiber M, Beheshti M, et al. PSMA PET/CT: joint EANM procedure guideline/SNMMI procedure standard for prostate cancer imaging 2.0. Eur J Nucl Med Mol Imaging. 2023. PMID 36604326.
5. Lamers RED, Cuypers M, de Vries M, et al. Differences in treatment choices between prostate cancer patients using a decision aid and patients receiving care as usual: results from a randomized controlled trial. World J Urol. 2021. PMID 34272972.
6. Merriel SWD, Hetherington L, Seggie A, et al. Best practice in active surveillance for men with prostate cancer: a Prostate Cancer UK consensus statement. BJU Int. 2019. PMID 30742733.
7. Patrikidou A, Maroun P, Patard JJ, et al. Helping patients make informed decisions. Two-year evaluation of the Gustave Roussy prostate cancer multidisciplinary clinic. Clin Transl Radiat Oncol. 2018. PMID 30094353.
8. Santos JEMD, Brasil VV, Azevedo C, et al. Pelvic floor muscle training in men with post-prostatectomy urinary incontinence: a scoping review. Rev Lat Am Enfermagem. 2024. PMID 39476142.
9. Seminara G, Meduri L, Leuzzi M, et al. Penile Rehabilitation After Surgery for Prostate Cancer: An Umbrella Review on Traditional Approaches and Novel Perspectives. J Clin Med. 2026. PMID 42355856.
10. Spohn SKB, Grosu AL. [Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer]. Strahlenther Onkol. 2024. PMID 38289359.
11. Sundi D, Cohen JE, Cole AP, et al. Establishment of a new prostate cancer multidisciplinary clinic: Format and initial experience. Prostate. 2015. PMID 25307625.