@bdouglas67 Yes, PSMA PET scan, biomarker (genomic), and genetic (germline) tests are all necessary before making a treatment decision.

As for urologist’s often perceived bias to surgery and RO’s often perceived bias to radiation, I view it more as “if all you have is a hammer, everything looks like a nail.”

Note that with radiation, if there is local recurrence after initial radiation, choice of salvage treatment would depend on the nature of the recurrence; with modern treatments there are many backup options - focal therapy (e.g., cryo), brachytherapy, SBRT, and yes even re-radiation in some cases.

So, with success rates comparing surgery with radiation being statistically equivalent no matter what treatment chosen (https://www.nejm.org/doi/full/10.1056/NEJMoa2214122), it all 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.”).

RP is often done with the assumption that if it’s taken out, then the cancer is gone. But as the data clearly show, recurrence rates company RP to RT are statistically equivalent (and RP often has to do RT anyway, so why do both?). With the success of modern radiation in breaking DNA strands (see attached graphic), the cancer cells die when they can’t divide.

Note that proton is radiation therapy (it’s a heavy particle with wavelike characteristics); and proton is combined with hormone therapy just as with photon.

However, there are so far fewer proton centers than there are photon centers, that explains why you don’t see many comments on Proton. Plus, in practice proton is quite successful with few serious side-effects (due to the Bragg-Peak) so, you won’t find many proton patients hanging out here…..