Surgery or Radiation?

I was 73 1/2 with two Gleason 4-3 and two Gleason 3-4's out of 30 cores (big prostate). I elected for the five proton treatments at Mayo Phoenix as I figured if I get fifteen years before the prostate might kill me, I am 88 and really don't want to wind up in a nursing home. I too am physically fit and walk three miles a day and never got sick with anything other than the PC. A lot of good advice from many of these commentors. It still boils down to your choice. My three-month PSA and nine-month PSA were both undetectable. So far so good.

I just with Dr Percy Lee at city of Hope in Irvine. He recommended IMRT of 28 sessions and Brachy therapy and hormonal therapy to do it right first time and gave me a choice of skipping Brachy Therapy.
I will consult with Dr Kishan this Friday at UCLA. Still trying to get an appointment at California Proton Center.
One question, if I am going to have 28 treatments of IMRT, is it better in terms of reduced side effects, to have 28 IPRT treatment at Proton center?

@ava11 What treatment did you have? I hope your choice went well.
I just found this thread a month after I had my 5-fraction (5 x 8 Gy = 40 Gy) SBRT, and after I read the @brianjarvis post shown below: No statistically significant difference in outcomes between surgery and radiation -- as my doctors said.
I'm 68. My initial choice was RARP surgery, but my family was quite concerned about it. After doing more research/readings, and consultations with my PCP, medical oncologist, and radiation oncologist, I finally chose SBRT. (The urologist who did my biopsy does open surgery with another surgeon in a regional hospital. He referred me to the MO and RO in a cancer center where they do about a thousand prostate SBRTs annually, and more for other types of cancer.)
It's been a month and two days now since my last (5th) radiation treatment. Except for the loss of libido, I have not encountered the side effects that I have prepped my mind for, like hot flushes, fatigue, depression, etc. associated with ADT Orgovyx that my RO said we would see if I could stop after 8 months or a year.)

@ava11 I found your updates already in this new thread: https://connect.mayoclinic.org/discussion/prostate-mri-results-one-year-after-sbrt/
Thanks for updating our community.

You’ll find many studies showing success rates comparing surgery with radiation being statistically equivalent no matter which treatment is chosen (https://www.nejm.org/doi/full/10.1056/NEJMoa2214122).

And that paper studied outcomes even before today’s availability of precision radiation, PSMA PET scans, and other modern technologies.

It mostly comes down to side-effects and quality-of-life (or as that paper concludes, “… the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer.”).

So I have just joined the group, having received an updated biopsy with Gleason 3+4 and malignant cells in 20% of the cores. The literature seems to show equal success rates between radiation and surgery, but I'm very interested in gathering information about which treatment option has the best quality of life outcome. I'm 73 and still very active.

Considering that article’s conclusion (and others as well), that “… the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer.”), I knew that this would come down to personal choice. Here’s what I did —> Whenever I have a major decision to make - buy a house, a car, any choice that make impact my life, anything major, ,…..I make a list of outcomes — what I want and what I don’t want.

So, I first had to do some very serious introspection and truly understand myself and what I wanted to come out of my prostate cancer treatment.

I wanted to balance survival (of course!) with good quality-of-life, along with the possibility of treatment in the future if needed (as medical treatments progress). I wanted the least chance of ED, GU, GI, bowel or other similar complications - quality-of-life following treatment was an equal priority with success.

For me it was always about utilizing the best treatment techniques to get the best outcome while still surviving and maintaining my quality-of-life. (Every medical-related decision I ever made, I made the same way; why not this?)

I had referrals by my urologist (a surgeon) to specialists in all treatment modalities appropriate for my numbers - internal radiation, external radiation, and focal therapies, and thoroughly interviewed each of them.

So, I put together a spreadsheet and listed all treatment options from the referrals, research, and literature that I had read. Then I listed all possible & possibilities (%) of side-effects from each type of treatment, and gave each one a score (1-x). The one with the lowest total “score” ranked highest. I then took that list, and narrowed it down based on the prevention techniques available for each side-effect.

I then “scored” the quality of life priorities that came out of my personal introspection (1-x) , and compared that final score result with the multiple treatment options score result.

The score that was closest matching was my 1st choice (proton radiation), 2nd was IMRT (photon), 3rd was SBRT (photon); surgery ranked last. (Due to having two lesions, one on either side of my prostate, I was not a candidate for focal therapy.)

So at 65y, (during April-May 2021), I had 28 fractions (2.5 grays each fraction) of proton radiation + ADT (two 3/month injections of Eligard) + SpaceOAR Vue.

That was how I decided on treatment. So far - 4 years later - everything is going great.

Also, note that I was making those decisions between 2018-2020. Technology, treatments, and medicine have all advanced since then so, you may have options and considerations that weren’t available to me back then.

Ultimately, you’ll have to come up with a methodology that’s suits you, and then choose a treatment that fits your life priorities, psyche, view of life, and side/after-effects you’re willing to deal with.

Good luck!

Just wanted to add that if you have cribriform cells or IDC , you might have better result with RP. Radiation is definitely still an option and can give very good results, but cribriform cells sometimes can evade radiation and both cribriform and IDC are features that point to very aggressive cancer that tends to metastasize.
Wishing you the best of luck with whatever you choose to do .

thank you @brianjarvis and @surftohealth88 for your comments. I don't think I have either cribiform cells or IDC--at least this is not mentioned in the biopsy report or by the urologist today--both of which are pretty damn scary. The urologist said I was not a candidate for his ultrasound technique because of the increased size/location of the cancer within the prostate. So he said the choices are radiation or surgery (he does robotic prostatectomy, which presumably is more precise and less damaging). I know nothing, as yet, about photon and proton technologies. Can you recommend reading material on this? Thanks again.

This Dr. (Rossi) has a lot of information about proton in his portion of this 2023 Mid-Year PCRI presentation: https://www.youtube.com/live/WTqPnSRYtW4?feature=share
—> Starting at 3:38:45

There’s a Proton Q&A session at the end of his presentation with these topics:
—> 4:25:00: Proton & Insurance
—> 4:30:45: Proton SBRT
—> 4:34:30: Proton & ADT
—> 4:36:55 Proton & Supplements
—> 4:39:00: Proton & Diet
—> 4:40:00: Proton & Repurposed Drugs (Statins; Metformin)
—> 4:42:00: Proton & Post-Treatment Side-Effects Urinary
—> 4:46:00: Proton & Hyperbaric Therapy
—> 4:48:15: Proton & Pre-Existing Bowel Issues
—> 4:49:30: Proton & Hydrogel
—> 4:53:00: Proton & Re-radiation

(Scientifically and properly administered, proton should have better outcomes and fewer side-effects than photon (x-rays) because of proton’s Bragg-Peak characteristics. However, there have been no completed head-to-head studies indicating better outcomes or fewer side-effects of either one over the other.).