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Trying to decide on treatment for prostate cancer
Being new to prostate cancer and from all my research it has become a hard decision what treatment to start! I have been seen by 2 of the top hospitals in the US. I'm unfavorable intermediate risk because of high PSA. 4+3. Clear PSMA & MRI (Stats below)
The treatment options offered: First is a trial with HDR Brachytherapy boost, 5 sessions of Proton therapy & 4-6 months of ADT. Second option from the other cancer center of excellence is HDR brachytherapy boost, 23 sessions of "adaptive" IMRT radiation & 4-6 months of ADT. I'm having a hard time deciding, the trial looks really good with only 5 sessions but no long term data yet (similar trials have been done with HDR brachy, SBRT, etc and good results ) but the other option with Brachy & 23 sessions "adaptive" IMRT has proven data of around 90% success rate 10 years out. They both would use some radiation in the pelvic region as well because of the high PSA. Also SpaceOar gel will be used. The PSA is higher in my case partly due to the fact the localized cancer is only in the Transition zone which will typically present with higher PSA. Was hoping someone could comment that had same or similar treatments, side effects, etc. Especially with the Brachy boost & short course of Proton or SBRT.
Really a tough decision and having a hard time deciding. May come down to a coin flip...... Thanks in advance
Age: 68, PSA 40, Gleason 4+3 Grade 3
MRI:
FINDINGS: PROSTATE GLAND: measures approximately 5 x 4.4 cm corresponding to a volume of 45 mL. PERIPHERAL ZONE: No evidence of prostatitis. CENTRAL GLAND: Moderate changes of BPH. Lesions 1 PI-RADS score: 5 Location: Right TZ Mid at 11 o'clock Max dimension: 3.66 cm (slice: 14) Volume: 9.492 ml Extraprostatic extension: - NONE
Extraprostatic Tumor Extension: Slight bulging of the prostatic capsule but no visible tumor extension beyond the capsule. Neurovascular Bundles: Normal. Seminal Vesicles: Normal. Urinary Bladder: Normal. Pelvic Lymphadenopathy: None. Pelvic Osseous structures: No suspicious osseous lesion identified.
Biopsy , 17 cores 14 cores benign, 3 cores from same area (transistion zone) (50-60% pattern 4)
(2nd opinion on slides reviewed by chief pathologist at Univ of Penn who concurred with original findings)
PSMA:
1. Marked PSMA-avid disease in the prostate consistent with biopsy-proven prostatic adenocarcinoma.
2. The minimally PSMA avid largely symmetric pelvic lymph nodes are favored to reflect reactive/inflammatory uptake. No suspicious PSMA avid lymph nodes identified.
3. No radiotracer avid distant metastases
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@johnt15
If I may ask what was your Gleason score, Prostate size, psa, and Decipher score if you have ?
Thank you...deciding
@mlabus3
I had a second opinion from DR Himanshu Nagar who is at MSK in New York city. He was at Cornell Weill when he gave his opinion to me. Very knowledgeable and his experience includes the use of the Mridian and Elekta Unity MRI guided SBRT.
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2 Reactions@ray092271
I was classified as intermediate/unfavorable
PSA was 8.34
Gleason score was 4+3
Prostate size was 32cc (I am pretty sure)
I took the Decipher 2 years ago and don't remember the actual number but was in the 4ish range. That was when I was Gleason 3+4 and intermediate/favorable
I recently took the Artera and it indicated that I would benefit from ADT, but I was right on the cut-off line and opted not to due the side effects and my radiation onocologist was OK with that decision.
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2 Reactions@johnt15
With a 4+3 they recommend six months of ADT. It will not change your life, but it could extend your life since it can kill off the cells that are trying to reproduce after radiation. Some of them do survive.
I’ve been on it for eight years, It is not a day today problem it seldom is an issue of any sort.
My brother had six months of it and so did I when I had radiation. That was before I went on it permanently a couple of years later. Neither of us had serious issues with it, Hot flashes were the biggest problem for my brother. When they put me on it for two months before my radiation, I had no idea what it would do and didn’t notice any side effects. When I had it Two years later, I had a lot of hot flashes, Strange how it doesn’t always do that.
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1 Reaction@jeffmarc
Yep, ADT is definitely the current standard of care. And I'm glad it is not affecting you. I recommend looking at the video from the PCRI titled " Intermediate Risk: Radiation without ADT" (I don't think you can post links here or else I would do it). To summarize the video, the vast improvements in radiation accuracy and pre/post treatment monitoring (PET scans, MRIs, etc) over the last 10 years, have shown that not everyone needs ADT. Granted, this is one perspective and we all need to do what we think is best for ourselves.
@johnt15
You can post links here, but you have to wait about a month after you join before you can do it. You probably have noticed a lot of links from other people.
I’m actually familiar with the NCCN guidelines which show when people should have ADT. Your PSA is not high enough to require it, but I’m not sure if you are a T2b or c or higher.
Another important thing is is 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 and make ADT more desirable.
My brother at 77 had a 4+3 and they had them on 2 3 month shots of ADT when he had Five sessions of SBRT radiation. They can have a difference on recurrence.
Here are current NCCN Guidelines in 2025. They now suggest 0 (zero) months of ADT for low intermediate (GG2); 4-6 months for high intermediate (GG3), and 18-36 months for high risk (GG4 and 5). Actually, the footnote suggests ADT + abiraterone for T3b with lymph node involvement.
The meta-analysis suggests:
* 0 months for 1 intermediate factor (PSA 10-20, GG2 or 3, T2b-c)
* 6 months for 2 or more intermediate factors (PSA 10-20, GG2 or 3, T2b-c)
* 12 months for NCCN high risk (PSA >20, GG4 or 5, T3 or 4)
* undefined for NCCN very high risk (2 or more PSA >40, GG4 or 5, T3 or 4)
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2 ReactionsAs I mentioned earlier in this thread the Proton trial I'm considering at Univ of Penn does cover the pelvis region (not sure if it's overkill because MRI or PSMA didn't show anything outside capsule) Both RO's say the PSA of 40 is the game changer. Specifically Penn Trial is Brachytherapy boost first with the SpaceOar gel & fiducial markers put in at same time procedure is being done (3-4) hrs under general anesthesia, then 2 weeks later start 5 HypoFractionated whole pelvis Proton therapy (one session per week for 5 weeks), and 4-6 months of ADT.
Or other option the "proven" treatment with long term data at another top cancer center which also includes brachytherapy but done after 23 sessions of IMRT or VMAT & 4-6 months of ADT. Just having a hard time deciding.
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1 Reaction@copyman
Either of these choices would be good. A 40 PSA is pretty high when it comes to treatment. The NCCN recommends ADT in that situation. The 4+3 isn’t the problem? It’s that PSA. Check out the NCC recommendations below, Just having a PSA of 10-20, they recommend ADT. It might make more sense to go with a second option.
Here are current NCCN Guidelines in 2025. They now suggest 0 (zero) months of ADT for low intermediate (GG2); 4-6 months for high intermediate (GG3), and 18-36 months for high risk (GG4 and 5). Actually, the footnote suggests ADT + abiraterone for T3b with lymph node involvement.
The meta-analysis suggests:
* 0 months for 1 intermediate factor (PSA 10-20, GG2 or 3, T2b-c)
* 6 months for 2 or more intermediate factors (PSA 10-20, GG2 or 3, T2b-c)
* 12 months for NCCN high risk (PSA >20, GG4 or 5, T3 or 4)
* undefined for NCCN very high risk (2 or more PSA >40, GG4 or 5, T3 or 4)