Decipher risk: prostatectomy RP vs radiation.

I went for surgery with your exact thoughts. Seemed like the best option for work down the road. I had nerve sparring surgery at 68 otherwise healthy and sexually active. Cancer was contained in the prostate post op. I have had no other treatments. I have both ED and incontinence. Thats the fact of the surgery. You roll the dice. As everyone has said the experience of the surgeon etc. makes a difference but not a guarantee. You have options with ED. I tried the Viagra and Cialis no luck. The trimix injections work. You can also look into an implant. That was my next option. Incontinence has some options. I am looking into an AUS device. You could also try ProAct. ProAct can only be used with surgery not radiation. However, you could be one of thousands that have no issue. In any case, it is a hit to your manhood but you adjust hopefully cancer free.

I am in the middle of this process, so my knowledge is limited. I am almost 61, so similar age.

I think Decipher is becoming more mainstream and being ordered earlier in the process. My Decipher was ordered on 1st visit after Biopsy. Main reason was to help decide between Active S. versus treatment. My biopsy was gleason 3+3, but with a good size Pirads5 lesion.

I do not think (from my studies and discussions with surgeon), your decipher score will dictate a more aggressive RP. Decipher is a piece of the puzzle, to help determine treatment plan(s).

My decipher was a 0.48. Since my mri showed a Pirads5 lesion and Decipher was in the intermediate range, my doctor was able to get insurance to cover a PSMA PET scan. This was to provide another piece of information. I would see if your surgeon or radiation oncologist could get a PSMA PET scan approved/completed. This will be a bigger factor for nerve sparing. If the PSMA PET also shows no cancer outside of the prostate, this will be info used in treatment decisions.

Biopsy mapping and MRI will be largest factors on location(s) of lesion(s) or cancer cells (if no lesions are visible on MRI). If you have no extracapsular extension or are not close to the bladder, surgeon should be able to perform nerve sparing (in a lot of cases, I think).

In April, I will have a 2nd biopsy to try and determine is my Pirads5 lesion Gleason6 or Gleason7. Did initial Biopsy miss higher gleason? MRI, biopsy, decipher, PSMA, etc are are pieces of info to try and guide treatment decisions for each unique individual.

With my limited knowledge, you may be a good candidate for nerve sparing RP with no ADT. You could also choose radiation, weighing the risks of how to treat if cancer recurred in the future.

Best Wishes.

Decipher is not the only biomarker (genomic) test available to provide pre-treatment information. There are many different biomarker tests, depending on what you’re looking for:

> FoundationOne®Liquid CDx; Guardant360; Caris Assure.
> Decipher; Prolaris; OncotypeDx.

Liquid biomarker tests:
> (blood): 4KScore; EpiSwitch PSE; Phi Prostate Health Index;
> (urine): SelectMDx; PCa3 (PC Antigen 3); MyProstateScore (MPS), ExoDx.

(I’ve probably missed others.)

So, it depends on what biomarker information you’re looking for. (I had the OncotypeDx and Prolaris tests; never had a Decipher test.)
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At 65y (about 5 years ago), I had radiation first for a 3+4=7 (upgraded to a 4+3=7 immediately prior to treatment, for which I simply added 6 months of ADT) for a number of reasons, one being that should I have a recurrence, I would have more salvage options available.

“Getting the cancer out” provides no statistically significant benefit for success than doing radiation.

My thoughts went the other direction —> I couldn’t imagine starting with surgery as first course for treatment for me at age 65y in otherwise good health, initially with 3+4=7 contained Pc. (Why have surgery first and then (in case they didn’t get it all or if there was recurrence) to have do radiation also? Why not do radiation first, and then if there is a recurrence have the options of cryo, brachy, or SBRT (because they’re all very targetable), or possibly even re-radiation in some cases.)

The idea that “if you choose radiation first, you cannot have surgery later” has some historical truth to it, but is old-school thinking and doesn’t consider modern treatment techniques.

Lifelong hormone therapy isn’t really a treatment option (though, some choose that form of palliative care for some reason).

There are some things missing in your explanation of your choices.

Did you get a PSMA pet scan? That is sort of essential to decide between radiation and surgery because if you have spread outside the prostate, then you probably want to do radiation. You do say it’s contained to the prostate as that is a result of having the PET scan?

Another very important question is Were any of these things found in the biopsy intraductal, cribriform, Seminal vesicle invasion, EPE or ECE. (Extraprostatic extensions extra capsular extensions). They can make the cancer much more aggressive.
 In some cases, radiation is the best solution.

In my case, I decided to have surgery at 62 because my father had radiation and died of prostate cancer. At the time Lupron was the only drug available, these days we have a wide range of drugs that can keep the cancer suppressed.

Have you had genetic testing? That can be important to find out whether or not other drugs are available for treatment.

You don’t mention how many cores were taken in the biopsy and how many were 3+4 or 3+3. Also, what percentage of the 3+4 was tumor and what percentage of it was a four. If those percentages are very low, you could consider active surveillance. There are a number of videos you can look at that discussed that.

The decipher test is used more often these days to figure out whether or not a case is aggressive. Your result of .61 is high but we have people that are 98, 99 and even 1, which are truly aggressive. It can be a factor in deciding about active surveillance, but the percentage of four is another major issue.

I was 62 and chose surgery in Oct 2025 for the similar reasons others have detailed. Had high gleason and cribriform. Went through the necessary test cycle: MRI, fusion biopsy, PMSA PET scan - and then RARP after much research and discussions. Going through the follow-on issues that I expected- incontinence and ED, but steadily improving. Your approach will be based on your research and discussions and may result in a different choice then some of us made, but the choice is yours. While the paths might be different, we all choose what is right for us, hope for improvement, and work through the issues if they arise. Best to you and yours.

I'd suggest asking the surgeon at Northwestern, based on your tests, whether he thinks he'll be able to spare the nerves. I'd also suggest asking him what he thinks, for your specific case, what your odds of incontinence and ED are based on his experience and record. When I asked my surgeon those questions he told me he was very confident (based on the tests) that he'd be able to spare my nerves, and at 1 year I'd have a 90% chance of being continent and 70% of no ED. In my case, after surgery he told me everything was exactly as expected and he was able to spare the nerves. Of course, if things had been different when he got in there, he'd have done what he needed to do. But my point to you is don't assume either way; ask the expert what he thinks. He's seen a lot more than any of us have. Best wishes.

@davederousseau
Thanks David...so appreciate that advice on choosing your own right path. It's just so much information to process and then make a critical, non-refundable decision.

Wishing you continued side effect improvement and continued strength.

@jeffmarc

Jeff-those are really good questions and things that I don't understand yet (cribriform, Seminal vesicle invasion, EPE or ECE. (Extraprostatic extensions extra capsular extensions).

My understanding is that it is contained to the prostate and not in the sheath.

My hope is that by doing surgery, it might buy some time for additional drug treatments to be approved for any possible recurrence.

• On the biopsy, short version: The tumor is noted in 9 cores of a total of 24 cores examined and
represents approximately 5% of the entire available tissue.

• On the pet scan, short version;
1. No PET evidence of metabolically active nodal or visceral metastatic disease.
2. Mild focal radiotracer uptake in the left lateral prostate mid gland, likely related to the biopsy-proven malignancy.

•I had a Decipher test, but just have the number and not the report yet. I don't know if that tells the gene makeup or not?

•Haven't had any gene testing beyond that. But, am waiting on Prostect test results to show toxicity for low-dose IMRT.

I'll put more of the biopsy information below; not sure how to read all of it. Thank you for these really good tools....I need to learn more about what is buried in the test results. Not sure how to interpret all of it.

Thanks!

BIOPSY RESULTS
A. RIGHT BASE PROSTATE BIOPSY:
- BENIGN PROSTATIC TISSUE

B. RIGHT LATERAL PROSTATE BIOPSY:
- BENIGN PROSTATIC TISSUE

C. RIGHT APEX PROSTATE BIOPSY:
- BENIGN PROSTATIC TISSUE

D. LEFT BASE PROSTATE BIOPSY:
- PROSTATIC ADENOCARCINOMA, GLEASON SCORE 3+4=7, GRADE GROUP 2,
INVOLVING 3 OF 6 CORES REPRESENTING APPROXIMATELY 5% OF BIOPSY MATERIAL

E. LEFT LATERAL PROSTATE BIOPSY:
- PROSTATIC ADENOCARCINOMA, GLEASON SCORE 3+4=7, GRADE GROUP 2,
INVOLVING 5 OF 6 CORES REPRESENTING APPROXIMATELY 15% OF BIOPSY
MATERIAL

F. LEFT APEX PROSTATE BIOPSY:
- PROSTATIC ADENOC
ARCINOMA, GLEASON SCORE 3+4=7, GRADE GROUP 2,
INVOLVING 1 OF 4 CORES AND REPRESENTING APPROXIMATELY 10% OF BIOPSY
MATERIAL

COMMENT:
The tumor is noted in 9 cores of a total of 24 cores examined and
represents approximately 5% of the entire available tissue.

Properly controlled multiplex immunohistochemical stain PTRIP
(P504S/HMWK/p63) is performed on parts C, D and E. In Part C, PTRIP
shows no diagnostic evidence of adenocarcinoma. In parts D and E,
PTRIP supports the diagnosis of adenocarcinoma which is noted in
several foci of both specimens.
•••••••••

This is the PET scan data:
PET-CT SCAN:

Accession Exam Completed Date/Time
PT15515321 PETCT PROSTATE (SKULL BASE TO MID THIGH)
----------------------------------------------------------------------------
PET-CT SCAN:

COMPARISONS: No direct comparisons in PACS at the time of this dictation.

CLINICAL INDICATION: Prostate cancer, high risk, staging
prostate cancer

QUALITY OF STUDY:Good

FINDINGS:
Head/Neck:
No abnormal focal radiotracer uptake in the head/neck region. Expected radiotracer uptake in the bilateral lacrimal and salivary glands.
No metabolically active cervical adenopathy.

Chest:
No metabolically active mediastinal, axillary or hilar adenopathy.
No metabolically active pulmonary lesions.

Abdomen/Pelvis:
Expected radiotracer uptake in the liver, spleen, small bowel, kidneys, ureters and urinary bladder.
No metabolically active retroperitoneal para-aortic, iliac or inguinal adenopathy.

Mild focal asymmetric radiotracer activity in the prostate left lateral mid gland with SUV max 3.0. This is likely related to the biopsy-proven malignancy.

Musculoskeletal:
No suspicious focal metabolically active osseous lesion.

IMPRESSION:
1. No PET evidence of metabolically active nodal or visceral metastatic disease.
2. Mild focal radiotracer uptake in the left lateral prostate mid gland, likely related to the biopsy-proven malignancy.

@retireditguy
OK-those questions are on my short list now. I didn't know if the Decipher score would make it so that nerve sparing was no longer an option or not. Surgeon would know.

Seems like a coin flip on ED/incontinence where the coin has more tails than heads....

Super glad that your surgery went so well. Thanks for the advice!

@fritzo
Your biopsy information looks good. They don’t appear to have found any of those aggressive things I mentioned, though a biopsy of the prostate after surgery is more informational. In my case, my PSA was 3+4 before surgery and 4+3 after.

Your comment about Additional drug treatments in the future is actually here already. Eight years ago, my cancer came back after surgery and radiation and I went on ADT for 2 1/2 years and when it failed and I became castrate resistant, I went on Biclutamide For a little over a year and then Zytiga for 2 1/2 years. I stopped taking it and went on Nubeqa Which has kept me undetectable for 27 months. So after 16 years, the drugs that are available today have made a major difference in my survival. There are a number of drugs that are going to be coming out in the next few years that are going to work when what I’m taking now stops working. I was reading about one study where they are turning cancer cells back to normal cells so there are lots of options available in our future. You are just starting and there is a long path ahead of you.

Now that I’ve seen your biopsy and you’ve had multiple 3+4 active surveillance is definitely not in the picture, especially with the .61 decipher.

The decipher score does not decide whether or not you can have nerve sparing surgery. It all depends on where the cancer is located in the prostate. This is something you can ask your doctor about.

After my surgery, I had no incontinence and complete ED. There are a lot of solutions for that today between an implant and injections you can use that can get a very satisfying erection. If you do have incontinence issues, they usually don’t last long and there are multiple solutions.

You definitely want to get genetic testing, talk to your doctor. They can easily do it. It’s covered by insurance.