Prostatectomy vs Photon radiation vs Proton Beam Therapy

@soli thank you for your input. It’s a challenging time to make life altering decisions. I have no symptoms. Everything is by test eg initial PSA then MRI or biopsy results. Radical Prostate removal does get the cancer out and possibly reserves radiation for any reoccurrence - but it comes with what’s seems higher potential side effects that may impact one’s quality of life. Radiation has its own longer term effects and as I hear here rules out sugury in the future. Both options seem to be statistically effective but each person is different. If you have a genetic mutation that raises reoccurrence. Like you, the aggressiveness of the underlying disease is a factor. I will gather a little more intel and meet with a RO. Thanks for your time. Stay healthy.

@jeffmarc thank you for providing this information. I’m doing a PETscan and waiting on decipher and genetic results. Everything is hurry up and wait. My urologist is a surgeon and honestly state he is biased to RP (with keeping radiation as a backup). I am meeting with a RO who is at a center that does both Photon and Proton. Each nugget of intel and other’s personal journey helps both emotionally and decision wise. I’m glad you had a fast recovery with little issues. Genetics are what they are. It seems you are dealing with any RO quite well. You must have an amazing positive attitude :). Thank you again for your time. I hope other men read these as it’s not something in my circle that’s talked about.

Hello bdouglas67,

You have received some great advice from this group (thank you as always Jeff M, et al) and I agree with gather all the data you can prior to a decision. I am something of an outlier in the PC world and occasionally share my story here when I think it is beneficial to a poster. Firstly, as discussed, oftentimes a comprehensive treatment plan is not a simple choice of photon, proton or surgery as a first line. In my situation, I was diagnosed two years ago at age 67 , low PSA (2) with a large lesion (10% of the prostate) Gleason 3/4 MRI negative (invisible), ultrasound negative, T2, with favorable decipher score PC. The biopsy was done without MRI (obviously), but the tumor was easily found. Technically I should fit into the Dr. Mark Scholz bell curve of infinite possibilities for treatment including Active Surveillance (AS)..right?. Not really, after reading everything I could and speaking with Surgeons and Radiation Oncologists along with my Urologist, it became clear that there was definitely a preferred treatment plan.

Treatment Option - Active surveillance (AS), PSA and MRI are primary tools and with my MRI invisible PC, frequent biopsies would be the plan. Also.. AS for 3/4 is very risky and no medical professional I spoke to would support that. Also a s a professional pilot, the FAA scrutinizes... and has set limits on allowable yearly PSA rise.

Treatment Option - Focal therapy such as IRE was my first choice however not available due to poor MRI imaging.

Treatment Option - Proton or Photon - poor MRI imaging could not accurately determine the extent of the tumor or where it was ...was there EPE or? The PSMA scan showed a large blob of uptake confined to to the prostate. As such the radiation oncologist told me I was not a good candidate for Proton, but he could do Photon (SBRT) however he would need to throw "a broad net" to include lymph nodes and such in an attempt to get the PC wherever it might be hiding. ...(possible greater side effects). Also a subtle plot complication was due to my low PSA. Following SBRT my PSA dropping to NADIR might mask BCR since my PC does not make much PSA. As a result the RO stated that "I would do well to get to PSA zero" (aka ...surgery) and if the surgery pathology revealed the need for a second modality treatment he could do it.

Treatment Option - Surgery - my last choice, but became my first choice based on all the data. I chose surgery in an attempt to get a cure, but as importantly to get to PSA zero so that any following up treatment would be based on a clean sheet of paper. Surgery performed 12 months ago and the benefit besides prostate removal is a complete pathology report of what I had and what I might expect.

In summary, PC treatment is about probabilities and your comprehensive treatment plan should account for as many as possible. My nerve sparing surgery at a center of excellence went well, margins clear, and I was thrilled that I had zero incontinence! My ED has been improving steadily, but will likely plateau at less than what I started with. At your younger age (if you chose surgery) your outcome with respect to ED recovery should be on the positive side of the recovery bell curve when compared to a 67 year old.

Good luck with your treatment...Have a plan...have a backup plan!

I thought it odd that an RO and a urologist at a top flight facility that had proton therapy in house would discourage its use for prostate patients, if all there is to it is cost or specific side effect profiles. Medicare and at least some insurance plans pay for protons.

I could see specialists telling their management that until there is a clear advantage shown for protons they don't see the point in spending the tens of millions of dollars to build such a facility to administer them. But once they've got protons in house, there must be some reason in their minds that they would discourage proton use for a particular cancer type. I didn't explore the issue as the appointments were short and there were more urgent things on my mind.

@climateguy
Not sure you heard about this, but they are now able to build proton facilities in One or two rooms in a current building. Used to be, they had to build a whole building for it.

They expect the cost for proton radiation to drop a lot once more facilities get built, and as a result, it will be more competitive with photon radiation.

@climateguy It is confusing that my RO stated that Medicare did not cover Proton and no advantage plans did either. I'm 76 with second biopsy showing Gleason 3+4 and PSMA-Pet scan showing small PC confined to prostate. I would like to know who is currently paying for Proton as we are in the time period for updating our medicare coverage to a plan that does cover it.

With Gleason 3+4 virtually all the various treatment modalities are applicable including, Focal (Cryo, Laser, Ultrasound, Electricity etc.), RP (robotic), external beam radiation like IMRT or SBRT (CT-Guided or MR-Guided, Photon or Proton), LDR brachy, and of course surveillance.

The issues with Focal are: not a lot of long term outcome data available compared to other modalities but the biggest issue is that there is a tendency for radiologists to be lazy and only report the first sizable lesion they see and stop looking for others. Focal requires that all the lesions are identified. So it is essential that you have an expert radiologist who is familiar with focal requirements to provide a second opinion of your MRI images. You're under general anesthesia so it seems like the procedure only took a minute. Recovery takes about a week and requires a catheter for much of that time. Focal has the best side-effects profile.

The issue with RP is that it is extremely invasive with a high potential for life-long side-effects. Providers including radiation oncologists will push younger men in this direction saying that once you have radiation (IMRT or SBRT) you have no more options for treatment if there is a relapse whereas with a relapse after RP you can get radiation. While technically that is true the point being missed here is that the prostate does much more than just create seminal fluid and provide an income for urologists. It provides the framework for holding the urethra, internal and external sphincters, and the neurovascular bundles. When you take it out and then apply IMRT or SBRT to the region you are hitting both sphincters, the bladder, and the neurovascular bundles (if they were able to be saved in the RP procedure). Then you may end up requiring a permanent urinary diversion (pissing in a bag). They also don't typically tell you that you will lose an inch (more or less) of your flaccid penis length and many men can't afford to lose that much real estate. Perhaps they should lead with that bit of information. Recovery takes several weeks and full urinary control and sexual functionality could take as long as 2 years if ever.

It has been shown in a recent study (2025) as pointed out by Dr. Mark Sholtz of PCRI that external beam radiation Photon or Proton either IMRT (low dose) about 20 sessions or SBRT (high dose in 5 sessions) does not provide adequate dosing to achieve the curative results that we would expect. Recovery time is quick and usually a catheter is not required. The long term side-effects profile is only slightly better than RP.

Mark Sholtz favors LDR Brachy and this is probably why:

- a single session that takes about an hour and you're done.

- you're under general anesthesia so it seems like the procedure only took a minute

- recovery time is virtually immediate (you can leave the recovery room and immediately go out for dinner and drinks)

- usually a catheter after the procedure is not required.

- the permanent seeds provide a sufficient dose to achieve the best curative results of any treatment modality as evidenced by the ongoing study of 129,000 men who underwent all the different modalities of treatment. It measures their outcome by modality. You can look this up at prostatecancerfree.org

- Because Brachy treats the prostate from the inside out with little overspray to surrounding tissues RP, Focal, and even radiation can be utilized later in the case of a recurrence however recurrences are extremely rare. The side-effects profile is only slightly worse than Focal but better than RP or external beam.

In your case, if you have some 4+3, I would imagine that a radiation oncologist (RO) who offers Brachy would suggest the following line of treatment: permanent seed brachy followed by maybe 10 sessions of IMRT followed by 6 months of ADT. However, it likely wouldn't be unreasonable to do Brachy and then some time with active surveillance to see how things are looking. In my opinion, the worst thing you could ever do is radical prostatecomy (RP). I had LDR brachy and it was extremely uneventful. I liken the experience to going to a spa for a couple of hours. No pain or discomfort afterwards. Immediate recovery. Only a slightly slower stream for a few weeks. I can't really understand why, when LDR brachy is available, people would bother with focal especially when focal isn't covered by all insurance companies and not at all in Canada. I would be happy to tell you my experience. Feel free to PM me.

@ketter1 Re: does Medicare over proton therapy? I haven't had proton therapy or attempted to get Medicare to pay for proton therapy so I don't know. Your RO could be correct, but it also seems to be correct to say Proton therapy can be covered by Medicare.

I found this on CMS.gov Search for the page using this term without the quotation marks: "LCD - Proton Beam Therapy (L35075)"

"PBT is considered reasonable in instances where sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of added clinical benefit to the patient."

Also: "Prostate Cancer: Coverage and payments of proton beam therapy for prostate cancer will require: Physician documentation of patient selection criteria (stage and other factors as represented in the NCCN guidelines);
Documentation and verification that the patient was informed of the range of therapy choices, including risks and benefits."

@kikito1
In the latest PCRI conference, about a month ago, A radiation oncologist who specialized in SBRT Gave a long talk with a lot of information about the fact that SBRT radiation is better than other types for most cases. The higher dose of radiation that they use causes more cells to die Quickly then if you have IMRT or other types of radiation. You could watch the PCRI conference and see what they were talking about.

Yes brachytherapy Seems to be another really good choice and is used heavily in Europe, but not very much here unfortunately.

Another thing to be aware of is that there is a very small chance of photon radiation, causing future cancers. There was information from a Stanford study.

In a study of about 145,000 men with prostate cancer, the team found that the rate of developing a later cancer is 0.5% higher for those who received radiation treatment than for those who did not. Among men who received radiation, 3% developed another cancer, while among those who were treated without radiation, 2.5% developed another cancer.
https://med.stanford.edu/news/all-news/2022/070/prostate-radiation-slightly-increases-the-risk-of-developing-ano.html

@jeffmarc I've seen others, though I can't remember where, quoting about a 1 in 1000 men who have IMRT / SBRT get another cancer. In any case, Brachy is almost exclusively hitting only the prostate will little over spray. IMRT / SBRT must pass through normal tissue to get to the prostate. We know that the prostate can withstand radiation at much higher doses than normal tissue. That's another reason why I think Brachy, either LDR or HDR, is the best choice. It's not practised as much here because it takes more effort and doesn't pay nearly as well as other modalities of treatment. Mark Sholtz has a segment about that aspect also.