MSK Experience - RO vs Surgeon

MSK is a really good place to go for treatment. You do have a very mild case with the Low percentages of four. You could go on active surveillance, but with three sevens I don’t know if I would want to. Because it is such a mild case, it’s understandable that the radiation oncologist feels they can knock it out. You have to realize that the people that come here are those that have problems more than those that recover and don’t have problems ever again. That’s a high percentage of people.

Being 59 you do have a lot of years ahead of you. If you get radiation, there are a lot of future solutions, And you may not need them. Many of us are waiting for the future and new drugs and hanging onto what’s available now.

Some in here would tell you take a look at Tulsa PRO Because it could knock out what you have and still leave radiation as a possibility in the future. There are other types of focal therapy that work similarly.

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.

If you do pick radiation, the below information gives you the options available to you. If it comes back, it is not guaranteed to come back in the prostate area so that may not be a problem.

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

No cribiform, no intraductal or any of the otehr things you mentioned. RO at MSK tells me less than 10% chance of this recurring and the majority of the time comes back in the same spot and is treatable. Metastasis risk appears very low with Artera score of 2%. I understand the mental “burden” that may come with radiation vs surgery I just like those odds assuming they are accurate. What is hard is when a surgeon makes you feel as if you are making a risky decision by going with radiation at my age……..that’s just not what I’m reading and hearing from RO’s

@broderbund1
Because your case is so mild, the RO’s feel they can treat it without future issues. The surgeons don’t look at the options you have if it comes back, Options I have outlined above.

@jeffmarc

Thanks…but just to confirm the article is regarding focal treatment salvage options and not SBRT …correct?

@broderbund1
The article is in reference to having radiation first and what treatments are available if you have a reoccurrence after radiation, and your PSA starts rising.

I would just want to add that all options for treatments after primary RT and BCR are "possible" but with VERY specific requirements. Not everybody will have those options.

Each of the methods will be limited by patient's status in regard to urinary status and ED level and also colorectal SE that appeared after initial RT.

Also, there are other parameters that would make or not make somebody suitable for post RT treatments, inclooding but not limited to level of PSA at BCR, presence of mets., age, comorbidities, etc .

For example - salvage RP is associated with poor functional outcomes and high complication rates and about 25% get severe incontinence. Salvage RP is performed on patients that have more than 10 year life expectancy, PSA less than 10 with no lymph-node involvement, no mets , and pre initial RT gleason must have been less than 8 and clinical stage T1 or T2 before primary RT therapy ! Now it is way to many requirements IMHO to even be considered to have salvage RP. : (

And this goes for every other "option" for treatment post primary RT. Every single one has it's own limitations and special guidelines when and if it can be done. Urinary status, colorectal SE, comorbidities, age, lymph-node involvement, mets, pre initial primary RT findings (gleason, T, pre initial RT PSA level ).

BTW, as a side note, HIFU (as post RT salvage) has 2-year relapse free time considerably lower than other methods.

There is a bias towards what a doctor knows so Urologists tend to prefer surgery (especially for younger patients) while ROs tend to prefer radiation. If the surgeon was recommending radiation and the RO surgery, then you would have a problem. Check the RP nerve sparing post on this board if sex is important to you. Surgery side effects tend to happen immediately while radiation side effects can take a few years to manifest as damaged healthy cells create scar tissue. With all of the 3+4 on one side you can also look at focal therapy combined with AS. Less side effects but a higher risk of recurrence (reason AS is still required). There is no good treatment for prostate cancer. You have to pick your poison based on what will give you the best quality and quantity of life since no treatment maximizes both.