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Surgery? Radiation? Can I have an independent suggestion?
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?
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One big factor in whether you do surgery or radiation is how old you are. The younger you are under 70 the more Surgery may make sense since it gives you a better chance of progression free survival. It also allows you to have radiation after surgery. If you have radiation and it comes back in the same area you cannot have radiation again.
Unfortunately, surgery does tend to leave you with erectile dysfunction. There are many ways around it, But it is quite inconvenient.
This doesn’t mean that radiation won’t do the same thing, It just has a smaller percentage of people that it affects right away, but overtime ED. seems to be a problem.
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2 ReactionsI'm 73 but otherwise very active and healthy enough to live another 15+ years unless something else takes me down. I am familiar with the pros and cons of each approach and it's a toss-up in terms of long-term prognosis. Leaning toward the radiation as being less impactful on qualify of life in the short-run, but I was wondering if the upcoming Decipher score would tilt the balance.
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1 ReactionI think the Decipher score is a big factor. I’m not absolutely certain, but that test of aggressiveness ‘may’ take into account IDC/cribriform which is not always dealt with effectively by radiation of any type.
Do you know if your biopsy found these features? Sometimes they do, sometimes not - only surgical pathology can tell for certain.
You absolutely need more info on which to base your decision since surgery is much more impactful than IMRT on your quality of life; but in the end you may need to have surgery anyway if it offers a better chance of long term remission. Just my opinion as someone who has had both treatments.
Phil
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1 Reaction7-years out from the prostatectomy.
PSA 2-days ago < .10
70 now
Grateful that I didn't do radiation although we researched it and had advice from 5 buddies that faced the same situation.
They consulted with the best.
My cancer requiered removal of the 'right nerve bundle' as well as the prostate gland which essentially leaves your tool nearly useless.
My very competent surgeon mentioned two things to me that stuck in my head.
1) my job is to keep you alive
2) radiation is the gift that keeps on giving
You can look into what that means.
Advice:
There are deeper meanings to intimacy with your partner than routine intercourse; assuming the bride buys into it.
Kegel exercises. My incontinence was virtually gone in 7-weeks and I was flying cross country with no incidents.
75+ reps a day for a month before the procedure and afterward to a lesser degree. I was doing them while sitting at traffic signals.
Personally, I'm a Christian and turned it all over to my maker.
Went into it with a positive attitude and trust in my Mayo surgeon and team.
Wish you the best on your decision.
I had my surgery 8 months ago at age 78. My urologist gave me my options so I talked to the radiologist several times. What I felt was important was the fact with surgery if I needed further treatment I could do radiation but if I did radiation first that limited my options. Even though the tumor board recommended radiation I chose surgery. Fortunately the cancer was within the prostate and so far PSA is undectable. For me surgery was the answer and it in itself was uneventful, the incontenance has been hard to deal with but that is still better than dealing with other potential issues. You will make the right choice for you.
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1 ReactionI am in the same boat but 4+3. At your age, radiation is preferable, but I would look into Tulsa Pro and IRE before either of the others. Substantially no side effects comparatively, with similar outcomes, and you can radiation later.
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2 ReactionsAs tk192 mentioned, I would at least look at Tulsa Pro. I am 66 and did it last July at Mayo for my 4+3. Medicare paid for it. The low risk of side effects, the technology, and the follow-up plan sold me!
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1 ReactionI had radiation ten years ago. every is fine but no climax with sex. I think things are different now. I'm at .01 on my test. good luck
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1 ReactionI agree with some of the other comments in regards to consider your salvage options if cancer comes back. It also depends on the surgeon.
After doing my research, I am leaning towards NeuroSafe surgery. So far, I have only found one person on the US who does it (Mt. Sinai). Long story short, they do a biopsy during surgery to determine how much to take out while trying to stay away from the nerves. I believe this is better than intraoperative cavernous nerve stimulation (by stimulating the nerves that control erections, the surgeon can confirm their location and preserve them, a procedure known as a nerve-sparing radical prostatectomy), as with that process they might be sparing the nerves but aren't quite sure about getting all of the cancer.
NeuroSAFE stands for Neurovascular Structure Adjacent Frozen Section Examination. It is a technique that was first described by the Martini Klinik in Germany in 2014 that involves analysing the margins (edges) of a prostate immediately after it has been removed from a patient and whilst the surgery is still on-going to see whether cancer cells have reached the cut edge of the specimen. The prostate is delivered immediately to a pathologist in the room next door where it is frozen using a cryostat, cut into thin slices, stained with special dyes and examined under the microscope.
This analysis is done whilst the operation is still ongoing (the urethra has to be joined to the bladder after prostate removal), so it has to be done rapidly – typically within 20 minutes of the prostate being removed from the body. The team processing the tissue needs to work together quickly and efficiently to get the report to the surgeon within this time frame
This sounds like a real interesting technique. One of my wife’s best friends husband is a pathologist who worked in a hospital analyzing tissue. One of the things he did was analyze the tissue as the surgery was going on to make sure that the margins were clean. He did this with many different types of surgeries, and this was pretty standard.
It makes me wonder why prostate cancer surgeries don’t always get this treatment.
He was good to have around when I Was diagnosed with prostate cancer 15 years ago. He had me bring him the slides, and he reviewed them to tell me if they confirmed what they had diagnosed. He did agree with what they had told me.