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Recent diagnosis with some questions and looking for feedback
Hi, I have enjoyed reading everyone's comments and found them so helpful while my husband has been undergoing testing and diagnosis. He is A 73 y.o. male with strong family history of prostate cancer. Stage IIB cT1cN0M0, prostate adenocarcinoma. PSA: 6.2 (finasteride adjusted from 3.1 ng/mL), Grade Group: 2.
DECIPHER Low Risk, (0.15) Luminal A subtype.
The options presented thus far are - the Urologist recommends robot-assisted radical prostatectomy (daVinci robot) and he is a potential candidate for nerve sparing (dorsal hood approach). The Radiation Oncologist said as a candidate for radiation, he would treat intermediate risk prostate cancer +/- short-term ADT in conjunction with external beam radiotherapy to a total of 70 Gy over 28 fractions. IMRT-VMAT would be necessary to reduce dose to the rectum and bladder. He originally recommended 6 mos ADT therapy, but with his recent DECIPHER score, he said omitting hormone therapy is reasonable. Two primary questions I asked at our last visit were about using Prostox testing and using a rectal hydrogel spacer. He does not feel the clinical studies support the value of using the Prostox test, and did not feel my husband would need a spacer (but they could if he asked?).
Here is the rest of his profile:
Gleason Score: 7 Biopsy on 3/25/26 found cancer in fewer than half the core samples. The original lab interpreted this as Gleason 4+4 (GG4), but UCSF reviewed the same tissue and downgraded it to Gleason 3+4 (GG2).
PSMA PET: No evidence of metastatic disease.
Imaging (2/15/26): Focal T2 hypointense lesion involving the right peripheral zone at the level of the midgland and apex measuring at least 9 x 10 x 15 mm with prominent restricted diffusion and abnormal enhancement on the DCE images, highly suspicious for prostate cancer (PI-RADS category 5). This lesion does demonstrate long segment capsular abutment (> 1 cm), a risk factor for microscopic extracapsular extension (ECE), but there is no evidence of gross extracapsular extension on these images.
Pathology (3/25/26), Outside Slide Review (4/16/26):
Prostate, L post lat, needle core biopsy:
- Prostatic adenocarcinoma, focus too small for precise Gleason grading, involving 6%, (1 mm) of 1 of 1 core. - Gleason pattern 4 is present, although focus is too small for quantitation.
- Perineural invasion is not identified. This core was read as GS 4+4 at OSH.
Prostate, R lat mid, needle core biopsy:
- Prostatic adenocarcinoma, Gleason score 3+3=6, involving 6% (1 mm) of 1 of 1 core.
- Perineural invasion is not identified.
Prostate, R med apex, needle core biopsy:
- Prostatic adenocarcinoma, Gleason score 3+3=6;, involving 17% (2 mm) of 1 of 1 core.
- Perineural invasion is not identified.
Prostate, Right mid peripheral zone, needle core biopsy:
- Prostatic adenocarcinoma, Gleason score 3+4=7, involving 23% (5 mm) of 1 of 2 cores.
- Gleason pattern 4 comprises approximately 5% of tumor volume.
- Perineural invasion is not identified.
The Gleason pattern 4 in this case is comprised of glomeruloid and poorly formed glands. We feel that the volume of tumor in part D is too small for precise Gleason grading, and therefore a grade group is not assigned. Otherwise, we concur with the diagnosis of the outside institution.
The real surprise was getting the results of the germline testing - Family history of prostate cancer in his father, paternal grandfather, and 2 brothers. BRCA1/2 Analyses with CancerNext® +RNAinsight®: Analyses of 40 genes. Associated with Hereditary Cancer: NEGATIVE: No Clinically Significant Variants Detected.
He would prefer avoiding surgery, and go with the RT especially if he can get away with avoiding ADT. My main questions are about how helpful getting the Prostox test would be and whether he should ask for a rectal spacer. Thanks!
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I may be mistaken- probably am! - but I think the Prostox test is more helpful in high dose cases, such as SBRT (5 dose) and HDR Brachytherapy due to the greater impact it can have on the bladder.
The test does, however, give you a score for IMRT so it would still be useful.
The gel spacer is a toss-up because no one really knows with absolute certainty that no rogue cells have escaped from the gland; they could be lurking near the rectum and the radiation would get those too.
IMRT is incredibly precise these days; I have often described it as ‘carpet bombing’ vs ‘smart bombing’ but it really is much more discerning than that.
The beams can be shaped to go around structures (rectum especially) and cause minimal damage. The fact that the RO is already doing this in his planning should give you confidence that the spacer might not be necessary.
Still, I would ask the pros and cons of having it. Best,
Phil
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1 ReactionI can't comment on surgery as I did not have it, but I did have IMRT to prostate in Oct 2025. Cancer was already metastatic at the time, and a rectal spacer was not offered. I did ask and RO said that he does not use one once the disease has progressed beyond the capsule. Some moderate bowel urgency for a month or so afterwards that resolved quickly, otherwise no issues from radiation so far. Best wishes.
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3 ReactionsSPACE OARS is a must. No rectal colon troubles for me over two years ago.
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2 Reactions(A lengthy response…..)
Note that:
> urologists will almost always recommend prostatectomy, because that’s what they do best.
> radiation oncologists will almost always recommend radiation, again because that’s what they do best. (Though I am a little surprised that they would recommend ADT for just a 7(3+4), unless they’re trying to not under-treat it. If that’s the rationale, then OK. Studies show that ADT adds little value for 3+4 - unless there are other risk factors).
IMRT-VMAT is a good option to reduce dose to the rectum and bladder. (I used proton beam radiation.) You want them to avoid overshooting his prostate and hitting nearby otherwise healthy tissues and organs.
Regarding your two primary questions:
> Prostox became available in 2025 so, it was not available when I was treated during April-May 2021. However, if it had been available, I would have taken advantage of it. It would simply have been another datapoint in my treatment decision.
> From what I have read, even though IMRT-VMAT (& proton) is a good option to reduce dose to the rectum, I would want the extra “insurance” of a rectal spacer. (Your husband absolutely does not want to risk rectal damage.). SpaceOAR reduces what little radiation might reach the rectum by 70%. (Newer rectal spacer options these days are Barrigel and BioProtect.) Unless there’s a good reason not to use a rectal spacer, I would opt to use it. (I did use a rectal spacer (SpaceOAR Vue) for my 28 proton radiation treatments that I had in 2021, and had no rectal issues; my oldest brother did not use a rectal spacer for his 28 photon radiation treatments that he had a year ago, and he had no rectal issues. Still, I would opt for the “insurance.”)
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Here’s his (& your) dilemma - it’s his Gleason score.
A Gleason score is a pathologist’s educated, experienced opinion of what he (she) believes he sees under a microscope. Much of the interpretation of tissue slides (as well as images and scans) is often as much an art as it is a science, and depends on the skill and experience of the person interpreting them. What one sees as an 4+3, another might see as a 3+4, and another as a 4+4.
You mentioned that “The original lab interpreted this as Gleason 4+4 (GG4), but UCSF reviewed the same tissue and downgraded it to Gleason 3+4 (GG2).” There’s no way of knowing which Gleason score was “right.” That leaves you with a dilemma - do you go with the 3+4 and possibly under-treat it, or go with the 4+4 and possibly over-treat it? (When I was faced with that dilemma - a 3+4 and then a 2nd opinion of 4+3, I chose to be treated to the higher Gleason score.) If I were in his situation, I would at least get a 3rd opinion (if only to break the impasse).
Looks like the risk of ECE (and maybe it being a 4+4) may be why they brought up the possibility of using ADT for just a 7(3+4)?
See the attached NCCN guidelines for 3+4 (favorable intermediate)and 4+4 (high-risk) prostate cancers.
No PNI (that’s good!).
The pattern “4” in the 7(3+4) is small (5%); that’s good! (How one said 4+4 and the other 3+4 still hangs out there.)
It’s great that he had a genetic (germline) test to see if he inherited any gene mutations related to prostate cancer. The results show that his “strong family history” does not play as much of a role in his specific diagnosis.
It’s good that he has you in his corner and actively advocating for him. Still he (and you) have decisions to make.
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3 ReactionsHi ekdart. Regarding your radiation oncologist, you wrote "He does not feel the clinical studies support the value of using the Prostox test". As far as I could determine the Prostox clinical studies are conducted by the developers of the Prostox test. But then again, that's true for many a test or treatment option.
Because my husband had a weak stream and radiation could potenti--*probably* would make his urinary issues worse, we ordered Prostox. There are two tests: Ultra for SBRT and Standard for IMRT. Note you can score high for SBRT and not IMRT. Or the other way 'round. Then there's us.
Prostox results came back with him scoring HIGH RISK on both Ultra/SBRT and IMRT. He's an outlier, one of only 1-2% who score High for both. Radiation was OUT for us. (And yes, prior to ordering the tests, we knew all Prostox studies/papers were conducted/presented by the developers/UCLA.)
Google "Wiedhaas" (developer) "Kishan" and "Prostox" there's a lot of YouTube videos and papers out there.
As for rectal spacer, absolutely!
Last, here's 👇 what our Prostox results came back as.
Cheers
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5 ReactionsI agree with those recommending PROSTOX testing before deciding on radiation treatment. It is a simple cheek-swab test that can identify whether someone belongs to the small minority of patients who are at high risk of developing urinary and other side effects after radiation treatments such as IMRT or SBRT. Acclaimed and groundbreaking UCLA radiation oncologist Dr. Amar Kishan uses it in his practice, which shows that this is not a fringe idea.
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4 ReactionsThis recent podcast is a discussion between a urologist and a radiation oncologist about BioProtect, the latest spacer design.
https://www.prostatehealthpodcast.com/112-bioprotect-balloon-spacer-reducing-side-effects-in-modern-prostate-cancer-radiation-therapy-jeffrey-p-wolters-md-and-coyt-rountree-md/
They advocate the use of spacers even as they rave about this latest design.
Dr. Neil Desai, in this podcast https://www.youtube.com/watch
says "you know what's better than having injuries that are healable... why not just prevent the injury altogether by limiting the dose to the rectum that's what a rectal hydrogel spacer does. We do this for almost all of our patients..."
and, he looks further down the road and says: "because these men are going to live for many many years... the last thing they need is a rectal bleed when they're age 80 trying to manage afib and anticoagulants so we use spacers quite routinely"
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3 ReactionsAs others have commented, why not do the rectal spacer...?
Here's more "information" to assist in discussing with his medical team - https://www.urotoday.com/video-lectures/prostate-cancer/video/5461-rectal-spacers-in-prostate-radiotherapy-balancing-efficacy-safety-and-patient-experience-michael-greenberg-daniel-welchons.html.
Have you discussed a shorter term radiological approach - https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/167922-ultra-hypofractionated-versus-conventionally-fractionated-radiotherapy-for-localised-prostate-cancer-hypo-rt-pc-10-year-outcomes-of-an-open-label-randomised-phase-3-non-inferiority-trial-beyond-the-abstract.html
@brianjarvis makes a valid point on the GS, it's an art with some science to it, worthy of discussion and consideration. My biopsy said 4+5, my pathology report after surgery said 4+4...
Them there is the decision to treat, yes, no, when, with what, for how long, what's the criteria to -de-intensify,,, https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/168250-natural-history-of-untreated-prostate-cancer-a-comprehensive-review-of-long-term-progression-patterns-and-survival-outcomes-beyond-the-abstract.html
Keep in mind, there is no single "right" decision...there are choices, generally all will work,
There is a guy who's posted on MCC, a great writer, satirical, but he speaks frankly, his posts are at the The Oncology Underground, this post may be useful reading for you and your husband - https://nutmegphantasy.substack.com/
Kevin
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