How to cite: Carroll PR. Combination Therapy Revisited. Grand Rounds in Urology. November 2025. Accessed Jan 2026. https://grandroundsinurology.com/combination-therapy-revisited/
Summary
Peter R. Carroll, MD, MPH, Professor of Urology, University of California, San Francisco (UCSF), San Francisco, California, presents a detailed review of prostate cancer management, emphasizing when and how to combine therapies while maintaining quality of life. Drawing from more than 3,000 men in UCSF’s active surveillance program, he shows that long-term outcomes for Grade Group 1 (GG1) disease remain excellent, with metastasis rates under 1 percent and prostate cancer–specific mortality near zero.
For Grade Group 2 (GG2) disease, Carroll notes that there is growing evidence that many men can safely undergo surveillance. At UCSF, patients with GG2 and a prostate-specific antigen (PSA) density below 0.15 ng/mL/cc, a minimal pattern 4, and a negative magnetic resonance imaging (MRI) have metastasis-free survival rates of over 98 percent at ten years. He cautions, however, that higher PSA density, adverse genomics, or visible MRI lesions significantly increase risk and warrant earlier definitive treatment.
He discusses the expanding role of genomic classifiers such as Decipher, which reclassify risk and help personalize the timing and intensity of intervention. In localized and locally advanced settings, Carroll reviews randomized data supporting combination radiation and androgen deprivation therapy (ADT), but he stresses that treatment duration should depend on genomic risk and response rather than a uniform timeline. He highlights ArteraAI, which utilizes digitized histology from clinical trials to predict the benefit of adding ADT, enabling clinicians to individualize therapy while avoiding overtreatment.
Turning to imaging, Carroll emphasizes that prostate-specific membrane antigen positron emission tomography (PSMA PET) should be used selectively for the detection of biochemical recurrence and metastasis, warning that indiscriminate early use may lead to over-staging and unnecessary therapeutic changes.
He concludes with a look toward theranostics and intraoperative innovation, showcasing early work at UCSF using PSMA-fluorophore imaging to improve surgical margin detection. Dr. Carroll stresses that multimodal integration, combining imaging, genomics, and tailored systemic therapy, defines the future of prostate cancer management, replacing the one-size-fits-all approach with precise, data-driven personalization.
ABOUT THE AUTHOR
Dr. Peter Carroll holds the Ken and Donna Derr-Chevron Professorship in Prostate Cancer and the Taube Family Distinguished Professorship in Urology at the University of California, San Francisco (UCSF). He is also the Associate Director of Strategic Planning and Clinical Services and Program Leader of the Prostate Cancer Program at the Helen Diller Family Comprehensive Cancer Center at UCSF.
Dr. Carroll graduated with honors from Georgetown University School of Medicine. He then went on to complete general surgery training and a urology residency at UCSF, as well as a Fellowship in Urologic Oncology at Memorial Sloan Kettering Cancer Center in New York City. He has taught at the UCSF Department of Urology since 1986, and he became the department chair in 1996. Under his leadership, the department has been consistently ranked one of the top urology departments in the country by U.S. News and World Report. The department has grown, serving an increasingly larger patient population, expanding its research programs, and attracting future leaders in the field for training. Under Dr. Carroll’s leadership, the department managed an average of over $10 million in research grants that put UCSF in first place for urology funding for five consecutive years. Dr. Carroll also established the UCSF Department of Urology’s Tissue Core, a biobank of blood, urine, and residual prostate, bladder, and renal tissues for more than 6,000 consenting patients. In addition to his many accomplishments at UCSF, Dr. Carroll has authored or co-authored over 650 publications, is an active member of numerous professional medical societies, and is currently principal or co-investigator on numerous scientific studies. He is also Past-President of the American Board of Urology (2006-2008). His drive to perfect nerve-sparing prostatectomy has led to many technical innovations, and his pioneering efforts in standardizing an active surveillance regimen has led to many patients postponing radical treatment while maintaining a low risk of cancer progression.
