Treatment Decision - Radical Prostatectomy versus Radiation Therapy

@dougharris, your post is so incredibly helpful. My husband is 49 with a recent diagnosis (4+3, cT3a) , and we are currently looking at Mayo Phoenix. Like you, he is very active and worried about the QOL impact of a 'wide dissection' near the apex versus radiation.

After all your research, what did you ultimately choose? And if you're comfortable sharing, which doctors in Phoenix did you find most helpful for this specific decision? We are feeling very stuck in that 'no man's land' you described."

@saba12
Getting prostate cancer, so young can be due to a genetic problem. You really should have him tested for hereditary genetic issues.

Is there cancer in his family? Breast cancer, Pancreatic cancer and prostate cancer can all be due to hereditary issues. Some of them can be treated with a drug that is not available to people that don’t have hereditary, genetic problems.

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. Look through the biopsy report for any of these words.

T3a prostate cancer is a stage III, locally advanced cancer where the tumor has extended through the prostatic capsule (covering) into nearby tissues on one or both sides, but has not yet invaded the seminal vesicles. It is considered a curable cancer, typically treated with radical prostatectomy, or radiation therapy combined with hormone therapy.

Thank you so much for your reply — I appreciate the suggestions.
Gleason 4+3 prostate cancer. MRI suggests EPE( extracapsular extension cT3a) with neurovascular bundle involvement on the right side, which is what has made the decision between surgery and radiation more complicated for us. His biopsy showed cancer only on the right side.
We haven’t done germline genetic testing yet, but it has been mentioned because his mother had breast cancer . We plan to schedule an appointment soon.

If you’ve seen others with T3a disease choose surgery first versus radiation + ADT, I’d really appreciate hearing about those experiences. We’ve received different recommendations and are trying to understand how people in a similar situation approached the decision.

In particular, it would be helpful to know:
what factors influenced the choice between surgery and radiation
whether surgery ended up being followed by radiation and/or ADT
how recovery and quality of life turned out afterward

Hearing real experiences from others with similar staging has been very helpful as we try to navigate this decision.
Thank you!!!

@saba12
He needs to have Hereditary genetic testing? It is Covered by insurance you just need to ask your doctor to do it. Some medical centers do it for everyone. Having breast cancer in the family, makes it more necessary. My mother never had a problem, but both of her sisters had breast cancer. Turns out I have BRCA2 a genetic problem that gave me prostate cancer at 62.

Has he had a PSMA PET scan? If that finds metastasis outside the prostate, then radiation is usually the direction you go.

Thank you for mentioning the genetic testing — we will follow up on that.

He did have a PSMA PET scan and fortunately it did not show any metastasis outside the prostate. The MRI suggests extracapsular extension, and the surgeons we’ve consulted feel that if we proceed with surgery it would very likely be followed by adjuvant radiation.
Because he is relatively young (49), we’re trying to think carefully about the long-term path.
If anyone here had EPE and chose surgery knowing radiation might follow, I would be interested to hear how that sequence worked out for you. And for those a few years out from treatment, how do you feel about the decision you made looking back?

Hearing others’ experiences has been very helpful for us as we try to navigate this.

@saba12
T3a can be successfully treated with radiation or surgery. Because of the EPE and NVB radiation may be preferable because of Serious side effect problems. I think it might be useful for you to attend a ancan.org Weekly advanced prostate cancer meeting. There is a meeting tonight at 3 PM Pacific time. If you get there about 10 minutes early, they will talk with you about your case and give you advice. You have to install goto meeting, Which is free to Install on any device. You just join the meeting and put answercancer as the meeting name. They’ve been helping people for 17 years. There are usually ar least three doctors in every meeting.

You have to realize that prostate cancer is a chronic disease for most people not a deadly disease. Even in this case with serious issues, you can live for decades with the treatments available.

Because of the EPE they may Preferred to do radiation, But it can be treated with surgery as well.

If surgery is chosen, a non-nerve-sparing (radical) prostatectomy is generally required. The neurovascular bundles should be resected widely to reduce the risk of positive surgical margins (PSM).
Surgery provides immediate pathological staging and the ability to detect if the cancer was fully removed.
Limitations: High-risk patients (like T3a) often require adjuvant radiation therapy afterward if margins are positive (cancer detected on the edges of the removed tissue).
Mayo Clinic Connect

Radiation for cT3a with NVB Involvement
Radiation is usually combined with long-term androgen deprivation therapy (ADT) for 24–36 months for high-risk, locally advanced disease.
Benefits: It is often preferred to avoid the functional side effects of major surgery (such as severe incontinence).
It requires a long treatment course, and there is a risk of bowel/rectal irritation.
Cedars-Sinai

Both of your situations sound very similar to mine and I was in a serious quandary as to which way to go; I ended up with surgery on 9/22/25 at age 71. Going in I knew I had Gleason 7 (4+3), clean PSMA PET scan, .89 Decipher score (aggressive), Cribriform, IDC, possible EPE, and nerve involvement (so nerve sparing surgery could only be done on one side). I did not do the genetic testing and there is no prostate cancer in my family. Post surgery confirmed these (non-focal EPE), plus clean margins, lymph nodes and seminal vesicles. Knowing that both options have similar long-term life expectancies, I chose surgery because:
1. It is very likely I will experience BCR and that I will need radiation and ADT (or the estradiol patch???) sometime in the next few years. I bike and travel a lot. I wanted to maximize those experiences while I was stronger and younger. Since the surgery, I have done lots of biking, have had several trips and I am heading to Morocco next week for a 3-week vacation. I was back on a bike (indoor) 3 weeks after surgery and felt very good after about 6 weeks. I doubt I would be doing these things and felt that good had I chosen radiation and ADT. I am trying to do all I can before any possible BCR occurs.
2. While you can do radiation after surgery, it is very difficult (or near impossible) to do the reverse.
3. I knew my surgery would result in incontinence and sexual dysfunction. The incontinence was not that much of a hardship and I just adapted. As of today it is much better and I am down to two pads a day and I am optimistic it will completely abate. I am hoping for improvement in sexual function as well, but it is on a slower track.
4. As an active person, the side effects of radiation and ADT sounded really bad to me and they would have started right away. Why go through that if I am lucky and don't have BCR and I don't have to have any treatment, or if I can at least delay the treatment/side effects for a year or more?
I remember well the quandary from the different recommendations from my surgeon and RO and from all my reading. I hope this helps a bit and good luck whichever option you choose.