1. < Prostate Cancer

Surgery? Radiation? Can I have an independent suggestion?

Posted by hanscasteels @hanscasteels, Dec 19, 2024

As a Canadian, I apologize in advance for my self-centered question. I have done all the preliminaries and now must make a choice. When asking urologists, they’d advocate for “cutting”. When talking to radiation oncologists, they’d say “radiate” - statistically, the odds are equal or better, and the side effects - well, perhaps, eventually, you might have to deal with those. Which leaves me, as someone reluctant to understand issues related to cancer that I never wanted to know, to make a decision.

In short, here are the parameters: over 4 months, PSA readings of 26, 21, and 25. Biopsy showed cancer in the left nodule, Gleason 3+4 in 5 out of 12 cores. Cribriform and suspected perineurial invasion. Bone scan and CT scan showed no metastasis. PET scan shows a significant uptake (3.7) in the prostate but also, no metastatic activity, except for a minuscule uptake in L4 lumber (but judged to be benign). That doesn’t eliminate microscopic events, I suppose. Also had a prior appetizer of a heart attack and had CABG (9 bypasses).

The question now: what would be an optional approach for me, specifically. ChatGPT says a short course of agonist/antagonist ADT, Brachytherapy, and EBRT. The urologist says “if you want it gone, call me”. The radiologist says “the isotopes are at your service”. How on earth can I make an informed decision that’s best for me if everyone advocates for what they do/know as the best approach?I suspect some answers might be - it depends what consequences you want to deal with - granted. But medically, what gives me the best chance to conquer this, well, shit?

Where would you take it?

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

bens1 | @bens1 | Dec 20, 2024

@hanscasteels I had 3+4 as well but no cribriform with a PSA of 11.2. I chose the mridian 5 hypo fractional treatments because it had narrow margins of 2 mm and a built in MRI which is why the margins were 2 mm. Basically, most radiation machines treat the entire prostate PLUS a margin (usually 3-5 mm) around it. The higher the margin number, the more side effects, as a general rule. Check out the Mirage randomized trial.

There is an Elekta radiation machine in Montreal or thereabouts. Elekta does make a radiation machine with built in MRI. I am not sure which machine they have as they do not all have built in MRI's.

I finished my treatment on Valentines day 2023. No real side effects to speak of other than initial urine restriction flow which Flomax took care of, overnight, and I was on that for about a month. I would make that choice again. If I ever had a biological re-Occurrence (my psa test a few weeks ago was .8 which is different than when you have your prostate removed), I would have to have another type of treatment but removal would not be the best choice as it is difficult after radiation but I knew that going in.

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retiredboomer71 | @retiredboomer71 | Dec 20, 2024

I found this video very helpful...

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heavyphil | @heavyphil | Dec 20, 2024

Hans, what is your age? That has a big impact on what you decide. If you are older than 70, and with previous health issues, 5 sessions of radiation might suit you best in terms of efficacy and less side effects.
Surgery is still surgery no matter how they dress it up with “robotic”, “nerve sparing” and all the rest. There are still inherent dangers for heart patients especially ( which I think you mentioned).
I chose surgery at age 64 because I was in excellent health and my surgeon said that my Gleason 4+3 unfavorable had a chance of coming back. So I left myself the option of radiation down the road - and just finished with that 5 yrs after surgery.
But to cut thru all the fancy rhetoric and speak frankly, the greater your age, the less your projected life span. Therefore, if you are in your 70’s, have radiation and your cancer comes back (IF!) you might have other serious health issues that may kill you first; and your cancer can then be controlled with ADT if you are still alive.
Remember, the outcomes (success and failure) for surgery and radiation are basically the same - neither is “better” - but one or the other may be better for YOU. Hope this helps!

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1 reply
hanscasteels | @hanscasteels | Dec 20, 2024
In reply to @heavyphil "Hans, what is your age? That has a big impact on what you decide. If you..." + (show)
@heavyphil

Hans, what is your age? That has a big impact on what you decide. If you are older than 70, and with previous health issues, 5 sessions of radiation might suit you best in terms of efficacy and less side effects.
Surgery is still surgery no matter how they dress it up with “robotic”, “nerve sparing” and all the rest. There are still inherent dangers for heart patients especially ( which I think you mentioned).
I chose surgery at age 64 because I was in excellent health and my surgeon said that my Gleason 4+3 unfavorable had a chance of coming back. So I left myself the option of radiation down the road - and just finished with that 5 yrs after surgery.
But to cut thru all the fancy rhetoric and speak frankly, the greater your age, the less your projected life span. Therefore, if you are in your 70’s, have radiation and your cancer comes back (IF!) you might have other serious health issues that may kill you first; and your cancer can then be controlled with ADT if you are still alive.
Remember, the outcomes (success and failure) for surgery and radiation are basically the same - neither is “better” - but one or the other may be better for YOU. Hope this helps!

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67. I suspect I will probably die from an infected hair follicle when all is said and done. I think I’ll go the brachytherapy and EBRT route, sauces with a clinically minimum relevant sauce of ADT

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1 reply
michaelcharles | @michaelcharles | Dec 20, 2024

I think that one needs to follow his feelings after researching the choices; and it sounds as if you have done that and selected the radiation option. I think that is a good choice for you.
I selected surgery at age 72; now 74, and my choice would be surgery if choosing again.
Why? The Cancer was my primary focus. I wanted a chance at a cure; I wanted the "mothership" removed; I wanted a full biopsy of the prostate and I wanted the radiation follow up available, which was necessary in my case with postop confirmation of Gleason 9 and a new finding of extra prostatic extension (EPE). That was me.
Best wishes to you for a successful treatment.

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heavyphil | @heavyphil | Dec 20, 2024
In reply to @hanscasteels "67. I suspect I will probably die from an infected hair follicle when all is said..." + (show)
@hanscasteels

67. I suspect I will probably die from an infected hair follicle when all is said and done. I think I’ll go the brachytherapy and EBRT route, sauces with a clinically minimum relevant sauce of ADT

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I think that is an excellent choice given your age, medical history. A few men in your age range were having this done at Sloan (with ADT) while I was having my 25 salvage treatments.
None reported any side effects at the time and one man- whom I had dinner with a month later - said he had no side effects at all, save the occasional hot flash from Orgovyx.
And please watch out for those ingrown hairs!😆

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clandeboye1 | @clandeboye1 | Dec 20, 2024
In reply to @jeffmarc "There’s a recent video that shows that if you have cribriform the cancer is more aggressive..." + (show)
@jeffmarc

There’s a recent video that shows that if you have cribriform the cancer is more aggressive than 3+4 would imply. If the cribriform Is larger than .25 mm then it is even more aggressive. Ask for a second opinion on your slides if the current person reading them doesn’t know the answer.

Here is a link to the video about cribriform and more.
https://www.urotoday.com/video-lectures/a-journal-club-for-patients-with-prostate-cancer/video/mediaitem/4452-unfavorable-histology-classification-aims-to-reduce-unnecessary-treatment-journal-club-jesse-mckenney-jane-nguyen-cornelia-ding.html
Yes Nubeqa Is easier on the user because there are fewer side effects than other lutamides.

The thing is it’s better off to start with Zytiga and When it is no longer desirable move on to Nubeqa.

Here is a link to an article discussing that.
https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(19)30688-6/abstract?mc_cid=c2dca8aa74&mc_eid=99575fc699
Surgery or radiation—— It is a toss up. Results are above equal from each. If you have surgery later, you can have radiation. If you have radiation then you can have surgery, but its capabilities are limited. If you have surgery, then getting an erection may be difficult,. If you have radiation that would usually not be an issue. If you have surgery, ask for nerve sparing surgery, which would increase the chance you can get an erection after surgery. Brachytherapy Is another option it is frequently followed by radiation.

I would not hold off on getting treatment soon. Cribriform makes a Gleeson 3+4 much more aggressive, the video discusses it. Try to speak to more radiation oncologists, and urologists about your options. ADT would at least retard the growth of your cancer while you think about it.

Are you able to get CyberKnife SBRT? MRIdian Would be better, less nearby tissue damage but I don’t think they have that in Canada.

There are other things you can do which don’t involve radiation, but I don’t think they are available in Canada they are HIFU, cryotherapy, TULSA-PRO.

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jeffmarc. F.Y.I. Cyberknife SBRT , HIFU , NanoKnife , Cryotherapy and TULSA-PRO , which was invented at Sunnnybrook Hospital in Toronto , are ALL available in Canada . Cryotherapy is covered by the peovincial medical system in Alberta . An associate of mine had the Cryo treatment recently in Calgary , by a former Urologist from UCLA .
Monotherrapy SBRT is very popular at sevveral hospitals in Toronto and other parts of the country .

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1 reply
clandeboye1 | @clandeboye1 | Dec 20, 2024

What Focal Therapiess have you researched ? Where do you live in Canada ?

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1 reply
clandeboye1 | @clandeboye1 | Dec 20, 2024
In reply to @jeffmarc "There’s a recent video that shows that if you have cribriform the cancer is more aggressive..." + (show)
@jeffmarc

There’s a recent video that shows that if you have cribriform the cancer is more aggressive than 3+4 would imply. If the cribriform Is larger than .25 mm then it is even more aggressive. Ask for a second opinion on your slides if the current person reading them doesn’t know the answer.

Here is a link to the video about cribriform and more.
https://www.urotoday.com/video-lectures/a-journal-club-for-patients-with-prostate-cancer/video/mediaitem/4452-unfavorable-histology-classification-aims-to-reduce-unnecessary-treatment-journal-club-jesse-mckenney-jane-nguyen-cornelia-ding.html
Yes Nubeqa Is easier on the user because there are fewer side effects than other lutamides.

The thing is it’s better off to start with Zytiga and When it is no longer desirable move on to Nubeqa.

Here is a link to an article discussing that.
https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(19)30688-6/abstract?mc_cid=c2dca8aa74&mc_eid=99575fc699
Surgery or radiation—— It is a toss up. Results are above equal from each. If you have surgery later, you can have radiation. If you have radiation then you can have surgery, but its capabilities are limited. If you have surgery, then getting an erection may be difficult,. If you have radiation that would usually not be an issue. If you have surgery, ask for nerve sparing surgery, which would increase the chance you can get an erection after surgery. Brachytherapy Is another option it is frequently followed by radiation.

I would not hold off on getting treatment soon. Cribriform makes a Gleeson 3+4 much more aggressive, the video discusses it. Try to speak to more radiation oncologists, and urologists about your options. ADT would at least retard the growth of your cancer while you think about it.

Are you able to get CyberKnife SBRT? MRIdian Would be better, less nearby tissue damage but I don’t think they have that in Canada.

There are other things you can do which don’t involve radiation, but I don’t think they are available in Canada they are HIFU, cryotherapy, TULSA-PRO.

Jump to this post

FYI Followup.
There are two Trials # currently recruting in Toronto.
# 1 NanoKnife headed by Dr. Nathan Perlis at the Princess Margaret Hospital . Ranked in the top 5 Treatment & Cancer Research Centers in the WORLD .
# 2 TULSA-PRO , at the Sunnybrook Hospital where it was invented . It is headed by Dr. Laurence Klotz who was part of the original TULSA-PRO research team
The leading NanoKnife surgeon in the Toronto area , and there are several , is Dr. Robert Nam at North Toronto Cancer Associates .

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1 reply
clandeboye1 | @clandeboye1 | Dec 20, 2024
In reply to @hanscasteels "Thank you very much. Good to know. Doesn’t exactly ease my anxiety… but better to be..." + (show)
@hanscasteels

Thank you very much. Good to know. Doesn’t exactly ease my anxiety… but better to be informed.

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Have you studied Dr. Patrick Walsh's book " Guide to Surviving Prostate Cancer " The 5th Edition .
Money well spent . You may get your answer there . You have many options -- All with similar results .

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