In this episode of First Assist: GU Oncology Unpacked, host Taylor Goodstein, MD, sits down with Pretesh Patel, MD, associate professor of radiation oncology at Emory University, for an in-depth conversation about modern approaches to radiation therapy in prostate cancer. Patel breaks down complex terminology, evolving technologies, and patient-centered strategies for delivering precise, effective, and individualized radiation care. The discussion begins with an overview of radiation modalities — from external beam radiation (IMRT, SBRT/SABR, proton therapy) to brachytherapy (LDR and HDR). Patel explains how imaging advances, fiducial markers, and rectal spacers have made treatments safer and more accurate, and how hypofractionation—fewer sessions with higher daily doses—has become standard for many prostate cancer patients. Goodstein and Patel explore how image guidance and adaptive radiation planning have revolutionized precision, even allowing real-time treatment plan adjustments. They also discuss patient experience, outlining what to expect from fiducial placement to simulation scans and the short, painless daily treatments that define SBRT. Patel highlights how biologic factors like the prostate’s low alpha-beta ratio make it especially responsive to higher-dose, shorter-course radiation. He details patient-specific considerations—such as urinary function, prostate size, and median lobe anatomy — that help determine whether external beam, brachytherapy, or combination therapy is best. As the conversation deepens, Patel outlines treatment paradigms for different risk groups: Low-risk: active surveillance preferred; if treated, short-course SBRT or brachytherapy without ADT Favorable intermediate-risk: radiation alone often sufficient Unfavorable intermediate-risk: radiation plus 4 to 6 months of ADT, guided by genomic and AI-based classifiers like Decipher and ArteraAI. High-risk: combination approaches—brachytherapy boost plus external beam—and longer-term ADT (18 to 36 months). Patel shares insight into ADT decision-making, comparing GnRH agonists and antagonists, discussing cardiac considerations, flare effects, and recovery timelines. The episode concludes with an honest conversation about toxicities and survivorship—urinary and sexual function, bowel changes, and the dramatic reduction in rectal injury seen with modern imaging and rectal spacers. Patel emphasizes the importance of shared decision-making, balancing cancer control with quality of life, and integrating patient priorities into every step of radiation planning. Chapters 00:22 Defining radiation in prostate cancer 6:44 IGRT guidance 12:30 The patient's experience with radiation 21:27 When hypofractionation is not recommended 28:10 Risk groups 35:15 Timing of ADT 40:10 High-risk prostate cancer 52:31 Timing of sexual dysfunction

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