Decisions to be made after biopsy confirmation of prostate cancer.

@georgemc
George I would not really be all invested in needing proton radiation. There is a minimal difference between proton and photon radiation in long-term survival and you are 90 years old.

I had 8+ weeks of photon radiation 12 years ago and I’ve had no secondary cancer from it after all these years. That’s pretty normal. There’s a very low rate of secondary cancer. Here’s information from a Stanford study Based on photon radiation.

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
In order to protect yourself, you may want to have one of those barriers put in like SpaceOAR, Barrigel, or BioProtect to your protect your rectum from damage During radiation treatment.

@georgemc Just keep in touch with this support group that has proven helpful to many -- older or younger alike.
https://connect.mayoclinic.org/discussion/encouragements-from-prostate-cancer-support-groups-share-yours/
I am gathering new and additional information for the book I authored, that I plan to publish the second edition. (The paperback format is mentioned in the above hyperlink; I can't add the link for the e-book version, this comment may be filtered out by Mayo Clinic's algorithm if I did.) I will be following up/keep updated on what you post in the future, and see if I can add anonymously in my book's second edition. I wish you well in the years ahead.

@georgemc
I had 30 rounds of proton radiation at UFHPTI and Medicare paid and covered. I had secondary insurance through FEHP being a retired federal employee which covered the Medicare co-pays.

I am not sure you posted but did you have the Decipher test?

My oncologist(s) and I have decided that proton therapy is the way to go for me, particularly coupled with the use of BioProtect Rectal Balloon Spacer. The 9 week procedure will be administered at the Hampton University Proton Cancer Institute (HUPCI). The decision was made despite a recent professional journal report which minimized the benefits of proton over photon. The evaluation in that study appears to be "oranges vs apples," in that it did not address the benefits of proton therapy WITH an appropriate rectal spacer. Use of the relatively recently approved BioProtect Rectal Balloon Spacer (August 2023), along with the longer term/lower dose regimen, appears to be the best fit. It has been the experience of HUPCI that the incidence of negative side effects following treatment are markedly lower when BioProtect is used. Wish me luck (a prayer or two would also be appreciated - lol). Will let you know how it goes.

Has anyone out there had experiences involving Proton therapy with and without ADT? I am currently "consulting" with 2 urologists who seem to have differing opinions. Both agree that a 9 week proton therapy is appropriate, and that is scheduled to begin in early February. However, one wants to add 4 months of ADT (Orgovyx). The other doesn't think that is a very good idea, given my age (90), and the range of side effects negatively impacting quality of life. Your thoughts/experiences are invited.

@jc76 Sorry I am so slow in responding to your question. No. I have not had the Decipher test.

@georgemc

NCCN Which sets the standards for Treatment Has these guidelines for when to do ADT. You have really not supplied enough information To say whether or not you need ADT based on these guidelines. It Requires information about Your case that doesn’t appear to be available to us. Hopefully, you know The answers to these things and can see what is recommended.

People in their late 70s and 80s get five sessions of SBRT radiation and that lasts for a long time, A decade and more for most.

Here’s some more information on ADT optimal duration. After the guidelines are a synopsis of the study of optimal duration for the use of ADT. There’s a summary of the main issues and then the article which is quite lengthy and interesting as well.

Here are current NCCN Guidelines in 2025. They now suggest 0 (zero) months of ADT for low intermediate (GG2); 4-6 months for high intermediate (GG3), and 18-36 months for high risk (GG4 and 5). Actually, the footnote suggests ADT + abiraterone for T3b with lymph node involvement.
The meta-analysis suggests:
* 0 months for 1 intermediate factor (PSA 10-20, GG2 or 3, T2b-c)
* 6 months for 2 or more intermediate factors (PSA 10-20, GG2 or 3, T2b-c)
* 12 months for NCCN high risk (PSA >20, GG4 or 5, T3 or 4)
* undefined for NCCN very high risk (2 or more PSA >40, GG4 or 5, T3 or 4)

Some unique finding of the below study were:
1. All endpoints tailed off significantly after 9-12 months albeit with marginal improvements and fewer prostate specific deaths. High risk men had the least to gain beyond 12 months .
2. Increased duration, especially over 18 months, resulted in greater other cause deaths, albeit fewer prostate specific deaths. In the past only cardiovascular deaths were seen to increase with more ADT.
3. For very high risk men, the length of time should be tailored individually over 12 months.
4. NCCN risk groups may not be the best way divide treatment
5. Shared decision making should be included in determining how long to stay on ADT
6. For younger, healthier high risk men, there may be greater benefit to staying on ADT longer than 12 months.
https://jamanetwork.com/journals/jamaoncology/fullarticle/2841671

@georgemc
Hay no problem.

Since you posted having some doubts what to do especially getting ADT at age 90 I will give you my personal experience with this and why I asked about did you have Decipher.

My biopsies indicated intermediate risk and my treatment plan from Mayo was radiation and hormone treatments. I had the PSMA, bone scan, negative. I had the Decipher and it came back low risk not intermediate risk.

Thus changed my treatment plan from radiation/ADT to radiation only. Having the Decipher may help you make a decision on what treatment to decide. It did for me. And I had two different opinions (Mayo and UFHPTI) that both concurred on radiation only and my diagnosis treatment option after I got the Decipher and PSMA.

@georgemc That Decipher test could be THE decision maker for you, George; so by all means, have it done.
Since your goal is to live 10-15 more years, based on your family’s longevity, recurrence really is something to consider, even at age 90.
If your Decipher score is low, the aggressiveness of your cancer is lower and no ADT would be required. If it’s higher, then ADT is usually recommended. Best,
Phil