Cancer in Prostate and Seminal Vesicles: Prostatectomy or SBRTw/ADT?

Great analysis.!!!

@northoftheborder So true, North, and these retrospective studies that look at 350,000 men treated over a 20 yr period with Gleason scores of X or Y, come to conclusions that have zero regard for contributing factors such as Decipher, Surgical path findings, etc…
You really have to wonder at the ‘scientific’ nature of these…
Phil

I totally agree with your urologist - have the radical prostatectomy, then in any year to follow, and if necessary, you have radiation, that in your case, is the great likelihood that the cancer returns. The fact that the cancer is in both seminal vesicles makes you, at minimum, a pT3b with a 25-50% probability of the cancer recurring "within" the next five years, despite your Gleason 6 or 7 status. I know, because...
I am the same pT3b. This is also a good example of how someone like me or you with what was barely a 3+4=7 (I had only 6-10% of cells being "4"), had Extraprostatic Extension (EPE) of the tumor that allowed spread into the seminal vesicles. Only my left seminal vesicle was involved without tumor or nodules...just "cells." You don't mention if your seminal vesicles were tumorous, nodular, or just cellular. The fact that you are a Gleason 6 or 7 means your cancer is fortunately slower growing..."maybe." My own doctor was quite humbled/solemn when my "barely a Gleason 7" turned out to be an aggressive cancer with the EPE, surgical margins (do you have?), Cribriform gland tissue, and left seminal vesicle involved. You don't mention having Cribriform gland tissue or surgical margins which is a very good thing (I have both).
After quoting what my doctor told me, which was that if you do radiation "first", it turns your prostate into a walnut sized piece of scarred concrete that is nearly impossible to surgically remove after the fact if the cancer returns after radiation, I decided on the surgery, and was glad that I did. The biopsy never revealed how aggressive my cancer is nor all of the additional pathology. So he, like your doctor, always does surgery first, leaving radiation as an option if/when the cancer returns.
Hopefully you have a supportive and understanding wife/girlfriend who will accept that your sex life, in terms of penetrating sex, will likely be over following the prostatectomy. Urologists give a lot of false hope to what is unfortunately the majority of us. I have been strung out for the last year by my urologist: 1) "Ya...you should be able to regain the ability for an erection and your sexual function between 6-9 months." Nope. 2) "Ya...some men take longer, so you'll probably be ready to roll between 9 months to a year." Nope. 3) "Ya...a lot of men can take up to two years before they regain the ability to have a lasting erection, but some men never do." Oh great. I am at exactly one year, and I have not had so much as a twitch down there. You can have an organism through stimulation of the Frenulum on the underside of your penis - solo or with/by your wife, but it will be without an erection.
So...bottom line, there are things we must prepare ourselves for in the post-prostatectomy life, but the key word is "life." We can all thank God that prostate cancer is, for the most part slower growing. Our Gleason 3+3=6 or 3+4 = 7 is a much slower growing cancer which will/should see you get 10-15 years of life or more. And here is the really odd news to confuse us all about the "should I" or "shouldn't I" seek treatment of any kind: My maternal grandfather lived to 96 "with prostate cancer." There were not many treatments in the 1980's until his death in 1992, but all he got, I am told, was Lupron or some other type of injection straight into the prostate every 3-6 months. He died with his cancerous prostate at that ripe old age of 96, and he died of Alzheimer's. not prostate cancer. And...my own father lived to 99 years 10 months "with" prostate cancer, and no treatment whatsoever. By the time his physician figured out he had it (PSA >200 ng/ml), and had had it for years, it was too late to consider surgery or radiation. He suffered monthly severe urinary tract infections (UTI), many with yeast/fungus that caused hospital admissions to receive I.V. anti-fungal medication for a week. He had a permanent "bio-film" of drug resistant bacteria living/growing on the lining of his bladder that constantly seeded new infections. He'd barely be off antibiotics for 7-10 days before the next infection started up. He suffered greatly his last five years with those UTI's and age-related incontinence, but he did have a long life. There are men who decide: "Hey...I am 75 years old (or 80, or 85, etc.)...I can live with this slow growing cancer for the next 10-15 years, so...I am not going to have the surgery or radiation." That is a big roll of the dice, but many do survive that 10-15 years and were grateful when they passed away. But I am sure a lot of men rolled the dice and died within five years...not a good bet, when you're just 70 years old, but maybe better when you are already 80-85. Whatever your decision is...good luck...and keep us all posted as to your journey.

@heavyphil Exactly. Peer-reviewed retrospective studies are useful, but just not in the way people think (I sigh whenever I read "A new study has shown…" in the media).

Major trials cost many millions of dollars, so they're not practical for trying out speculative "what-if?" questions. But even a grad student can carry out a respective study with just a laptop and spreadsheet program (along with access to raw data, close supervision, and ethics reviews, of course).

After a while, if study results accumulate and are reproduceable — big "IF"s — then there's justification to fund a proper trial. And it's mostly the big-trial results that shape our treatment.

Best wishes to you! My husband was 47 when he's diagnosed with PC. He chose robotic-assisted prostatectomy. His scans then showed the cancer was confined; however, the pathology report confirmed 1-mm cancerous cells in the right seminal vesicle. The tiny lesion didn't show up on any scan because it's too small. I did all researched on both options (surgery/radiation) and did the pros & cons tables for him, plus summary of the studies & trials. He read through it and made his own decision on the treatments. He did get two of second opinions before choosing the treatment and then 2 of second opinions after the surgery. Surprisingly, he had not experienced critical side effects. He has never experienced any incontinence. They kept him in the hospital for 6 days and let him come home a day after they took the catheter out. We live in Germany, so that is their medical protocol.

He had been in remission for almost 5 years until Jan when his PSA went above the threshold. He's going to start getting salvage radiation treatment in 1-2 weeks.

@charlesprestridge - Is it common for the patient to request that the tumor tissue be tested for the Decipher score? I'm wondering why this hasn't been suggested or even mentioned.
I had an RP 16 months ago, and am soon to have IMRT. PSA is at 0.07, but with close to 3 month doubling, (0.02, 0.04, 0.07). I have a Gleason 4+5, EPE, SVI, pT3b, pN1. And 8/27 lymph nodes with tumor. Seems like I'm an ideal candidate, or is it too obvious I'm in deep do-do.
I am now questioning if ADT with ARI along with the IMRT regimen is required if it's less aggressive. Often the ADT is delayed as it can cause hormone resistance.