We still have patients that prefer face-to-face visits, even though they know we’re not doing anything except discussing a PSA level with them—they just want that security of seeing our face. Some patients are very nervous, and they don’t necessarily want to be discharged, so to speak, back to primary care. Also, for those patients that travel a long distance to clinic, we offer an appointment in the video chat clinic, with the community-based outpatient clinics in Bakersfield and Santa Maria, California.
William Aronson. I probably see a patient about every 4 to 6 weeks who has a low PSA after about 10 years and has a long distance to travel and mobility and other problems that make it difficult to come in.
The challenge that I have is, what is that specific guideline to give with regards to the rise in PSA? I think it all depends on the patients prostate cancer clinical features and comorbidities.
Nicholas Nickols. If a patient has been seen by me in follow-up a number of times and there’s really no active issues and there’s a low suspicion of recurrence, then I offer the patient the option of a phone follow-up as an alternative to face to face. Some of them accept that, but I ask that they agree to also see either urology or their PCP face to face. I will also remotely ensure that they’re getting the right laboratory tests, and if not, I’ll put those orders in.
With regard to when to refer a patient back for a suspected recurrence after definitive radiation therapy, there is an accepted definition of biochemical failure called the Phoenix definition, which is an absolute rise in 2 ng/mL of PSA over their posttreatment nadir. Often the posttreatment nadir, especially if they were on hormone therapy, will be close to 0. If the PSA gets to 2, that is a good trigger for a referral back to me and/or urology to discuss restaging and workup for a suspected recurrence.
For patients that are postsurgery and then subsequently get salvage radiation, it is not as clear when a restaging workup should be initiated. Currently, the imaging that is routine care is not very sensitive for detecting PSA in that setting until the PSA is around 0.8 ng/mL, and that’s with the most modern imaging available. Over time that may improve.
William Aronson. The other index patient to think about would be the patient who is on watchful waiting for their prostate cancer, which is to be distinguished from active surveillance. If someone’s on active surveillance, we’re regularly doing prostate biopsies and doing very close monitoring; but we also have patients who have multiple other medical problems, have a limited life expectancy, don’t have aggressive prostate cancer, and it’s extremely reasonable not to do a biopsy in those patients.