Prostatectomy or Radiation? Lot of stress over which to choose

@paulsheldonfoote While I do agree that a significant percentage of surgeries ‘fail’, some pathologies such as cribriform or IDC are not completely eradicated by radiation. Nor are those cells which give a high Decipher score.
If you are in the lucky category of complete glandular containment and have none of the contributing aggressive pathologies, SBRT is definitely the way to go.
But some of us view surgery as merely the first stop on a long train ride with no idea how many stations we’ll have to pass!
Phil

@heavyphil
I had asked one radiation oncologist for SBRT. She refused. She said that at my age and physical condition that SBRT would result in a very long recovery time. Today is my last day of 28 days of EBRT. I understand now what she meant. My sleep will be interrupted for a long time because of running to the bathroom.

I agree about the long train ride. Every 3 months, I shall be going for PSA blood tests. If the result is bad, then I shall need to do another PSMA PET-CT. As you noted, PSMA PET does not identify some IDC-P cases. If I need another stop, the next stop might be a brachytherapy boost. I have not heard any oncologist mention that more than 30,000 men die annually from prostate cancer (not with prostate cancer) because they do not respond to any of the treatments.

For men who live near proton beam facilities, I urge them to read:
You Can Beat Prostate Cancer And You Don’t Need Surgery To Do It by Robert Marckini.

Paul

@heavyphil
He really hit the nail on the head with the fact that radiation doesn’t always get IDC and cribriform.

Those are cases where HDR brachytherapy could finish those things off. Problem is, that’s not done very often.

At recent ancan.org Advanced prostate cancer meetings Rick has been talking about this and the fact that IDC is really aggressive and has to be treated aggressively. He tells people they should get surgery, followed by radiation If appropriate. It’s been brought up in multiple meetings since IDC seems to be pretty common with advanced cases.

@jeffmarc
You are correct. I have and have read his books. I should have looked at the books for the correct spelling. Thank you.

@paulsheldonfoote I am not an authority by any means...I will tell you two friends of mine had the Da Vinaci surgery and still has incontinence after 5 years, my other friend had seeds placed for a less aggressive cancer is doing well but his PSA is still 3.9, I had my surgery and never had incontinence but after 6 years come January 2, 2026 I'm still not able to get an erection without using a shot, but I have a PSA test every 4 months and it's undetectable at .01. I don't think there is any clear or definitive answer on any of this personally...I chose my doctor because he said there is not a machine in the world that has a tactile sense for feeling other than a human being to do a nerve sparing surgery. He did my radical prostectomey and I think it was my best choice after seeing 3 surgeons and a radiologist. Please ask your radiologist if surgery after radiation is possible if your PSA starts to rise...mine told me there is not a surgeon in the world that would touch a radiated patient because of all the scar tissue. Do your do diligence and research every angle...I am so sorry you are in this position...Good luck and God Speed.

@bobby1313 I should have mention I had a very aggressive cancer....I was told not to wait to make a decision...your on a great place to ask questions if you have the time...keep searching...it does help. I wish I had been on this Mayo Clinic sight before I pulled the trigger. My surgeon was Dr William Catalona at Northwestern medical in Chicago, Illinois...he takes care of very famous people all over the world...maybe see him too...just a thought...

I was a Gleason 8 who chose radiation and ADT over enucleation. My decision was made based on continence issues post-surgery. Everyone should understand that as far as your sex life is concerned, IT MAKES NO REAL DIFFERENCE. Prostate cancer will end your sex life as you know it no matter which treatment options you choose. Oncologists/Urologists should be more up front about preparing their patients for this inevitable outcome. Some patients try to sugarcoat it or compromise or claim that everything is still great because their partner is so supportive, blah blah blah. No. It's not and it won't be. FACTS.

@jsh327 ,
You say, "getting the best possible surgeon operating at a prostate cancer center of excellence with a documented history of 1K+ prostatectomies resulting in a high percentage of continence (>90% within 6 months) and sexual function (comparable to pre-surgery within 18 months, assuming nerve sparing)."
It's not practical for me to travel to a center of excellence. I was going to choose radiation but my ProstoxUltra and ProstoxCMRT both came back high risk for radiation, so I've chosen surgery. My surgeon has done hundreds- not thousands. I have read no bad reviews of him. How are surgeons ever going to get to over a thousand RP's if they don't start with a first one and gain experience? I imagine that they are highly supervised at first and not allowed to do it independently until they've proven their skill.

@mouser26
A lot of the people in this forum are able to get erections and have normal sexual relations. Other people have to use injections into the penis like bimix or trimix, They can have fulfilling and normal sexual relations once they have that injection. None of them can ejaculate sperm anymore, But they can climax.

In some Cases, people need Cialis or Viagra and it works for them.

If you have surgery and have the nerves spared, people can get a normal erection eventually.

Most people that have radiation are able to get erections right after, the ability can wane over time.

@jc76 I was curious about proton therapy, so at my first appointment with an RO at an NCI designated facility that heavily advertises proton therapy, I asked about it. The RO explained that the facility should stop advertising protons for prostate cancer: he said the people in the prostate cancer department all favored photons.

I was astonished that an experienced RO at a facility that had protons available, would not recommend protons, but that's what he did. One thing he mentioned was that although protons theoretically appear to not damage normal tissue on the way to the target cancer, the proton has an effect on other particles to get them on the way to causing problems the therapy hasn't been studied deeply enough to figure out.

Protons are a form of external beam therapy, as are photons. I became more interested in internal beam therapy, i.e. brachytherapy. The radiation source is placed right inside the target, i.e. the prostate or semincal vesicles, etc., either temporarily or permanently. Brachytherapy can deliver a higher total dose to the target area than any other RT. There is a lot of data supporting the idea that the higher the total dose that is administered to the target, the higher the likelihood of a kill.

The TRIP study supports the idea that if the local cancer source, the prostate, is blasted with more than 200 gray, the treatment failure rate is lower over a longer period than any external beam therapy alone can achieve. (The higher than 200 gray is achieved by adding a brachytherapy boost in addition to an EBRT).

I concluded that what matters more than theoretical descriptions of relative advantage is the data on outlook. I was surprised that there are many different ways to figure out what the outlook is. A common way is long term survival. Two treatments are compared and pronounced roughly equal in terms of survival at 5 or 10 years. What is left out is that one treatment might require less salvage therapy afterwards than another, which could be crucial to a patient's analysis, i.e. what is my quality of life going to be?