My example...when my PSA started rising in 2022 and we met our decision criteria in April 2023 to image (three or more consecutive increases spaced three months apart and PSA between .5-1.0), the imaging showed a single lymph node.

I met with my radiologist and oncologist. My thought was SBRT and six months ADT for micro-metastatic disease.

My radiologist supported that. My oncologist proposed 24 months ADT + ARI and SBRT.

I countered with SBRT, 12 months ADT, hold off the ARI unless PSA didn't drop to undetectable in the first three months, decide at 12 months based on the clinical data to continue or stop.

We did not add the ARI and at 12 months, I argued for coming off based on PSA dropping to undetectable in the first three months. Radiologist supported that, so did the oncologist though I could see he was gritting his teeth. I think he was ok because he knew I would do labs and consults every three months and go back on treatment when the clinical data indicated.

The other time was triplet therapy in January 2017 after surgery and SRT failed. My clinical data didn't support it but I felt it did and when my medical team didn't support it, went to Mayo, they did, found a new team to administer locally, except my radiologist.

Was triplet therapy over treatment, possibly, I don't think so. While my clinical data didn't support it based on the STAMPEDE and CHAARTED trials I felt my Grade Group, GS, time to BCR coupled with my PSADT and PSAV meant left untreated, I would be soon!

Was either the right decision? We'll never know since we can't run a parallel study of the other treatment choices.

Medicine is based on science but the application to individuals is the art. Guidelines such as NCCN are based on science, but they are population based and historical given the exponential advances brought about by medical research.

So, what do I look for in my medical team...active listening, shared decision making.

Kevin