81 with localized grade 3: I want quality over quantity. Thoughts?

Watchful waiting, Now known as active surveillance, It’s not really a great idea for somebody with 4+3. How much cancer did they find what percent and how many 4+3 or 3+4 cores did they find? What percentage of four was found in each.

You usually don’t want to consider active surveillance with a 4+3. That can lead to early even more aggressive cancer.

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.

You could consider focal therapy. Instead of radiation that would protect you so that if it comes back, you could have radiation or surgery, though at your age, they would only want to do radiation. With focal therapy, you do not have the problems with urinary retention or ED.

Here is some of the latest information on focal therapy
https://howardwolinsky.substack.com/p/focal-therapy-in-the-spotlight-landmark
Here is the full UK article
https://www.sciencedirect.com/science/article/pii/S030228382602169X

Once you get into the eighties the probability of testosterone never returning after ADT treatment ends is much higher. You probably should avoid if quality of life is a consideration. If doctors suspect micro-metastasis that can be treated with IMRT. Much better than in the past at minimizing side effects. If biopsy cancer is on a single side than focal therapy is an option. If you decide not to treat and the cancer spreads your only option will be ADT with ARSI for as long as that suppresses the cancer.

I'm 10 years younger than you and was diagnosed with Gleason 9 (5+4) that had already metastasized. I've been on ADT/ARSI for 14 months and had IMRT to prostate and SBRT to bone mets. Side effects are apparent but not debilitating. If, knowing what I know now, I was diagnosed @ 81, I would have no problem following the same treatment plan. That said, one of the unfortunate things in combatting this disease, is that no two people react the same to treatment protocols so my experience may not be yours. Also, only you can define what acceptable quality of life is for you. Be thorough in your research and in questioning your care team. Best wishes in your treatment decision and outcome.

I would take a look at Tulsa Pro given the info you have provided It is a focal therapy, but it is done in an MRI in real time so they can monitor the temperature and the lesion to make sure they ablate the targeted area completely. I had it done at Mayo Rochester two years ago for my 4+3 with cribriform. I just completed my 2 year follow up and there’s no evidence of disease. It has a much lower risk of side effects than radiation or surgery. Does not have a lot of long-term data yet but early results look promising. If you click on my name, you’ll see my review of Tulsa.

@mjp0512 Thanks so much for the reply. It's helpful.

When you mention a “negative PSMA PET” scan, did anything light up at all?

“Watchful Waiting” and “Active Surveillance” are two different protocols.
> Watchful Waiting: https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/watchful-waiting-for-prostate-cancer

> Active Surveillance: https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/active-surveillance-for-prostate-cancer

If you want to know whether or not ADT is necessary, get the ArteraAI prostate test. ArteraAI assesses your biopsy tissue to predict whether you will benefit from hormone therapy and estimate long-term outcomes.

> With your 4+3=7, what % of that was “4”?

My oldest brother (80y) is currently going through treatment for Grade Group 3 prostate cancer, Gleason 4+3=7. He already completed 28 fractions of IMRT (photon) and is halfway through two years of ADT (due to suspected spread to lymph nodes).

During April-May 2021, for a Grade Group 3 prostate cancer, Gleason 4+3=7, at 65y I had 28 fractions of proton radiation + SpaceOAR Vue injected + 6 months (two 3-month injections) of ADT.

I had no serious side/after-effects from the proton radiation: no GU, GI, rectal, or ED issues. The ADT did result in muscle atrophy (& 33% loss of strength), complete loss of libido (but no ED), and mild warm flashes. Those recovered once the ADT left my system & testosterone levels returned. (A robust resistance-training exercise program helped minimize ADT side/after-effects.)

(I considered brachytherapy. But, 3 guys I knew (high school classmates) all had serious urinary and ED issues with that treatment. (They told me that other guys they knew had similar outcomes.) So, I ruled that out early on. That was back in 2019.)

You can have both quality and quantity. It depends on the treatment decisions you make.

I made it clear to my medical team that successful treatment and quality of life were equal priorities for me. (These priorities are not mutuality exclusive.) That laid the foundation for open and clear discussions and coming up with a game plan that suited my personal goals.

I’m still active - lift weights 2-3 times per week; go on long walks with my wife; travel often; swim regularly (I’ve swam 84 miles so far this year; goal was to swim 100 miles; I’ll clearly make that). My relationship with my wife is good. Some time after treatments were over she told me that if she hadn’t known I was undergoing radiation treatments, she wouldn’t have realized it from any change in me. (That’s how benign this process can be.)

I spend a ton of time with my young grandkids. Life couldn’t be better.

This will work out well for you.

I was diagnosed earlier this year. I'm 76. My PSA had gone from just below 3 to near 7 in one year. The digital rectal exam seemed normal. The MRI report was "PI-RADS v2.1 score 5: clinically significant cancer is highly likely to be present.... Bilateral seminal vesicle invasion seen", although there were no other indications of spreading outside the gland. The biopsy showed: Grade group 3, gleason 4+3, seminal vesicles involved, cT3b.

So, some of this sounds like you.

I have been treated with photon external beam with an HDR brachytherapy boost. I decided I would prefer this combination as appears to give the best odds of the longest recurrence free period. I liked the sound of a long recurrence free period or cure, compared to a long overall survival.

The "industry" seems to think if two treatments tend to produce equal overall survival times the treatments can be described to patients as giving roughly equal results. A patient who has surgery then salvage SBRT radiation then lifelong ADT then whatever the latest last ditch treatment is by then who lives as long as another patient who is treated and cured and dies after about the same time are actually said to have experienced treatement giving about the same result.

Many doctors in the US seem to think brachy is obsolete, or more dangerous, or that external beam RT is now as good. Dr. John Sylvester gave a presentation at a symposium in 2024 rebutting all of this that I found convincing.

With radiation, apparently there are acute side effects, and later developing ones. I've made it through the acute side effects. Things went differently than I expected though.

I was amazed there was nothing that bothered me after the HDR. Supposedly the acute side effects of HDR can be a problem. I braced myself for that.

But I crashed after finishing the 20 sessions of external beam. The fatigue surprised and depressed me. I looked and felt many years older. When I did manage to go out I'd see a lot of very old people shuffling around looking like life was a burden. (I live in a town where 45% of the population is retired geezers). I realized, that's what I look like now.

All food tasted horrible. I lost about 5 pounds really fast, until I started forcing myself to eat even if I could barely keep it down. When I breathed out it felt like my lungs were expelling something bad. Diarrhea was bad. My butt got so sensitive I dreaded taking a crap. It was painful even to use a bidet. Resting did not improve things, no matter if I stayed inactive all day.

After about a week I could feel a slight trend towards improvement. Each day from then on I'd feel just a bit better. I'm back to what I was prior to the radiation now - a bit more than a month later. Improved LUTS, no bowel symptoms at all, energy level good and still improving, great mental outlook. When things are as bad as they were, it feels wonderful to come back to life.

So all is good. I'd go through this again, no problem, for the chance of a cure the data I looked at shows.

My improved urinary symptoms are probably due to the treatments reducing the size of my gland. It seems also due to the fact the operators may have managed to avoid blasting anything that would have made things worse. I had a rectal spacer.

I thought it might be better to have some sort of procedure to improve urinary issues prior to radiation treatment. Many docs advocate this. Mine did not. There are tradeoffs with anything the docs do. I went along with not doing anything.

My radiation oncologist is the chief of brachytherapy at Fred Hutch in Seattle. Fred Hutch is the closest NCI designated cancer center to where I live. I came to trust and respect him, which helped me accept what was happening to me a lot. I felt he placed a very high priority on doing the least damage to his patients while giving them the best chance he knew how to give.

He used rectal ultrasound to guide his HDR. MARS sounds better. With brachy I think it is more important to have the most experienced clinician doing the work as opposed to if they are using the latest equipment. If you've got a doc you like who is using MARS that sounds ideal.

My doc also supervised the photon external beam. The facility has an Ethos Hypersight which is a fairly new design that uses cone beam CT. It has some ability to modify the treatment plan on the day, and apparently it can shut its beam off if it is set to do so if it detects the target has moved. MRI sounds like an even better imaging system for this type of thing. I liked the sound of MRI-Linac, but I would have had to transfer my care out of state.

What I had no idea about was what an assembly line process external beam treatment is. You'll see. The operators of this machine at this facility were aiming to treat patients every 15 minutes. Compromises are being made. I have no real idea what they are. The operators deal with the fact they know what they do is not perfect by consoling themselves, if they've been around long enough, with how much things have improved over the butchery and mayhem they know has gone on in the past. I'll find out depending what long term side effects I develop.

2024 Southwest Prostate Cancer Symposium https://grandroundsinurology.com/scottsdale-prostate-cancer-symposium-2024/

PS. My PET scan result was: "IMPRESSION: Negative PSMA PET. No uptake in the prostate. No evidence for metastatic disease."

I've always thought this means the PET proved nothing. The "no uptake in the prostate" means it couldn't pick up cancer where the biopsy proved there was cancer, so what difference could it make if it couldn't also pick up any evidence of cancer anywhere else?

At the time I understood this meant my cancer was one that was not picked up by the tracer that was used. My community urologist stated he was not aware of any other tracers that might work.

My RO at Fred Hutch proceeded as if the fact a PET showed there was no proof of metastasis, he could treat as if there was no metastasis. Its all a crap shoot.

There are other tracers. There is a detailed discussion about these in a P.C.R.I. video “2026 Mid Year Update Q&A | Mark Scholz, MD and Mark Moyad”

Had I known this prior to treatment I would have discussed why not use them with my RO.

@climateguy Can't tell you home much I appreciate your response.
I'm 81. Reasonably healthy. Never been a patient in a hospital & active. I'm weighing the possibility of the various available treatments to my life expectancy. Given the fact that I feel perfectly fine now & might have 10 years left, how much time should I spend letting the treatments making me feel awful either temporarily or permanently. If they cure the cancer, but the patient wishes he were dead, what has been accomplished. I am fortunate that I am 10 minutes from MD Anderson Hospital. I haven't made up my mind what to do yet, but you taking the time to describe your experience is very helpful. Thanks

@brianjarvis What can I say! Thanks so much for the encouragement & real experience description. You've been very helpful. BTW, I'm in Houston & will bee seen at MD Anderson. Stay well. Peter