Prostatectomy or Radiation? Lot of stress over which to choose

Prostatectomy is not an option. I finish this week with radiation therapy. My preference would have been proton beam. However, the closest proton beam for me is in Loma Linda and in San Diego, California. I suggest that you read books by Dr. Mark Stohs:
Invasion of the Prostate Snatchers
The Key to Prostate Cancer

His Prostate Cancer Research Institute (PCRI) has a free Helpline and Support Groups. He continues to post videos at YouTube.

While going to radiation therapy, I have met radiation patients who have had a prostatectomy. One patient had the prostatectomy in June 2025. The surgeon’s explanation was that the prostate must have spilled some prostate cancer cells during surgery. This patient must now do 38 days (fractions) of radiation therapy.

A second patient had a worse experience with prostatectomy. The cancer metastasized up to his cheeks. He is facing 38 days of radiation therapy plus Orgovyx. If the cancer in the cheeks does not disappear because of ADT, then he will need an additional 24 days of radiotherapy.

Simply search for the probability of cancer returning following prostatectomy. You will discover that the probabilities are at least 20% to 40%, depending on your Gleason score.

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.

@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?

@climateguy
I am not actively posting on MC Connect but if get a tagged question directly to glad to reply.

I am going copy on this post (directly from institution) information I copied about proton radiation from UFHPTI on benefits of proton radiation versus photon. I am not a medical professional or medical expert on PC. I copied information from a major medical institution and a R/O who have (institution and him) have been doing Proton Radiation for over 20 years. The institution and him are the PC experts.

I also will post a recent article from Mayo Clinic information book on the new cancer center now built at Mayo Jacksonville and the benefits of Proton Radiation and how it enhances the treatment options. I will have to do that on separate reply to you as getting to long.

I did not have Brachytherapy. I cannot give you my personal experience with that, how it works, pros cons just limit my posts to what my direct experience. I am sure others on MCC that have had Brachytherapy can give you their personal experience with it and the pros and cons of it.

I think from your post the Brachytherapy that treatment is strictly to a specific arear or tumor lesion. Is that correct. If So I will pass on what my UFHPTI R/O told me during consultations.

I asked does he just radiate the area that was identified by MRI and biopsies that showed cancer or entire prostrate. He replied that he treats the entire prostate. He explained they did not want to miss an area that the biopsies were not done on nor MRI showed. He went on to explain that in early stages of PC the cancer is at cellular level and does not show up as a tumor or lesion stage. Again this comes from a UFHPTI R/O doing proton radiation for over 20 years from one of the most experience proton radiation treatment facilities in the world.

I think each individual has to make his own decision of quality of life versus quantity of life and what treatment plan is best for them. No one can tell you what to do or not do nor should they try. I hope the copied (directly copied the article) helps explain proton radiation versus photon. I will also copy on separate reply Mayo information article on new cancer center at Mayo Jacksonville that will now be able to offer proton radiation.

Why your doctor discounted proton radiation. Don't know but have seen this both personally and what others have posted on MCC. I think some R/Os who have been doing photon radiation and/or specific types of treatments try to lean toward what they are experienced on and have been doing. I ran into this at Jacksonville where at that time could only offer photon.

UFHPTI article on proton radiation. You can read this directly from their web site.
____________________________________________________________
Effective Prostate Cancer Treatment
Proton Therapy Treats Prostate Cancer with a Low Risk of Side Effects.
The five-year results of over 1,300 men treated at UF Health Proton Therapy Institute for prostate cancer were recently published in a peer-reviewed medical journal.1 As reported by UF researchers, the results revealed that the majority of these men are living cancer free with minimal to no side effects. The five-year survival rates for low, intermediate, and high-risk prostate cancer are 99%, 94%, and 74% respectively – with less than 1% having experienced any bowel issues and less than 3% having experienced any urinary issues.

Because of the comparatively low occurrence of side effects such as incontinence, impotence, and fatigue, prostate cancer patients receiving proton therapy are able to continue working, playing, and living relatively normal lives both during and after treatment. That’s why more and more patients with prostate cancer are choosing proton therapy.

How Proton Therapy Effectively Treats Prostate Cancer
Proton therapy treats prostate cancer with high doses of radiation that are more accurate, and potentially more effective, than traditional radiation. Our targeted proton beams focus most of their destructive energy at the tumor site, therefore causing less damage to healthy surrounding tissue as they enter the body. Because of this, proton therapy patients don’t have to worry about many of the side effects and additional healthy tissue damage that is commonly associated with X-ray therapy.

Typically, proton therapy for prostate cancer is given over an eight-week period with 39 treatments. There is new evidence from the UF Health Proton Therapy Institute that a six-week, 28-treatment course of proton therapy is highly effective and achieves excellent prostate cancer patient outcomes. Researchers again noted minimal physician-assessed toxicity and excellent patient-reported outcomes. At seven years after treatment, the freedom from biochemical progression (FFBP) rate was 95.2% with continued low side effect rates.3

@jc76 Ask your RO if, for example, he thinks Michael Zelefsky in NY knows anything. Zelefsky says he thinks protons are good, but he's sticking with photons when it comes to the external beam he uses.

Whether protons are best is controversial, i.e. there is disagreement among some of the most eminent people in the field.

My comments on brachytherapy were about an option I'm considering, i.e. EBRT with brachytherapy boost. I view the therapy as a combination external and internal beam.

When this therapy is used, the entire prostate is radiated by a radiation source or sources placed inside the prostate, then EBRT is applied to the entire prostate and other areas. It is a way to administer a total dose to the entire prostate higher than any EBRT can safely deliver. Data shows, eg. the TRIP study, that if properly administered, EBRT + BT boost delivers longer recurrence free outcomes than any EBRT alone can.

4 plus years into Prostate Cancer experience. Had three chemo treatments, two year interlude, radiation directly to. prostate (20 treatments) three years ago, and in February 2025 took Pluvicto - two treatments. Radiation irritated (caused?) fissure and ulcers in rectum. EXTREME pain and pressure. NO relief. Oncologist sent me to colorectal sturgeon to remove irritant (stool passing over fissure and ulcer and irritating them) and of course the surgeon recommended surgery - divert the bowel and eliminate the problem. So, I submitted to a surgery five weeks ago and now have a colostomy bag, etc. for the rest of my life. STill have pain, pressure, and extreme discomfort and pressure.

Problem is that they are still 'practicing,' and two things: (1) they do NOT tell you all the side effectss, and when confronted, the radioactive docs deny any responsibility while (2) every article on the net and in medical communication says that radiation proctitis is a direct result of more radiation, and is irritated by the same drugs they prescribe to manage the pain. =

Instead of curing the problem which they created, the system prescribes more strrong narcotics, more frequently, and the docs get their prescription kickbacks, etc. and patients suffer.

My two cents: remove the prostate and never let them radiate you. There are many pleasurable ways to make love, not just one, and it sounds cold, but consider their situation. The docs cannot do anything that the insurance. ompanies won't pay for, or do it in the prescribed sequence, and NO ONE HAS THE PATIENT'S WELL BEING AS FIRST PRIORITY.

For months now all focus of my treatment has been on pain managment and keeping me drugged - meanwhile, the cancer grows and spreads and we talk about 'will this work?' "Lets try this?'

Praying you have wisdom, a doctor not interested in only making money and tikking off boxes. but in seeing you healed fully, and a strong support system for you. "Fight, fight, fight.'