Surgery or Radiation for Intermediate Prostate Cancer?

Hello and welcome to the forum. You’ve joined a club that no one wants to join, but there are a bunch of great people here who are all willing to help.
I’m on my second boat of prostate cancer, so I’m just sharing my opinion and not medical advice.

From what I’ve read outcomes are similar for intermediate risk prostate cancer patients receiving surgery or radiation. Since you’ve been diagnosed with unfavorable intermediate risk PCA, I would assume that your doctor will also prescribe at least a short term of ADT; Probably six months but perhaps as much as a year.

One thing worthy of consideration is understanding what your options would be in the event that your primary treatment fails. This is a big deal.

If you have a prostatectomy as primary therapy and PCa returns, you can receive radiation to the affected area as salvage treatment. If however, you have radiation as primary therapy and prostate cancer returns, with rare exception you can’t have debulking surgery to remove the prostate. Your next step might have to be chemotherapy or some form of immunotherapy. In other words, your options are more limited because surgery is typically off the table.

I opted for LDR brachytherapy as primary treatment in 2020 and PCa returned with a vengeance in 2023 with Gleason 9 Stage 3 locally metastatic. I was told that I couldn’t receive more radiation to the treated area where tumors reappeared. I could only receive radiation to untreated areas. My gene mutation doesn’t respond to chemotherapy so my outlook was not good. Luckily I found a surgeon that was willing to do salvage prostatectomy to debulk the tumor, remove one of the diseased pelvic lymph nodes and give me a fighting chance for salvage radiation combined with long term first and second generation ADT.

If I had to do it all over again, I would’ve opted for surgery as primary therapy and dealt with the short term incontinence and ED issues.

There are other factors you may have to consider depending on your age and overall health.

Good luck on your journey and don’t hesitate to ask more questions. We’re here for you.

The below is from the American Cancer Society reference definition and use of various options at treating prostate cancer. I had stage I, Gleason 3+3; PSA: 6.47. I selected proton radiation therapy. Every case is different as to metrics-there is no perfect fit, it seems from one comparison to another. Please note the comments below from the ACS.
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Proton beam radiation therapy
Proton beam therapy focuses beams of protons instead of x-rays on the cancer. Standard radiation therapy is given in the form of x-rays (photons), which release their energy both before and after they hit their target. However, protons cause little damage to the tissues they pass through and release their energy only after traveling a certain distance. This means that proton beam radiation can, in theory, deliver more radiation to the cancer while doing less damage to nearby normal tissues. Proton beam radiation can be aimed with techniques similar to those used for 3D-CRT and IMRT.

Although in theory proton beam therapy might be more effective than using x-rays, so far studies haven’t shown if this is true.

Proton beam therapy isn’t available everywhere. The machines needed to make protons are very expensive, and they aren’t available in many centers in the United States. Proton beam radiation might not be covered by all insurance companies at this time.
Nothing follows

I, as well as others will have an opinion on this matter, however, remember that every man has a different situation and therefore, what treatment is appropriate for one case with similar numbers may be completely different for another. That is why it is so important to find a highly skilled urologist and/or radiation oncologist that you trust, listen to everything they have to say, and follow thier advise. As I said, I have an opinion, but it is just that. I'm 67, have Gleason 9 Intraductal Carcinoma with cribriform, Stage pT3a. My cancer is very agressive and high risk. ADT has significant potential side effects and I would have had to do 18-36 months. In the end my team at Mayo recommended a non-nerve sparing prostatectomy - 6 weeks ago. All is well enough with the surgery but the incontinence and inability to have an errection are significant side effects that must be considered. Various radiation techniques are certainly options, and with intermediate risk cancer, it is most likely what I would choose. That said, I have a friend who had radiation 12 years ago and he is routinely dealing with urethra swelling caused by the radiation which is requiring more surigical procedures. Again, find doctors you trust, learn all you can, and move forward knowing there is likely no free ride! Good luck on your journey!

HRFT (hypofractioned radiaton therapy) uses a higher dose of radiation (GY) per treatment with fewer treatments. Prostate cancers have a lower sensitivity to radiation, so the thought is that a higher dose more efficiently destroys the tumor . Plus higher dose (theoretically, yet unproven) minimizes toxicity to nearby organs at risk.
HRFT would be a series of 5 treatments instead of the 28.
You might look at MRI guided prostate radiation treatment. It would be my choice with your numbers.
I would, as @westernflyer wisely advises, look at Proton. Carl Rossi MD director of CA Proton, doesn't prescribe hypofractionation with Proton. He does phone consultation and is well worth sending your scans to for his opinions.
Bless your choice

Yeah, I felt a bit lost when I realized I needed to pick my treatment plan. I was diagnosed 3/30/24 with 3 + 4 =7 with an 8 mm lesion classified as PI-RADS 4. Initially I had no idea how to proceed. One thing that helped me was someone on this site had recommended Dr. Patrick Walsh's Guide to Surviving Prostate Cancer Paperback – October 3, 2023. It's on Amazon and it's the best $20 I ever spent. It really helped educate me on some key points in my decision making. Also, when I spoke with the surgeon I asked what percentages he'd estimate for incontinence or ED when considering my specific case. The percentages he gave me for what to expect at 1 year were much better than I'd read in the general literature. For me, that was key information in my decision making process. I'm not a medical professional and I've only been in this unfortunate club since 3/24, so I'm one of the least experienced or knowledgeable you'll probably hear from. That said, here's what I did and how it's going so far for me. I'm 70 and reasonably fit (but not excessively so) at 5'11" and 187 lbs, and I had NS RALP (at a cancer center of excellence by an excellent doctor) 6 weeks ago. My recovery after surgery has been very good. Very little pain after surgery, and each day things are better. The initial week with the catheter was very uncomfortable, but manageable. After the catheter came out, things really started getting better fast. I never had any incontinence but I still wore a depends for 1 day, then switched to pads for about 4 days, and then I simply went back to normal underwear. I also have a large pad on my side of the bed under the sheet, just in case. Even though I never was incontinent after the catheter came out (except for a couple accidents as I figured out a few things), things do "feel a bit different". For example, with my prostate gone, I urinate like I'm 30 years younger. So when I step up to a urinal, I need to be ready when I "relax" as it starts to flow instantly. No pause like when my old prostate needed to relax before flow started. That's the kind of thing I mean about things "feeling a bit different". It took me a month to gain confidence that I wouldn't have an accident. I did do Kegels for about a month before surgery and resumed them after the catheter came out, so that may have helped my recovery. So at this point 6 weeks after surgery I'm generally "back to normal" for continence. Hopefully it'll stay that way, but who knows. Now to ED. I don't have normal sexual function, and I think that'll take longer to recover (if it does). I am taking Viagra nightly as part of penile rehab to help blood flow. I've only started trying to have intercourse within the last 2 weeks or so. When I try to have intercourse, I do get a response but it's far from satisfactory. I have seen improvement, but it's too early to know how much sexual function I'll recover. To be fair, before surgery I had needed Viagra so I wasn't starting from a pristine state. If I don't recover my sexual function to a satisfactory level, then there's a range of treatments I've yet to explore. As far as everything else (appetite, sleeping, general feeling of health) I overall feel great; just like before surgery. My wife and I are hikers and spend a lot of time together, and other than sex, we can still enjoy ALL our other activities. For me this has been a big plus. After surgery, the pathology report on the prostate found both Cribiform and IDC (not good). When I read that I was pretty happy I had the prostate removed. The margins were clean and indications are they got it all, but time will tell. At this point (6 weeks), I'm pretty happy with my decision to have the surgery but again, time will tell. Of course, every case is different and I have no idea what's best for you. I wish you all the best in figuring out how you should proceed.

Talking about this with your care team will be one of the most important conversations you've had in your life, and it's important that there's a lot of back-and-forth. Both surgery and radiation are much more precise and less damaging than they were in the past, and don't produce the same kind of collateral damage that they used to.

Radiation and surgery also have identical overall survival stats, so the choice isn't obvious if you have early-stage cancer that hasn't escaped the prostate yet. Radiation spreads a bit beyond the prostate (not much with proton-beam; a little with SBRT; and more with IMRT, if I understand correctly). That can be a bad thing for causing side effects like radiation cystitis or proctitis (not life-threatening, but annoying); it can be a *good* thing if the cancer has already started to sneak out of your prostate to the surrounding tissue, because it might kill that cancer as well, while simply removing the prostate would leave it in place.

I hope this helps you formulate the questions to ask your care team. Be stubborn, keep asking until you're sure you understand the answers, and get second opinions as needed. Don't worry about annoying people — it's your health. And make sure they're not pushing you to one option or another just because it's more familiar, cheaper, or more convenient for them. Also, bring someone with you to take notes, so that you can focus on the conversation without worrying about forgetting anything. It might also help to write down your questions in advance, so that you don't have to worry about forgetting one or two of them.

I agree, wholeheartedly with everything you said and especially with regards to bringing someone else with to take notes. I came prepared with a list of questions and my wife was furiously writing what the doctors told us. As a matter of fact, my surgeon, Dr. Ash, Ross, who I think the world of made certain to speak directly to my wife when he answered questions, since she was the one taking notes. After the appointment, the notes were helpful to review as nothing was ambiguous. Even now, six months later I’ve looked back at those notes memories change. Notes do not.

I would like to think I could make a better decision after 2+ years better understanding the challenges of PC than when I was a few months in and accepted the best recommendation I could find, which was for RALP given my intermediate unfavorable, multifocal cancer. But practically I'm only 2+ years into the journey and that does not sound like a very experienced urologist, does it?!
What I would say is that I've learned that "similar outcomes" does not mean what it sounds like. Why? Because statistically the PC most of us are finding takes too long to kill us. This confounds the research and in my mind directly leads to the chaos in which proponents of different treatments can argue there is no difference.
Googling the life expectancy of a 65 y.o. healthy male, I get about 83, i.e. 18 years. To actually die from PC with the various treatments available now typically takes 15-20 years. (If it isn't treated, that might not be true. But it isn't good medical science to not treat people who benefit from treatment, so these statistics are going to be less available. )
So here we have one of those classic dilemmas: short term suffering for long term (likely) benefit vs seize the day because tomorrow we may die anyway. It turns out my family was rather keen on keeping me around longer and that was a significant factor in my decision. For the research docs who were dealing with PC every day (as medical providers) I was a clear candidate for RALP they were not even going to do. I actually found a third generation urologist whose father was one of the top research urologists, and he himself was already around 15 years into his own career. (That's probably unusual enough some of you can figure out the name!)
The logical side of my brain told me I could trust his input, it wasn't self-serving, and so I acted on his advice. But I still don't know where I will be in 18 years, and I certainly don't know where I would be if I had taken a different path or not had access to that input.

I chose surgery and would do so again. I wanted the known cancer removed. And follow up Salvage Radiation treatment available if needed (which it was).
And I would make the same choice again.
At 72 I had RP at Johns Hopkins with excellent surgical results: Margins, lymph nodes and seminal vesicles clear. No incontinence; ED has been a recovering work in progress.
However, postop pathology confirmed G 9 w/ Extraprostatic Extension.
My 1st 90 day PSA was a disappointing .19
And I proceeded with Salvage radiation IMRT to the whole pelvic floor and pelvic lymph nodes together with a short-term 4 mos of ADT.
Treatment ended June 2023 and my 6, 9 & 12 mo PSA were undetectable at < .02
Next PSA test later this month.
Hoping and praying for continued good results for myself and everyone.
You have excellent medical facilities to help you make decisions and provide care.
Best to all.

Hello Spino,
Thanks you for your thoughts. Can you explain what RALP treatment is? Also, why was the treatment denied, even though you were a clear candidate?

Thanks,
LJBBoston