Radiation vs surgery: What criteria did you use to choose?

You should speak to multiple doctors across multiple adjacent specialities.

For me, at my age of 54, my doctors recommended removal over radiation since the long term impact of radiation can impact me down the road - plus radiation is always a backup-option. The way it was conveyed to me was that for someone older they might recommend radiation first because it is easier for an older patient than surgery and their natural lifespan was thus that they are less likely to encounter problems down the road. The way they phrased it was "those men are more likely to die WITH prostate cancer than FROM it".

I spoke to multiples in all the key fields: urology, medical oncology and radiation oncology - each said the same thing, without exception. Their expert advice put me on the path I'm on now. Radiation might have spared me some of the side effects but could have also caused more now or later and those were just simply risks I was not willing to take, and since I still have that as a backup option then it was logical to me.

This was MY experience, so I cannot say what you should or should not do, that is for you and your doctors to decide, strangers on a forum are no replacement for that.

Thank you for the insights. I appreciate the time you took. I agree with all that you said. Ron

Your biopsy report did not mention anything about Seminal vesicles, cribriform or intraductal?

Did you get a PSMA pet test? Was it clear?

Consider getting a decipher test. It will tell how likely you are to get future metastasis and cancer growth sooner.

Where are you being treated? Is it a center of excellence where multiple doctors review the decisions that are made about what’s best for you?

Have you gotten a second opinion? Have you gotten your heridatary DNA checked, It’s free in the USA at Prostatecancerpromise.org ? That can be a factor in what can be done in the future, and what makes more sense now.

I have had surgery and then radiation. I think both of them have long-term effects, incontinence is very common years after radiation, I am not sure about surgery. I know that some people have major incontinence problems after surgery but don’t know it’s long-term implications. You could read about some of them in this forum. Erectile dysfunction is very common, You want to ask the surgeon, if you decide on surgery, to spare the nerves, They usually can spare at least some of them, making a major difference in ED.

Thank you for the reply. I appreciate your insights. I am scheduled for a decipher test, PSMA pet, and at Artera test. My squamous cells were negative on the biopsy so I assumed that’s the duct.

I have not heard about the long-term incontinence associated with radiation therapy. Thank you for this insight and I will investigate it further. Ron

All of the oncologists I spoke with also mentioned the bowel incontinence, in addition to bladder incontinence, is not uncommon with radiation therapy either. I know that's not always the case, but it was one of the big factors that I weighed when considering radiation - any chance of having both was more than I was willing to bear.

@rsprehn

I was 69 when I was diagnosed in 2022 with 3+4 and an 11.2 PSA. I looked into removal and radiation. My focus was side effects and quality of life.

For me, removal had too many possible side effects even with the most skilled doctor available. There are certainly many stories on this site regarding its success for some but the risks were not for me and many seemed to come back later for radiation (%'s seemed too high and too many stories on this site regarding that).

In my research, radiation became too much of a catchall term (even today on this web site) so I drilled down into types of radiation and radiation machines. Not all machines have the same results in terms of toxicity/side effects. I narrowed things down to the Mridian machine (nowadays also the Elekta Unity machine) or Proton therapy. I did understand that once you are treated with radiation for your prostate, you can't be re-treated.

Although Proton therapy has a dosimetrist that calculates how far the beam penetrates before it stops, I went specifically with the Mridian machine. The Mridian machine has a BUILT in MRI versus non-MRI machines that used fused images for treatment. Also, the standard for radiation treatment was/is to treat the entire prostate plus a "margin" around the prostate which for most machines, including proton, was 3-5 mm. The Mridian uses 2 mm which to me meant half or more as much healthy tissue exposure which impacts toxicity/side effects. This was proven in the Mirage randomized trial which showed significantly lower side effects and toxicity for a radiation machine with a built in MRI versus non-built-in MRI machines. Here is a link to urology times talking about the study:
https://www.urologytimes.com/view/mirage-trial-margin-reduction-with-mri-guided-sbrt-reduces-toxicity-vs-ct-guided-sbrt
I finished 5 hypo fractional treatments in February of 2023. There was no ADT involved. I had slight urine flow restriction after the third treatment which Flomax took care of overnight. Orgasms were not as intense, sperm was less and thinned out a bit and my urine flow over time actually improved. My RO told me I might only have urine flow at the level it was before I had radiation treatment so I have been pleased and relieved.

I was diagnosed at 58 in late 2023. I had a PSA 14.7, G 3+4=7, low-intermediate Decipher risk, and no spread. I looked into surgery and decided the potential downsides, including a possible need for salvage radiation down the road, were too much to bear. Moreover, the surgical side seems to have peaked in the early 2000s after Dr. Walsh introduced robotic surgery to the menu.

On the flip side, radiation and other non-surgical treatments seem to have advanced a faster pace to deliver better outcomes with reduced side effects. I opted for a six month course of Eligard, and five rads of SBRT (TrueBeam STX) in early 2024. Fast forward, my last followup in December revealed a PSA of 0.08. Whatever side effects, such as fatigue, bloat and hot-flashes, I had have largely abated, and my strength and muscle tone are coming back. It's a long road, but I feel great and my RO is very pleased.

My advice: Take your time, explore all your options, ask questions and don't be afraid to get other opinions. Self-advocacy is so critical here. None of us has the same path, and what worked for me may not work for the next guy. Best of luck, warrior. You got this.

Thank you for this. More questions for my RO I meet on Thursday. I appreciate the advice at the end…I needed that!

I appreciate your perspective. Going into this I thought it was more well defined. Hearing your experience and perspective at this point is very helpful. But you are correct, this is a personal decision. Thank you

Thank you for these ideas. Meeting the RO and surgeon on Thursday. The RO has ordered a Decifer, Artera, and PSMA PET. So will have more info then.