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Treatment Decision - Radical Prostatectomy versus Radiation Therapy
Recently diagnosed and now stuck in that frustrating "no man's land" between surgery and radiation therapy. Diagnosed after an increase in my PSA to 5.2 and concerns about family history of disease (father). Particulars are as follow: MRI showed 2 lesions, PI-RADS 5, with no evidence of seminal or lymph node involvement. Follow-up perneaural biopsy showed Gleason - 3+4 from biopsy; Biopsy showed positive in 9 out of 22 cores with perineural invasion present in one biopsy sample. Surgeon indicated that I was not a candidate for AS and recommended surgery (robotic). The surgery, however, would be somewhat challenging due to the location of one of the tumors near the apex of the prostate and based upon this he gave me a clinical staging of cT3a. This would require a wide dissection to maximize the probability of negative margins which might have a negative impact on the ureal sphincter. The imaging was inconclusive for extraprostatic extension, but suggest there might be local extension. Surgery would probably include a partial nerve dissection with nerve sparing on one side.
Due to these complications, the surgeon suggested that I also consult with a radiation oncologist. Radiation oncologist confirmed the diagnosis and also felt that the EPE would be rated at 1 - 2. No surprise, the oncologist recommended radiotherapy over surgery. This would be IMRT or SBRT with or without ADT (informed by Decipher test results). A sample of my biopsy tissue was sent out for a Decipher test to assess the genetic aggressiveness of the cancer. This would also inform my eligibility to participate in a clinical trial relating to RT with or without ADT.
So there I am...learned much more about PC than I ever thought I would have to. My doctors are at Mayo Clinic - Phoenix and they really seem to know their stuff. I am a retired Engineer with a background in statistics so I have reviewed at least 15 study results at this time. The survivability is relatively easy to quantify. The difficult part is the quality of life impact. I am 66, in good health (I cycle more than 100 miles/week) so discussions that sort of put an "end date" to your survivability are a bit unnerving. The difficult part of this process is the "joint decision making" with your providers when you are stuck in the middle between two choices with very similar statistical outcomes, but potential divergent and uncertain QOL impacts.
My initial thought going into this was that surgery would be my path. The idea of removing the "source" was appealing. The challenges with my specific presentation, however, gave me second thoughts and after exploring the RT options, I began to rethink the surgery approach. I am stuck in that state and looking for any insight that might help me move forward...
Thanks!!!!
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I chose RP at Johns Hopkins at age 72 and would do so again.
I have posted details many times, but would add info for you if desired.
Best wishes
I am 71 and found out in April that I had PC. MRI and Biopsy showed PC in the prostate and seminal vesicles. Biopsy showed Gleason 7's and a 9, T3a, Score 5 and the cancer of the aggressive type.
My doc and I discussed the treatment options and since I have had many heart issues he said I might not survive the RP. I am in really good shape and I elected to go with the RP. My cardiologist said I was fine.
My thought process was that if you have radiation, you more than likely cannot have RP (but I learned recently that there are a few rare cases that you can). Yet, if you have RP you can have radiation and ADT. I thought of the RP/ADT/Radiation as a "triple antibiotic" type of treatment. We did the RP and now I am awaiting what the next steps are.
Yes, I have mild incontinence, and they had to remove one set of nerves which also had PC, which will make getting an erection extremely hard, but at my age that's not a big deal. I learned a long time ago marriage is not about sex, marriage is about love and mutual respect.
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6 ReactionsThanks for your sharing of this important personal information.
I am 75 and was told the outcomes were relatively the same. I chose radiation over surgery because of the heightened risk of incontinrnce, and I didn’t relish the thought of wearing diapers for the long term. So far, so good. I had a Gleason score 9 (5+4) that was localized and my PSA has remained at 0.0 for 6 mos. Of course, everyone has their own story, intentions and motivations, so it may or may not be for you. Blessings in your choice.
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4 ReactionsWhile you don’t have incontinence from radiation now, it may be an issue in the future. I didn’t have any incontinence issues until about six years after radiation. I started off with surgery and for 3 1/2 years I had no incontinence problems at all then I had salvage radiation.
My incontinence has gotten worse since it started, but I just found a drug that helps limit it greatly, so there is hope even if you start having problems.
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4 ReactionsYes, I think I would have started with surgery if I had been told that the outcomes were better (even slightly). Now, instead of second guessing my decision, I am enjoying a strong cup of coffee and watching my dog sleep…
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4 ReactionsI don't know that the outcomes from either are better; just different.
Most people who get radiation don't have long-term incontinence — any issue clears up quickly — but it can happen.
I had some permanent mild radiation cystitis that manifested a year after radiation, though I've learned to control and avoid the incontinence so it has little/no impact now.
A hot beverage and dog sound like a better choice than worrying about past hypotheticals in any case.
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6 ReactionsBest wishes for success with whatever you choose. We’ve got your back!
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1 ReactionYes, the dog and beverage treatment is one I plan on continuing for the long term…
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2 ReactionsMy two cents is make a decision based upon your current dataset analysis and don't look back. I had similar Gleason scores and chose RP over other options knowing I would lose one nerve bundle and some length with the removal of the prostate. My decision tree was simple as it began and ended with my best opportunity to remain on this side of the dirt while allowing for other procedures if the cancer returned.
I'm now 31 months post RP and have a clean bill of health and I feel like any 61 yr old feels like. I ride my mtn bike, backcountry ski, surf and play golf. My sexual health, while important mentally for both my wife and myself is back after some effort including using Trimix off and on for 6 months. I do not use ED meds since month 10 post op. Sexual health was a low priority, ex mentally, in the decision tree and contrary to most available publicly available research it can be a problem area hence my use of Trimix.
Good luck with your decision process!
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7 ReactionsCongrats on getting your mojo back in 10 months especially with the loss of one nerve bundle. That’s awesome! Starting Trimix early was a brave and productive decision.
I lost one nerve bundle too and am on week 6 of BiMix (TriMix resulted in pain) and some progress is already showing up without injections in spite of being on ADT.
I feel that our first priority as cancer patients has to be avoiding taking a dirt nap, but after that qualify of life should not be far behind.
Best wishes for you and your wife and your journey.
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