New Oncologist recommendation vs. prostectomy

I am a healthy and fit 64 year old. I had a PSMA MRI in January 2025 that found a 1 cm lesion with "gross extraprostatic extension". A biopsy in March determined that all four cores from the lesion were cancerous (Gleason 4+3, cibriform present) and the other 12 cores were normal. Intraductal carcinoma and periprostatic fat invasion were absent. Decipher is not available in Canada and I was not able to get any information on the size of my Cribriform or any consensus on the importance of cribriform size among the doctors I consulted. I had a PSMA PET Scan in June that found no indication of metastasis.

I researched every relevant and reliable source of information that I could find and tried to filter out the noise and opinion, which is not easy. I also consulted four different urologists (surgeons) and two radiation oncologists. I even travelled down to the Mayo Clinic in Jacksonville FL for two consults (urologists and radiation oncologists). All of the doctors agreed that radiation and surgery were good options for me that would have a good prognosis. One of the urologists did not perform surgeries, but had a practice helping patients with post treatment prostrate related complications. That doctor said with surgery you get the bad s??t out of the way upfront and with radiation it tends to crop up 5-10 years down the road. He told me if his dad was my age, he would advise him to have surgery, but if he was 75 or older, he would advise him to go with radiation. All of the doctors also stated that if they were in my situation that they would opt for surgery. The surgeons were primarily concerned that radiation would preclude later surgery because of tissue damage. I was told that recurrence post surgery is often still localized and that follow-up surgery is one of the treatment options if a patient has had a prostatectomy. The primary reason the radiation oncologists gave was the unpleasant and potential long-term side effects of hormone therapy that would be part of radiation treatment for me.

I opted for a prostatectomy, which I had five weeks ago to the day. My recovery is going well and I am essentially back to normal in terms of urinary continence. It terms of sexual function, it is too early to tell, but because of the location of my lesion, the surgeon removed the nerves on the left side of my prostate, and I was told that this will negatively affect the likelihood and degree to which I will recover sexual function.

Bottom line: Everyone's case is different and I am comfortable that I made the right treatment decision for me, though one can never know for sure. My advice is to make sure you are comfortable with the information you get from your consults and seek additional consults if necessary, until you are. There is no certainty as to which treatment will have the best outcome for any of us; you can only make the best decision for you based on good information, and a full understanding of the potential pros and cons of the options available to you. Make sure you have enough information to make a well informed decision. I wish you all the best.

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.

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 and my best wishes for a complete recovery. I am in the midst of plans (having only met with my urologist/surgeon) setting up second opinion(s). I have a considerable amount of work to do. I suspect I end with surgery combined with ADT (for the cribriform), and hope, like all of us, to keep the cancer in check. I am slowly coming to terms that eliminating cancer with cribriform is not a probability.