RALP or SBRT for a 51 year old?

I recommend talking to multiple surgeons and radiation oncologists, ideally at a center of excellence, and asking each of them specifically about your incontinence concerns.

That's what I did last year after my January biopsy at age 50 showed Gleason 7 (3+4) in 6/12 cores. I also had a negative PSMA and Decipher 0.56. I really wanted CyberKnife or MRI-guided SBRT, but none of the three RO's I saw recommended that approach based on my existing urinary issues (frequency, weak stream). The team at MD Anderson not only recommended surgery but refused to do radiation because they felt it would exacerbate my urinary issues. I had RARP at the Cleveland Clinic in June and was essentially continent from the moment my catheter was gloriously yanked out. I sometimes drink a lot of coffee so my occasional dribbling is self-inflicted. My pre-op MRI the day before surgery added EPE to the mix and my-post op pathology showed large cribriform pattern and SVI, but still Gleason 7 (3 + 4) and surgical margins and 15 lymph nodes all negative. I'm happy with my choice but everyone's situation is different and SBRT works well for many men with very similar long-term outcomes as RARP.

If you already have some incontinence issues, an RP will definitely make that worse. Check your chances for recurrence after an RP here https://www.mskcc.org/nomograms/prostate/pre_op I think your logic is correct about SBRT. See if you can make an appointment with a radiation oncologist at a recognized center of excellence to explore radiation options. See my bio for more details.

@mtcoastie
No one can tell you what to do. Can suggestion and give what they did and why. You are an individual and your priorities in life are specific to you.

What you want in life is crucial to your decision making. I could go on an on about why I chose proton radiation for a 3+4=7 Gleason. Your Gleason is low. Active surveillance I have seen many chose with a 3+3=6. There is no gurantee a Gleason score is correct. I see many post who had RP that the biopsy after was changed to higher.

I think when in doubt most of us would suggest second opinions. That is what I did and helped me not only get additional information but get to professional diagnosis and treatment options. Has your doctors mentioned Decipher and PSMA to you. I am not sure of the protocol with a 3+3=6 but I had both those test. My Decipher came back low risk and my PSMA was negative.

@jc76 my Dr said since I was a G6 a PSMA was not warranted. I have not done a decipher test just a prolaris which was favorable, had me at 1%. I know I’m not a candidate for AS, personally, meaning I don’t want to play the wait and see game, I worry about enough as is. So I’m going to pursue treatment sooner than later. I really just don’t want to be incontinent at 51. I suppose it’s better than really sick…

I recommend determining if your present continence can be improved prior to either treatment, given that you are presently Gleason 6 om active surveillance.

Presumably you have already attempted pelvic floor physiotherapy with experts. If this has not been successful, any device based continence improvements must be considered in the context of PCa treatments (RALP to RT).

Both treatment types can increase incontinence, prostatectomy sooner and radiation therapy later, depending upon the underlying causes of incontinence now, type of treatment, and quality of treatment.

@mtcoastie
You are very young compared to most of us. I was 76 when I was diagnosed and I am 79 this year.

What your doctor told you is what most doctors say with a 3+3=6. It is the lowest Gleason Score that will be given. Basically and not coming a medical expert just from my experience not much differences in cells.

I know if I was 52 when started having this I would have been probably in same frame of mind like you. What was your PSA number?

What is the prolaris test? I am not familiar with that. I would be really adamant with your doctors in what is important to you as only you not us can determine your course of action depending not only on physical health but your mental health.

What ever you choose to do I wish you the best. If you are still in doubt of what to do I would consider a second opinion to help you decide. When was your biopsy done. How long has it been since you got the 3+3=6?

In addition to numbers, you also have to consider your mental state and risk tolerance. If I was a 3+3 I could stay on Active Surveillance forever, but I was a 4+3. I did SBRT and six months of ADT. It doesn't bother me at all that my prostate is still physically inside my body. Several other people I know who've had prostate cancer are more of a "get it out of me!" mindset.

You've also got to consider aggressiveness of treatment you're willing to undergo. As a Gleason 6 you have a lot of options, even if you cross over into G7. You can choose super aggressive treatment but likely have more side effects while bumping up your chance of remission or you can be less aggressive and still have a good chance of remission with less side effects.

I was told six months of ADT was Standard of Care (SOC) and would give me an 80% chance of remission at 10 years but that 18 months might bump it up to 85-90%. I chose the former and am good with that decision. I wouldn't do anything less than SOC but that's me.

Ask your providers about ‘seeds’ .Mine said find someone who can do it. External beam radiation
must pass through healthy tissue
which limits the dose. Interstitial radiotherapy/ Low dose brachytherapy or seeds bypasses
tissues outside the prostate. Therefore the dose is optimal because it works over weeks or months. It is not taught at an adequate level in USA urological residencies to achieve competence. It is poorly compensated compared to External beam sources. Check out
Brachytherapy 101 a YOU-TUBE
video produced through the Prostate Cancer Research Institute (PCRI.org)

As has been said, you should get a second and third opinion by talking to another 1-2 urologists and radiologists. Have you looked into focal therapies (HIFU, TULSA, IRE)?

That said, if I had your cancer I would probably go on AS to delay RARP or RT for as long as can be safely done. But preferences differ.

Sorry you are in the low Gleason treat or not conundrum.
And as a layman, I certainly am not an expert.
However, my sense after reading both of your posts is that you would be more comfortable in the treatment category because you said so and particularly because of your family history.
I second the suggestion to have a 2d opinion from a COE for comparison.
Also like the suggestion of seeking professional PT assistance for kegel/pelvic floor training. Your episodes of incontinence sound a lot like post RP experience which often respond favorably to PT.
Best wishes.