Quandry on my chosen pathway

@dribbles The more information you have, the better you’ll be able to make a treatment decision.

With your SUVmax of 8.9, how does that compare with the SUVmax of your blood, liver, and parotid glands? (That’s how they’ll tell how aggressive it is.)

The genomic (biomarker) testing is especially important because it looks for genes, proteins, and tumor markers that tell more about the prostate cancer that might change treatment management. (I can understand about having no interest in genetic testing right now, but it may be of great value later.)

Genomic (biomarker) testing is always valuable - Decipher, Prolaris, OncotypeDx, or one of a dozen others. (Many guys today get Decipher; I had both Prolaris and OncotypeDx.)

@dribbles In a sense they are correct. You are getting treatment of some kind no matter what. Genetic issues would need to be managed later on with ADT, combos with -lutamides, PARPs, etc. if you even have mutations…that’s not something that’s going to help you now.
A Decipher test, however, IS very important since a high score could make you think twice about radiation as primary therapy; if your cancer were to recur after surgery, you would then have radiation as a back up.
Gleason 8 is aggressive; you need a Plan B and surgery (distasteful as it may be) might be your best first option all around. Best,
Phil

@heavyphil
thanks again for all the input , Phil you said "a high score could make you think twice about radiation as primary therapy; if your cancer were to recur after surgery, you would then have radiation as a back up." If the cancer were to recur after radiation I would also have radiation as a backup. Could you elaborate more on the distinction. Thanks

@dribbles
If you have radiation to the prostate and prostate bed as your initial treatment, then that area cannot be radiated again.

If you get a Metastasis somewhere else in your body, that can usually be radiated with SBRT radiation. There are some areas where it can damage nearby tissue and they won’t do it.

So are you and Phil are saying that if I have a high decipher score the chances of recurrence with Radiation or Surgery is higher. Are the odds worse that I get a total kill of the PC in and around the bed with SBRT and ADT? If so, it may require cryo or HIFU + ADT for salvage or a difficult Prostatectomy + radiation. That salvage would not be as effective as the salvage Radiation and ADT in the prostate bed after Prostatectomy? For distant recurrence it would all be treated the same likely with SBRT.
Sorry to pose all the questions back at you, it is very helpful to get my head around this.

@dribbles You probably could NOT have standard SRT available to you with BCR if you have either IMRT or SBRT (Cyberknife) as primary therapy; it is because after those tx, you have received the maximum lifetime dose in that area.
You can, however, have ‘spot’ SBRT to a node or a body part outside the original radiated field.
That is why surgery may be preferred as primary therapy in a case where recurrence has a high possibility.
Phil

@dribbles
Cryo and HIFU are used for initial treatment, not for salvage.

If you have radiation as your primary treatment it is possible to have salvage surgery, Not many doctors do it some specialize in it. The can result in permanent and continents and ED issues.

SBRT and ADT can give you long-term remission, A cure is very unlikely with prostate cancer unless you have a very mild case.

Issues are, if you have radiation there’s really no way to know what your prostate really had in it. There could be some very aggressive things found if you have surgery, but not if you have radiation. In my case, I went from a Gleason 3+4 to 4+3, I know many other people ended up with 4+5 even though they Had much lower scores from a biopsy. Those aggressive issues can make your cancer impossible to cure, even though you have a low Gleason to start with.

Just bringing these up for things to think about.

Yes, if you have a higher decipher score, it gives you a much higher chance of you having a reoccurrence sooner.

Other guys have commented to the contrary to my comments that follow: they say that there are newer/better means of receiving a long course of low dose radiation, and that they have not had any consequences…”yet.” But that is a big “yet.”
My urologist doesn’t believe in Active Surveillance, and he has repeatedly told me that if you do radiation “first”, you have just turned your prostate into a walnut-sized chunk of scarred concrete that is nearly impossible to remove “after” that radiation, if your cancer comes back. Then you’ve got a big problem.
You just have to make the decision for yourself and what you feel is best. Doctors have a lot of “art” and mechanical “skill” to how they handle their patients. They may prefer radiation first for whatever reason when weighing all post-radiation outcomes. Other urologists like mine only do the RP and radiation thereafter, if and only if the cancer returns. Some urologists roll the dice with your life and put you on Active Surveillance with absolutely no way to know what the anatomic and microscopic disease features there are to your cancer which can never be known unless the prostate is removed. The Gleason Score does not have that capability…it is a 12-core cytological “punch biopsy” procedure that only tells you if you do or don’t have cancer and how far along it might be.
Talk with your doctor, ASK QUESTIONS, talk with your spouse, talk with any male blood relatives who have already gone through this, and make your most comfortable decision.
Good luck to you. Keep us posted.

@dribbles YES. If your Decipher score is in the higher range, your chance of recurrence is HIGHER.
And the possibility of RETREATMENT is also higher.
The usual, most favorable course of retreatment is surgery FIRST followed by Salvage radiation later on (months, years, or never) if necessary.
Hope this helps!
Phil

Just a quick update to keep this going.
My testosterone reading came back at 30 after being on Orgovyx for 15 days. So that is working.
The radiation team ordered the decipher for me so that may be a turning point when that comes.
Interestingly when I posed the ? of plan B after a recurrence they said they would do either Cryo or Brachy or last resort surgery.
I would lean toward doing the PAE prior to the SBRT + the ADT I’m on now. I would get good shrinkage from the ADT and the PAE . Those 2 treatments separately will shrink the prostate 20-30%. I’m not sure what the cumulative effect would come out to.
I’ll wait for decipher score to decide.