Radical Prostatectomy vs. Radiation therapy?

With 4 lesions and that high of decipher score, you will need to try and put as much of your work pressures to the side and concentrate on your health. I know this will not be easy.

I have not had treatment, yet. No info I can share, other than what I have been studying.

One option you can research:
Some form of external radiation with HDR Brachytherapy boost. This is a combination of radiation from the HDR to the prostate and external radiation to some of the surrounding tissue with the external radiation.

Genetic testing along with testing for radiation tolerance/toxicity (Prostox test) will help you have better info for treatment decisions.

Best wishes

I am a 74, still waffling between SBRT and Surgery.If you have not looked into nerve sparing surgery you might want to at least consider it.Ash Tewari, MBBS, MCh, senior author of the study, chair of the Department of Urology at the Mount Sinai Health System.Our numbers a bit different but I am an older you workwise, with the same concerns.I also might recommend some of the videos if you have not already watched on PCRI.org My best to you, Ray
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Mayo Clinic Connect
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| @pnutbarm made their first post to Prostate Cancer Support Group.

Their discussion:
Radical Prostatectomy vs. Radiation therapy?
I'm a 65 year old very active workaholic male. I have a 100+ year old restaurant that is/was family owned and operated. Now there is just me as the remaining owner/operator. I'm also a part time professional stage technician (a passion of mine) and this job involves heavy lifting work.
I was diagnosed with stage 2b prostate cancer, 4 lesions 3+4=7 with a decipher score of .96, which I'm told is very high risk to metastasize. I had a PSMA PET scan and it shows, fortunately, that, at this point, there is no spread.
I'm very concerned about all options and their side effects. Biggest concern regarding surgery is incontinence, second is ED followed by the necessary time away from my business, which I am integral to the daily operation.
Radiation seems, with the issues stated above, like the best option, however I'm very concerned about long term health of other neighboring organs and the inability to due surgery post radiation if a reoccurrence should happen. Any thoughts/advice.
None of the listed concerns with exception of incontinence will prevent me from doing what is necessary for best long term outcome. Appreciate any thoughts and/or advice. Thank You, Michael
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I agree with @charlesprestridge - take care of #1 right now because YOU are everything: your life, your business, your passion.
Anything happens to you, it ALL goes away. We all think our jobs, businesses cannot survive without us - HAHA!!
If you can’t trust anyone to run the place, pay everyone 2 weeks salary and put a sign in the window: “Closed til June 5 for Repairs…”
Have your surgery and go back to work. Your customers will be thrilled when you re-open. MANY of us have done it!
Phil

I am a workaholic myself at my own multiple businesses that I have birthed, nurtured, and worked the hell out of because of the addictive joy of doing your own thing. BUT STOP EVERYTHING NOW! You have no time or you will lose it all as well as any friends, family, and personal joys you have in the world. As others have noted, with 4 lesions and a super-super-high Decipher score, you will die and painfully lose it all unless you take care of yourself immediately!

I don't mean to be dramatic, but the simple fact that you came to this forum means you are looking for us to explain how dire your situation is and beat you into submission to get something done.

It may have already spread and the PET scan simply has not picked up the individual cancer cells that will soon take over you. It may spread while you're on hold trying to get a second opinion, so start finding that opinion now. Go to a Medical Oncologist to get objective opinions of surgery or radiation. Seek out second opinions of Urologists, oncologists and seek them out now! It may take time to set up appointments and get scheduled, but you don't have time.

Mr Workaholic, put your business on temporary closure and take your skills of persistence, finding the best solutions, hiring the right people, and simple gut-feelings to create the business of saving your own life. Find the best place, hire the best doctors, and implement the best modes of treatment that you can find. The restaurant will wait, your loyal followers want nothing else but to keep giving you their business for a long, long time after your return. You will disappoint them if you do not return for them. Use your wits to figure out how to strategically put your business on hold...and use your intelligence to find your own solution. Effective workaholics don't dally, they put their eagerness and urgency to work. So do it!

Now that I've taken a breath form my own panic reaction to your post, I've got some more thoughts. You stated "Radiation seems, with the issues stated above, like the best option, however I'm very concerned about long term health of other neighboring organs and the inability to due surgery post radiation if a reoccurrence should happen."

Modern radiation treatments are effective and precise. There are slight differences between precision's whether it is Proton or Photon, and many discussions herein on that, but all are very focused on saving healthy tissue and minimizing exposure except where its needed . With modern rectal spacers (I used a recently approved BioProtect) and following the Full Badder/Empty Rectum protocols tightly, will provide good exposure from unintended targets. There is virtually no incidence of radiation treatments causing cancer in healthy organs.

Recently advances in radiation administration further reduce exposure of healthy tissues including "Adaptive Radiation" systems which track in real time using MRI, or near real-time using CT scans, while the radiation is being delivered. If the prostate moves just slightly during treatment, or gas occurs, or your bladder fills during and shifts position- the treatment stops until the target is re-positioned, and starts again.

I chose RT over surgery because of the potential incontinence, recovery time, and the reported need to do endless kegels and PT for success. Who's got time for that? During my radiation treatments, and online here, I met many men whose surgery failed to get stray cells and they are being irradiated anyway. The notion that post-prostatectomy treatment is impossible is an old notion, mostly told by surgeons who just aren't familiar with modern radiation.

Most people can work though radiation treatments, although fatigue is the limiting factor-- not so sure surgery is any less fatigue causing though. Many people go right from treatment to work. Being the Boss and owner has different demands, but those are considerations.

Best of luck in your decision. This seems like a ridiculously complex and frightful choice to have to make - but it is empowering once the decision is made which way to go. Just go do it!

At 65y/o (in 2021), I had the same decision to make. Though retired, both successful treatment and quality of life were equal priority for me (which is essentially what you’ve expressed).

In my case, I was diagnosed with a localized, Gleason 7(4+3), with PSA of 7.976.

I chose proton beam radiation treatments (primarily due to its Bragg-Peak characteristics) - 28 sessions, with 6 months of Eligard, & SpaceOAR Vue.

No incontinence, no ED, no downtime at all (except simply had to work the time into my daily schedule). Had only 1 day of adverse side-effects during treatments.

Inability to do surgery after radiation if a recurrence happens is not a big deal -
because with modern treatments there are other options - focal therapy (e.g., cryo), brachytherapy, and SBRT (because those are all very targetable), and yes even re-radiation in some cases. Surgery still ranks a distance last place.

Based on my analysis, proton beam radiation was the right choice for me.

My most recent PSA was 0.314.
I’ve attached a chart of my PSA results during my journey.

Well, you can have surgery. Your doctors are probably tell you to not lift anything heavy for six weeks. That’s going to definitely put a crimp in your stage technician side job.

I had surgery at 62. Four days after surgery, I drove to three of my clients offices and worked on their computer problems. No heavy lifting, just sitting down at a computer. I had a catheter in. It wasn’t a problem. I could go into the private bathrooms at their offices and empty my bag if I needed to. Seven days after surgery, I was back at work full-time. I didn’t move around anything heavy, but I worked full days without a problem. After the second day, the only pain medication I needed was acetaminophen. I had no incontinence after they removed the catheter, Only about 10% of people have that much luck. Most people having Incontinencefor a little while, but not long and you can use pads in your underwear. Starting to do Keagle’s ahead of surgery can alleviate some of the long-term incontinence.

Ask your doctor if they can spare the nerves. That can give you the ability to get an erection after the surgery. Even if that cannot be done, they have implants at work really well and you can have injections. You can use to get an erection.

If you decide on radiation, which works well for a case like yours, Five sessions of SBRT radiation would work well if you don’t have any aggressive issues. You have to be aware of something, however, Radiation Will damage if not destroy the nerves. You can get an erection for a little while after, but the ability goes away over time. Here’s some more information on treatment after radiation.

Were any of these things found in the biopsy intraductal, ductal, large cribriform, Seminal vesicle invasion, EPE or ECE. (Extraprostatic extensions extra capsular extensions). They can make the cancer much more aggressive.

People who have radiation as their primary treatment have been told by doctors that surgery isn’t really an option if there’s a reoccurrence. Other options are not really mentioned..

This study shows that both salvage focal therapy (HIFU and cryotherapy) and salvage surgery were equally effective at extending the life of a patient that started off with radiation.

Those that had focal therapy had fewer perioperative complications.
https://jamanetwork.com/journals/jamaoncology/article-abstract/2844900

I chose surgery over radiation, because in my opinion the accuracy of radiation is no match for that of a skilled surgeon using robot-assisted laparoscopic surgery. With a skilled surgeon, the likelihood of peripheral damage is much less than that with radiation.

And the result for me? Five tiny bandages along my beltline, no pain, & no incontinence. I resumed normal activities (eg, walking 1.5 miles) the day after release.

My husband is workaholic and he decided to have RARP. His recovery was very fast. Incontinence was mild and completely resolved in 4 months ( he did his exercises at home ). ED is recovering still but we are not stressed about it by any means. He had Decipher 1 and his gleason after biopsy was 4+3 with cribriform and IDC and after surgery pathology report showed that he was actually gleason 9 with one tiny EPE and PNI inside the gland. Those microscopic changes (such as EPE) are not readily seen on any scan, unfortunately. Due to high Decipher and cribriform + IDC he was advised by both doctors (surgeon and radiation specialist) to have RARP. RARP was also his preferred treatment since he hated an idea of 6 mos of ADT and radiation's possible long term toxicity effects. His first PSA was 0.014 but now after 7 mos it is creeping up ( now it is 0.026) and it is now question if RARP actually solved his problem. Luckily he has an option of having RT as salvage and that was one of the reasons he wanted RARP - he would have second line of defense available !
Yes, RT patients theoretically have option of salvage prostatectomy but it is not always possible and when it is, it is very complicated and long surgery that definitely has MUCH higher incidence of incontinence and ED as a result and very few surgeons know or are willing to do it ! RT by itself can cause both incontinence and ED but it develops over time, it is not immediate like with RP.

Bottom line, you will have the same results with either path you take - it really comes to what you are feeling comfortable with more as a person. There were some studies that showed that for cribriform RP gives better results but now there are new studies that show that RT gives better results - so even medical community can not agree ! IDC still has better results with RP, but I am not holding my breath that in 5 years some study will show that it is other way around. *eye-roll

All in all - I am wishing you all the best and complete eradication of PC with whatever method you choose. : ) As a spouse of workaholic ( my husband has regular full time job , and 2 startups on a side) I understand the drive - it is not only fulfilling , it also gives a refuge in times like those since focus is on productive things and not on PC - BUT, try to see PC treatment as a "project" that needs to be done ; ). I am still "working" on my husband in that aspect lol. I am now giving him "homework" and "reading material" that needs to be looked over *sigh XP

@jeffmarc I am nearly two years out from radiation treatment (26 IMRT sessions and one HDR-B session) with no nerve damage that I can tell and easy spontaneous erections with no aids needed whatsoever. I also see accounts on both the Mayo and Inspire forums of plenty of guys that don't have ED issues many years after radiation treatment. @brianjarvis comes to mind as one of many with no ED complaints years after radiation treatment. Whatever ED issues a man has before RT, he will have after RT. And of course, aging is always in play, but just based on what I read from personal accounts on the forums it doesn't seem to me like many men complain of nerve damage after modern radiation treatments that were done say, in the past 5 years.