Would you recommend proton therapy vs surgical removal of prostate?

@seekingclarity thanks for this post and the great questions. I will be following this thread as I am in a very similar situation, but a few months behind you. I had my first biopsy on 12/2 and it showed two G6's and one G7 (3+4). I am still waiting on my decipher results. I'm 57 and am going to take the next several months to research my options (surgery & if so where, tulsa pro, ongoing active surveillance, etc.), unless the decipher results indicate something potentially more aggressive than the "favorable intermediate risk" the dr. believes I currently have. To your question about PSA results, like the others have said, I think they consider it more of an indicator and not necessarily anything definitive. Also, it is quick, easy, and cheap, so it makes sense that the doctors would start with PSA. After several elevated PSA readings and a negative MRI a few years ago, my dr. recommended Iso PSA, which ended up being unusually high. From there we went to an MRI which was pirads 4, and most recently a biopsy with the results above. I think this is a fairly normal progression, even though I'm on the younger side. The one redeeming fact about prostate cancer is that it's fairly common and also usually slow growing. There's a lot of data out there, and most of us have time to weigh options and make decisions.

@seekingclarity
I (61 yo, 3+4=7) too was not sitting well with 2 different urologists recommending removal as best option, I sought an option from a oncology radiologist at Mayo. She would have gladly done SRBT if I wanted it. When talking to her team...the P.A. is male and if he were in my shoes, he would have had a R.P. . My decision came down to not waiting months to years to know if cancer free. I wanted to get rid of the cancer! In the Dr Walsh book, it talks about R.P. as being the gold standard for 100% cure. I had my robotic assisted radical prostatectomy last Wed. Pathology showed progression from 15% of sample as Gleason 4 in June to 70-80% 4s. in Dec When your time comes, RP is a great option that has advanced far beyond the earlier days.

A long response that answers all your questions —>

I’m AA; I was 65y/o when I was diagnosed with localized, 3+4=7, PSA = 7.976.
I spent many months evaluating all treatment options. My urologist (a surgeon) provided me referrals for focal therapy (cryo, HIFU, ablation), brachytherapy (LDR/HDR), SBRT (Cyberknife; Trubeam), IMRT & Proton.

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 came 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.”).

For me, I wanted to balance survival (of course!) with quality-of-life, along with the possibility of treatment in the future if needed (as medical treatments progress). I wanted the least chance of ED, GU, GI, bowel or other similar complications - quality-of-life following treatment was a priority.

After spending much time getting referrals and evaluating treatment options, I ranked them as:
#1. Proton
#2. IMRT
#3. SBRT
#4. surgery

I had 28 sessions of proton radiation during April-May 2021. Treatments were relatively uneventful. I only had 1 day of adverse side-effects. (My wife later told me that if she hadn’t known I was undergoing radiation treatments, she wouldn’t have realized it from any change in me.)

The idea that “if you choose radiation first, you cannot have surgery later” has some truth to it, but is old-school and doesn’t consider modern treatment techniques. With radiation, the DNA in healthy prostate cells get damaged just as do the ones in cancerous prostate cells. But healthy prostate cells have repair mechanisms that can sometimes repair the damage (though not always). Cancerous prostate cancer cells usually can’t repair the DNA damage. What’s left is a “healthy” prostate, 35%-50% smaller than it was, but damaged enough that it makes salvage prostatectomy challenging (though not impossible).

However, if there is local recurrence after initial radiation, choice of treatment would depend on the nature of the recurrence; there are other options (other than surgery) - focal therapy (e.g., cryo), brachytherapy, SBRT, and yes even re-radiation in some cases. Surgery would still be the distant last choice. So, I wouldn’t let the old-school “no options if recurrence after radiation” philosophy change my initial treatment decision.

About PSA testing —> With the current state of medicine, PSA testing (or PSE testing) is the only (& least expensive) test there is for early-detection of prostate cancer. However….. Remember that a PSA test is not a cancer test. The PSA number itself is similar to a “check engine” light in a car; it indicates that something may be wrong, and further checks should be made “under the hood.” Might be as simple as a UTI; might be BPH; might be more serious, such as cancer. Just need to have further checks. No need to panic, or rush to a quick treatment decision, or get overly concerned.

Yes, it is possible that someone could have the “seeds” of prostate cancer for some time, but too small to be detected. In my case, I was on active surveillance for 9 years (having been initially diagnosed in 2012 at 56y), before the prostate cancer which was initially low-grade became intermediate grade.

Note that there are only 47 active proton centers in the U.S. (The one at the University of Cincinnati was just a 40-minute drive for me.). Is there a proton center near you? —> https://www.proton-therapy.org/map/

If you have any more questions, feel free to ask.

I am a big advocate of radiation treatment (RT) over radical prostatectomy (RP). An RP causes a lot of damage that is hard to recover from. The surgeons talk about new nerve sparing techniques but the reality is that nerves are always damaged with an RP. You can easily become permanently incontinent after an RP as the prostate provides the bulk of the sphincter muscle to control urine flow. Regardless of how good your surgeon is, and no matter how many Kegel exercises you do, if you are lucky enough not to have permanent incontinence, you will still very likely experience urine leakage when you cough, sneeze, lift heavy objects or run. Permanent ED and very compromised sexual function is very common after an RP. As you read through cases on this forum, you will see that RP guys have a lot of incontinence and ED issues, far more than what RT guys experience.

In addition, the RP guys also experience a lot of recurrence causing them to have to use radiation as well. RP guys have a 30% recurrence rate overall but that climbs to 50% and 60% when the patient has Gleason scores of 8 and 9 respectively. Most surgeons simply do not emphasize enough how likely a recurrence is after an RP. Enter your data in the MSK nomogram here https://www.mskcc.org/nomograms/prostate/pre_op if you would like to see your odds of recurrence after an RP.

I believe that the reason that there is such a high recurrence rate after an RP is that there are microscopic escapes of cancer cells outside of the prostate that occur before the RP is even performed. These small cancer cell escapes can't yet be detected by our best scans like the PSMA PET scan. It is still too easy for some cancer cells to lurk in lymph nodes or seminal vesicles without being detected. This is especially true when you have a genetic predisposition like BRCA2, high Gleason scores and/or a high Decipher score. Extracapsular extensions and lesions broadly abutting the prostate capsule also increase the risk that some escape has occurred.

Having so called "clean margins" after an RP is really not much assurance that all the cancer was removed. With radiation treatment and possibly some ADT treatment if needed, cancer in the prostate gland itself and cancer as yet undetected in microscopic escapes can be killed both in the gland itself and the greater pelvic region.

Ideally, we all want to have a treatment plan that let's us be one and done with the least side effects possible and never have to deal with prostate cancer again. There are occasional side effects from radiation and there are some recurrences as well, but overall, as you read through scores of cases on this forum, I think you will find radiation yielding the best overall outcomes in terms of fewest side effects and less recurrences of cancer.

@gfeaglefan, did you have surgery? Have you had additional treatment? How are you doing now?

I am a big advocate of radiation treatment (RT) over radical prostatectomy (RP). An RP causes a lot of damage that is hard to recover from. The surgeons talk about new nerve sparing techniques but the reality is that nerves are always damaged with an RP. You can easily become permanently incontinent after an RP as the prostate provides the bulk of the sphincter muscle to control urine flow. Regardless of how good your surgeon is, and no matter how many Kegel exercises you do, if you are lucky enough not to have permanent incontinence, you will still very likely experience urine leakage when you cough, sneeze, lift heavy objects or run. Permanent ED and very compromised sexual function is very common after an RP. As you read through cases on this forum, you will see that RP guys have a lot of incontinence and ED issues, far more than what RT guys experience.

In addition, the RP guys also experience a lot of recurrence causing them to have to use radiation as well. RP guys have a 30% recurrence rate overall but that climbs to 50% and 60% when the patient has Gleason scores of 8 and 9 respectively. Most surgeons simply do not emphasize enough how likely a recurrence is after an RP. Enter your data in the MSK nomogram here https://www.mskcc.org/nomograms/prostate/pre_op if you would like to see your odds of recurrence after an RP.

I believe that the reason that there is such a high recurrence rate after an RP is that there are microscopic escapes of cancer cells outside of the prostate that occur before the RP is even performed. These small cancer cell escapes can't yet be detected by our best scans like the PSMA PET scan. It is still too easy for some cancer cells to lurk in lymph nodes or seminal vesicles without being detected. This is especially true when you have a genetic predisposition like BRCA2, high Gleason scores and/or a high Decipher score. Extracapsular extensions and lesions broadly abutting the prostate capsule also increase the risk that some escape has occurred.

Having so called "clean margins" after an RP is really not much assurance that all the cancer was removed. With radiation treatment and possibly some ADT treatment if needed, cancer in the prostate gland itself and cancer as yet undetected in microscopic escapes can be killed both in the gland itself and the greater pelvic region.

Ideally, we all want to have a treatment plan that let's us be one and done with the least side effects possible and never have to deal with prostate cancer again. There are occasional side effects from radiation and there are some recurrences as well, but overall, as you read through scores of cases on this forum, I think you will find radiation yielding the best overall outcomes in terms of fewest side effects and less recurrences of cancer.

@wwsmith I have to disagree with some of your comments. I had an RP after learning I had two cores of cancer, one at 3+4. When the pathology report came back at 4+5, I was glad I chose RP. Also, I did Kegels religiously for the month prior to my surgery and after my catheter was removed. I am not out over two years since my surgery, and ZERO incontinence issues. My surgeon said I was one of the lucky 10%. Your summary of your experience certainly is helpful, but as we know, not everyone is affected the same way.