New Oncologist recommendation vs. prostectomy

Thank you, Phil. Surgery is, I suspect, the best option. Part of my conundrum is that with my type of cribriform I am advised that 'we won't get it all'. Radiation (I am told), if it works, has a better chance of knocking it down. To your point regarding the elimination of the disease. You are correct per my oncologist. You have it until the policy can be cashed. I have heard for 50 years that prostate cancer is no big deal. I am stunned at the response I have had when somehow somone finds out I have it. Surreal... like it's a hangnail. I really appreciate the thoughtful reply. Trouble thoughts as I head out today to climb a couple hills here in the Berkshires.... Thank you, Phil.

From actual studies:
for men under 65, prostate cancer deaths at 15 years were 1.5% for active monitoring, 1.7% for surgery, and 2.9% for radiotherapy. For men ≥65, deaths were 5.9% for active monitoring, 3.0% for surgery, and 2.9% for radiotherapy.

Thank you. interesting results. If available it would be of interest to read the report. I frankly concerned about the quality of the life after any procedure. I am not suitable for restrictions and relying on pads etc. and pursuing life's interests seems, at this moment, an impossibility. That said, this news is all new to me and I have not been in a situation remotely similar except for physical injuries that resolved in less than 12-18 months. Until July 7th I was in the midst of assembling some of the more interesting and challenging goals of my life. At this point, I feel like I am back at work given the amount of time spent pondering cribriform and the fact that prostate cancer is not curable.

Everyone will have their own experience and recommendation, but I highly recommend the DaVinci Robotic- Assisted Radical Prostatectomy. Your urologist/surgeon, having done 4,000 "+" DaVinci RP's plus your younger age give you your best potential outcomes in my opinion. Your "youth" will yield a more rapid and easier recovery vs someone like me at age 70 (and those older). The one big falsehood, is that the biopsy and Gleason Score tell you how aggressive your cancer is. "Nope." Unless of course your Gleason score is an 8 or 9...then you know you have a problem, and can likely expect worse news in your surgical pathology report after your RP.
"Symptoms"? Unless you're a man with moderate to severe urinary flow restriction due to an enlarged prostate, most men do not have symptoms of prostate cancer. It is "caught" upon routine PSA and DRE with your Internist or General/Family Practitioner. My brief story:
My former physician abandoned his patients and practice without telling us...flat-out closed down and moved away with no letter or other notification. "Foolish me" went four years without a routine doctor appointment or annual PSA tests. I finally decided that I need a new doctor. Because I was a "new patient", I couldn't get an appointment for 9 months from first inquiry...NINE MONTHS. That certainly didn't help me. During that nine month wait, my Gleason score probably became what it was. So my progression thereafter was:
- October 2024 - PSA 6.5 ng/ml
- November 2024 - referral to Urologist with repeat PSA of 6.1 ng/ml
- December 2024 - 12-core biopsy
- Early January 2025 - Biopsy results: Gleason Score 3+4 = 7 with only 6-10% "4" grade cells. I was very close to being just a 3 + 3 = 6, but was definitely not. I also had perineural invasion which my doctor said everyone has. My physician said: "It is great that we caught it early...you'll be around ("alive") 15 years or more from now."
- April 2025 - DaVinci Robotic-Assisted Radial Prostatectomy.
- April 2025 - Surgical pathology report yielded more ominous results: Extra-prostatic Extension ("EPE"); Cribriform glands; "Surgical margins"; Left seminal vesicle invasion. NONE of that can be determined from a biopsy, not matter how many cores they take and what your Gleason Score is. "Surgical Margins" are basically surgical bad luck...incompetence...when the surgeon left some cancerous tissue behind in your body: (S)he didn't "get it all." That only happens 10-20% of the time, so being thrown into that reality, I am quite disillusioned with my urologist.
- April 2025 - Based on the above microscopic/cellular results, I am therefore a pT3b classification, and therefore, with a near-certainty that my cancer will come back within the next five years. It could be less than a year from now, or it could take five years, but it is nearly certain that it will return. The nature of a pT3b is because it entered the seminal vesicle(s), and even though both seminal vesicles were removed along with the two vas deferens, just somehow it always "comes back."
At biopsy when my physician was very confident about "we caught it early", he still said: "I'm taking your prostate...there is no use doing "active surveillance"...YOU HAVE PROSTATE CANCER, and there is no point watching and waiting for months and up to two years...it will only get worse, it is not going to spontaneously disappear."
July 2025 - I am doing PSA tests every three months for the first year post-RP, hoping they will stay at < 0.1 ng/ml, but...the moment it increases 100% to 0.2 ng/ml or more, my Urologist said "we'll need to talk about radiation." If you haven't heard (I was shocked), "radiation" is a 40-consecutive-day ordeal. Your life changes for those 40 days, because every single day of those 40 days, you will go to radiation therapy to get zapped. The downside of that, is that a low percentage of men end up with bladder cancer or rectal cancer or permanent incontinence, and a sex life that is dead and over...just exchanging one horrible reality for one, two, or more worse realities. The only good news about that is that I am 70 years old, and while I could perform well right up to my surgery, I am newly divorced, and there aren't a lot of 60-75 year old women who want too-active of a sex life. They're kind of over it at that age from what I have heard through friends and former coworkers. So again...my recommendation is to get the DaVinci RP done. You should have a nice outcome at your younger age.

Here’s the whole piece from “Open Evidence”. Get the app.
For a 63-year-old patient newly diagnosed with non-metastatic prostate cancer, expected survival varies significantly by management strategy, risk group, and comorbidities. The most robust comparative data come from randomized trials such as ProtecT and SPCG-4, as well as large cohort studies. Below is a summary table integrating key outcomes for the major management modalities, followed by a discussion of risk stratification and the impact of comorbidities.

Key points:

- Active monitoring/observation yields excellent long-term disease-specific survival for low-risk patients, with 10-year prostate cancer mortality [1][2][3][4]

- Radiation therapy (modern EBRT) provides similar long-term outcomes to surgery, with 10-year OS ~74–80% and disease-specific mortality [1][2][5][6]

- Surgery (radical prostatectomy) confers a mean of 2.9 years of life gained at 23 years in SPCG-4, with 10-year OS ~69% in older cohorts and ~78% in contemporary trials, and disease-specific mortality [1][2][4][7]

- Medical therapy alone (ADT) is associated with poorer overall survival, particularly in patients with limited life expectancy ([8]

- Combination therapy (Radiation + ADT) improves overall survival in high-risk patients, with 10-year OS up to 80%.[6][5]

Risk stratification and comorbidities:

- Survival outcomes are strongly influenced by risk group (low, intermediate, high), Gleason score, PSA, and comorbidities. For example, patients with Gleason ≥8, higher age, or significant comorbidities have worse OS regardless of treatment.[7][5]

- In the ProtecT trial, for men [1]

- Quality of life considerations and adverse effect profiles (urinary, sexual, bowel) are important in treatment selection.

Visual context:

The following table from the ProtecT 15-year outcomes study provides granular data on prostate cancer deaths by age, risk group, and treatment modality, illustrating the very low disease-specific mortality across all groups and the nuanced differences by age and risk.

This table demonstrates that, for men under 65, prostate cancer deaths at 15 years were 1.5% for active monitoring, 1.7% for surgery, and 2.9% for radiotherapy. For men ≥65, deaths were 5.9% for active monitoring, 3.0% for surgery, and 2.9% for radiotherapy. Stratification by Gleason grade, PSA, and risk scores further refines expected outcomes.

Summary:

For a 63-year-old with non-metastatic prostate cancer, expected 10- to 15-year overall survival is high (74–80%) with any definitive local therapy (surgery or radiation), and disease-specific mortality is low (Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. Hamdy FC, Donovan JL, Lane JA, et al. The New England Journal of Medicine. 2023;388(17):1547-1558. doi:10.1056/NEJMoa2214122.
2. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. Hamdy FC, Donovan JL, Lane JA, et al. The New England Journal of Medicine. 2016;375(15):1415-1424. doi:10.1056/NEJMoa1606220.
3. Radical Prostatectomy or Watchful Waiting in Prostate Cancer — 29-Year Follow-up. Bill-Axelson A, Holmberg L, Garmo H, et al. The New England Journal of Medicine. 2018;379(24):2319-2329. doi:10.1056/NEJMoa1807801.
4. Outcomes for Men With Clinically Nonmetastatic Prostate Carcinoma Managed With Radical Prostactectomy, External Beam Radiotherapy, or Expectant Management: A Retrospective Analysis. Barry MJ, Albertsen PC, Bagshaw MA, et al. Cancer. 2001;91(12):2302-14. doi:10.1002/1097-0142(20010615)91:123.3.co;2-g.
5. Prostate Cancer: A Review. Raychaudhuri R, Lin DW, Montgomery RB. JAMA. 2025;333(16):1433-1446. doi:10.1001/jama.2025.0228.
6. Effects on Life Expectancy of Treatment Decisions in Patients With Non-Metastatic Prostate Cancer. Tachibana A, Hori S, Nakai Y, et al. Anticancer Research. 2023;43(1):473-483. doi:10.21873/anticanres.16184.
7. Long-Term Overall Survival After External Beam Radiotherapy for Localised Prostate Cancer. Jahreiβ MC, Incrocci L, Dirkx M, et al. Clinical Oncology (Royal College of Radiologists (Great Britain)). 2023;35(12):e689-e698. doi:10.1016/j.clon.2023.09.017.
8. The Diagnosis and Treatment of Prostate Cancer: A Review. Litwin MS, Tan HJ. JAMA. 2017;317(24):2532-2542. doi:10.1001/jama.2017.7248.

Your assessment is not relevant since this patient has high Decipher score and cribriform glands - regardless of "no metastasis " his cancer is very aggressive and can not be placed in that general category.

Also, biopsy is not always correct. My husband had 4+3 biopsy result in just one core with cribriform and without any extensions BUT today's RARP pathology report showed actually gleason 4+5 with PNI and some other findings, so...

ONLY when gland is out and examined in detail one knows what is actually going on.

In medicine we look at outcome studies. That means if you don’t live longer or have less symptoms it doesn’t matter. Irrelevant is when you miss the forest for the trees

You will NOT be restricted from your life’s pursuits by any treatment you may choose.
With the exception of a few men here whose Stage 4 cancer affected their spines/hips and restricted their mobility, NONE of us are sitting at the window, staring blankly at the bleak horizon. WE ARE DOING!!
We engage in more activities than are listed on a box of Tampons 😉 - cycling, hiking, sailing, hunting, triathlons, bowling, etc, etc…
Sure, certain treatments might curtail you for a few weeks or months but even then, you’ll manage to do mostly what you want.
Cribriform is a scary word once you’ve learned its implications, but now that you and your drs KNOW it is there, you treat accordingly.
You may need surgery followed by radiation and ADT if your team feels you need it. You’ve got to fight fire with fire sometimes…
That would be more disruptive to your life but nowhere near as disruptive as being told that your cancer is untreatable and you won’t be around for your next birthday.
I have a copy of my surgical pathology report sitting in a drawer. I will not look at it! I might even burn it. I don’t want to see any words or phrases that are going to make me crazy insane with worry and negative projection. I mean, why bother??
No matter WHAT is written there isn’t going to change anything, is it? If I had cribriform or intraductal patterns in my pathology it is not going to change any treatment I may need in the future, OK?
If the PSA starts going up - even after surgery and salvage radiation with ADT - well I guess I have a more aggressive cancer than previously thought. So then I’ll have to treat it with combos of this drug or that…such is life and you just can’t control it. You just bend, twist and roll with it…Best,
Phil

Thank you. This took time to pull together and I really appreciate that work. I am about 1/3 through the articles and have built a sizable collection of questions for my doctors. Thank you very much.

When you receive treatment recommendation from doctor you want to know: “risks, benefits and. Alternatives”.