We have been redefining the asymptomatic disease state over the years, which is tremendously exciting. The increased understanding of the prognostic value of prostate-specific antigen (PSA) doubling time and the availability of improved imaging techniques have led to revisions in how we identify and treat asymptomatic patients. Approved and emerging positron emission tomography (PET) imaging techniques (eg, fluciclovine F 18, sodium 18F-fluoride, C-11 choline, prostate-specific membrane antigen, fluorodeoxyglucose PET) can now detect disease that would never have been found in the past. In some cases of oligometastasis, we may be able to use stereotactic body radiotherapy/stereotactic ablative radiotherapy to eradicate the disease in certain spots, potentially delaying the onset of hormonal therapy. In the nonmetastatic setting, patients with castration-resistant prostate cancer and more rapid PSA doubling times experience benefits from agents such as darolutamide, apalutamide, and enzalutamide, which are all now US Food and Drug Administration approved and reimbursable. 

As this is a rapidly evolving area, with new imaging, new therapies, new combinations, and new approaches, we have much to talk about with many of our asymptomatic patients. All of these options can be reassuring to patients. It is also true that asymptomatic patients are difficult to make better, and, at times, we can do better by practicing discretion, on an individual basis, when recommending immediate intervention. Consider an asymptomatic 84-year-old patient with cardiovascular disease who is a bit frail and not able to get around like he used to. Let us say that you find some very small lesions on imaging, perhaps 1 in a rib and another possible lesion in a lymph node. You might have a long conversation with that patient and decide that close surveillance is the best approach for right now, all while trying to remain free from symptoms or toxicities. I might convey to such a patient that there are some excellent therapies to consider when the time comes, but that we do not need to intervene right away. 

Obviously, the discussions will vary according to the clinical circumstances. In patients with rapid PSA doubling, I try to help them to understand that there is trouble ahead and that intervention may be warranted sooner rather than later. Even though they may feel good today, it is likely that some type of therapy will be needed in the near future. In addition to side effects, patients are often concerned about co-pays, deductibles, and donut holes, and they may require counseling and assistance with programs that can relieve some of the financial burden. I think that risk stratification and communication with patients about that risk stratification are very important components of good patient care. In addition, a better understanding of the progression from castration-sensitive to castration-resistant disease may help patients to anticipate the eventual need for additional newer forms of therapy.