Deciding between radiation and prostatectomy

I am was recently diagnosed and going through the same decision process as you. Age 63, , 3+4=7, contained to the prostate. Otherwise, in good health.

I listened to both the surgeon and the radiation oncologist, who both said for my situation, there was equal outcome of being cancer free at 10 years. Their advice was very similar, choose between which procedure whose side effects bother you the least. To me, they are making it sound like, "Hey, it's just a coin flip. Whichever one you choose, it's good."

I think that is absolutely the wrong approach. (at least for me).

I reframed the treatment decision question this way. "If there is recurrence, which initial treatment gives me the most treatment options later?" Why? Because lots of people have recurrence (both surgery and radiation) and the followup treatment journey sounds challenging. My doctor (who is a national expert) said that for my particular case, recurrence with surgery is 10 percent. Recurrence with radiation would be 13 percent.

With that frame of mind of making the decision based on recurrence treatment and not initial side effects profile, I am choosing surgery 100 percent. It allows you the option of radiation as a follow-up and then all the rest of the recurrence treatments.

I am not the expert by a long shot, but I've been working hard on learning. Here's what I've learned ...but so much more to learn!

If you start with radiation, surgery after is not an option because a radiated prostate shrivels and binds to the bladder/rectal wall and would cause too much injury to those tissues if surgeons attempted to remove the shriveled prostate.

Also, full radiation after IMRT is not an option because repeated radiation toxicity to those areas leads to serious injury to the bladder/rectum. This would create significant bladder/rectal problems that has a huge impact on quality of life (QOL).

However, with surgery, you can follow with IMRT or various other treatment options.

So, I locked in on surgery as my only choice. It allows me the most options for recurrence treatment later if I should need it.

This is based on me being relatively young and good health.

Second, if you chose surgery, make sure you find a surgeon who has done at least 250 RP surgeries. There's a really good chart in Dr. Patrick Walsh's book, "Guide to Surviving Prostate Cancer" (worth getting!) that shows that it takes a surgeons about 250 surgeries to actually master the surgery to lead to best cancer removal. It's a really difficult surgery. As a mater of fact, the chapter on radical prostatectomy repeats this theme over and over....get to a center with a truly experienced RP surgeon. Yes, it's written from a surgeon at a center, but the recommendation is backed up with research studies and data.

In doing my homework and help from folks on this forum, I actually switched from my local urologist who had done 100 RP surgeries to the same center as the co-author of the book. I had my pre-surgery consult with my new surgeon, Dr. Kent Perry Jr. at Northwestern in Chicago, just yesterday. When I asked how many RP surgeries he had done, I was hoping for that magical 250 number. Turns out, he has done 1,500 RP surgeries. He's using the latest methods to protect not just the nerve bundles, but also the other supportive structures around the prostate. Experience definitely counts because imaging only tells you so much. Surgeons have to get inside and then make decisions by what they find out during surgery. So, knowing how to make good decisions in the moment is key.

It's not an easy path, but I am now secure in my personal decision.

Radiation surely is the right choice for lots of people. I did actually explore the radiation option very seriously. I got the Prostox test (which predicts whether you are more likely to be affected by late toxicity from radiation treatment) as well as the Decipher test, which shows how aggressive your cancer actually is. In my case, I got a wonderful Prostox result, showing little risk of late toxicity. My Decipher test was less than happy news, showing my cancer was on the aggressive side (.61, just crossing the line from intermediate to aggressive). Because of that, my radiation oncologist recommended IMRT plus six months of hormone therapy. I had already locked in surgery, but I was like, "Hell no, I definitely do not want to start with hormone therapy if I don't have too." It just confirmed my decision to go with surgery. But, I did explore the options.

There are lots of incredibly kind and helpful people on this forum that have helped me a lot already! Good luck with your decision making process.

Thank you all for your insights. What is EBRT? Sorry, newbee here. I will see the urologist in a few days for the radiologist's report of my PET scan. I had 3 of 15 (20%) cores with the more aggressive form of cancer. My older brother had 50% of the cores with the same thing, so the dr. used the DaVinci surgical approach and he has been clear since then, very little complications, 2 weeks on the catheter to let the ureter heal up.

Not an EBRT expert, so not chiming in. Also, not an expert at staging, but I think a PET scan identification of "aggressive" cancer just indicates that is active cancer and is not the same as a Decipher test, which actually looks at the cancer cells from the biopsy samples and is a better gauge of whether cancer is aggressive or not.

Others who know more, please chime in.

Super glad to hear your older brother is doing well!

Suspect that if prostate cancer runs in the family, genetic testing is a good idea and perhaps if you have sons, to have them start screenings at an earlier age. Stuff I think about as a dad with a son.

@drcopp
EBRT is just an old radiation technique. It probably is IMRT not EBRT. VMAT is even better targeted version using 3-D.

More information

Intensity-modulated radiation therapy. (IMRT) is a highly advanced form of external beam radiation therapy (EBRT) that offers superior precision, allowing for higher, more effective doses to the tumor while significantly reducing toxicity to nearby healthy tissue compared to conventional, older EBRT techniques. IMRT is generally associated with fewer bowel side effects and lower rectal toxicity, making it a preferred choice for treating localized prostate cancer.

I chose radiation (28 sessions) after a 2nd biopsy, a year later than the first, indicated 3+3 had gone to 3+4. I was 73 generally in good health. I first decided against active surveillance since it was getting worse, although my Decipher score was thankfully low. Could have gone either way on mode of treatment, but I've been emotionally stressed by this all year and was not feeling "up to" the hospitalization and catheter for a period of time. Obviously both treatments have potential side effects and both relatively equal success in resolving the PC. So it comes down to subjective considerations--which side effect risks can you better get your arms around and which medical team do you feel most comfortable with?

@fritzo Thank you, Fritzo. I had two different genetic tests for various conditions, but only prostate CA came up. I had not heard of the Decipher test until now, but I think that my urologist saw something on my recent fusion biopsy that indicated mine was a more aggressive type of cells. I agree with you and so I let our son know, to start getting monitored early on.

I suggest going straight to the radical prostatectomy. People sometimes get hung up on the word "radical"...it carries a negative connotation. Radical only means "complete", as opposed to "partial." Semantics aside, "if" you decide on radiation first (I do NOT recommend), go for Proton Beam Therapy, not traditional radiation therapy. That will give you a better chance post-therapy to have the radical prostatectomy without difficulty or consequence. If you have traditional radiation therapy, your prostate will be - as my urologist said - "a scarred lump of walnut sized concrete that is very difficult to remove in its entirety." Proton Beam Therapy offers the better option because the radiation oncologist can focus the proton beam at your prostate and the proton beam will only go "to", but not "through" the prostate. There is no damage to other surrounding tissue like the bladder, bladder neck, urethra, rectum as occurs with traditional radiation therapy that not only goes "to" the targeted prostate, but also goes "through" and irradiates normal healthy tissue. In my first consult with a radiation oncologist, he told me flat out...unsolicited...that traditional radiation therapy has a nearly 100% guarantee of making you have urinary incontinence for the rest of your life...because it irradiates and damages your bladder and urethra. That is a HARD, flat-out NO for me, as a post-prostatectomy patient who has struggled to regain 98% of my urinary continence. That will not happen with Proton Beam Therapy (*guys please chime in if you have urinary incontinence after Proton Beam Therapy whether you still have your prostate or if it was removed). Good luck - let us know what you decide, and how you progress.

@drcopp My dad had Parkinson's Disease and several times had me hold out my hands to see that they were steady just to reassure him that I didn't have Parkinson's. Definitely a burden for any parent. We can't control what is passed on to us by our genes from generations past. But, medical science has made huge strides on prostate cancer, so positive thoughts for the future.

So glad I have found this group of sharing souls.
I really need the support and encouragement, and dare I say, optimism?
I am Gleason 7, 3+4 with favorable for spreading. My radical prostatectamy is the Monday after Easter and I am trying to stay optimistic.
My father survived prostate cancer and had his removed 25 years ago, so I was on the high-watch list since then. My PSA has fluctuated around 4 since then every six months, so there was no alarm. Just regular monitoring. In summer of 2024 the PSA was 3.1. Last summer it was 5 and my new doctor --suggested an MRI, then biopsy. Last April, I ran a half-marathon. This April I am having prostate cancer surgery.
My urologist/oncologist is optimistic, as I guess he should be.
But I'm praying this robotic surgery can get it all? And fearing spreading.
And ready to take on any challenge it is has gotten out.
Thanks friends, for reading

@rlpostrp Plus, add in ED issues. The stats show that radical prostatectomy and radiation treatments have equal ED outcomes at three years time after treatment....but guess radiation potentially gives you a few extra years before ED settles in. This is what the literature says, but don't know if this is what people experience.