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

Posted by nemco1 @nemco1, Jul 27 12:10pm

I am 81 with localized Grade Group 3 prostate cancer, Gleason 4+3=7, PSA that has doubled in the past year, and a negative PSMA PET. What's your opinion on MARS HDR brachytherapy, watchful waiting, whether ADT is necessary, and realistic urinary, rectal and erectile-function outcomes in men my age. I feel fine & I am active. I am concerned that treating the cancer may be successful, but the lasting side effects will make me feel terrible for the rest of my life. I want quality over quantity. Thoughts?

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rusjr | @rusjr | Jul 28 1:43pm

FWIW as someone about the same age, and with similar numbers (localised 3+4, etc), who is also trying to decide on the best paths forward, I believe you're thinking about it the right way. In my view, my quality of life needs to be prioritized at least as high as length of life, and that is guiding my decision making process. My urologist strongly advised against surgery… and at the other end of the treatment scale, he also advised me against Watchful Waiting. Fast forward several weeks and by the end of this week I will decide from among three option: SBRT, hypo-fractionated EBRT. and focal therapy (HIFU). Guided in part by the Decipher genomic test results, the oncologist assigned to my case has ruled out ADT. (If you haven;t already discussed Decipher with your doctors, you may want to do so.) Best of luck going forward,

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nemco1 | @nemco1 | Jul 28 2:35pm

Thanks so much for the reply. Sharing your experience is very helpful. Good luck & please keep me up to date. I'm in Houston & will be seen at MD Anderson. Peter

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Jeff Marchi | @jeffmarc | Jul 28 4:46pm
In reply to @nemco1 "@climateguy Can't tell you home much I appreciate your response. I'm 81. Reasonably healthy. Never been..." + (show)
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@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

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@nemco1
People with prostate cancer seldom feel anything. It can, however, get into the bones and cause pain in a fairly rapid sequence.

You do have a low Gleason score so it’s not real aggressive, That’s why I mentioned focal therapy. Just letting it go, may not be the best solution.

My brother at 77 had SBRT radiation. Only side effect was a little bit of urinary problems, which are resolved by taking Flowmax every other day. If you can get a spacer put in and have that radiation it can give you long-term remission. My brother is now 80 and has no side effects at all.

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xahnegrey40 | @xahnegrey40 | 6 days ago

I would discuss a 6 month course of ADT and maybe short radiation course...or they could remove prostate. But at your age, maybe a lighter hand of treatment would give you the lasting results without too much side effect regret. You have some time to fiigure it out.. ADT is not too bad and 6 mos will fly by- it will stop cancer spread and radiation should dry everything up..but as Jeff says, yours is prob not one you want to just watch...your PET scan is clear so I bet they can eradicate in 6 -8 months and then you can cruise the next 20 yrs !

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ozelli | @ozelli | 6 days ago

A Gleason 4+3=7 in isolation doesn’t mean that much to be honest. How many cores were positive, % of #4, etc adds a lot of meaning. Same with a PSA that doubled….3 to 6 is quite different from 15 to 30.

Can you provide more information?

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climateguy | @climateguy | 6 days ago
In reply to @nemco1 "@climateguy Can't tell you home much I appreciate your response. I'm 81. Reasonably healthy. Never been..." + (show)
Profile picture for nemco1 @nemco1

@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

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@nemco1 You could consider definitive therapy but no ADT.

If you are T3a or less, take a look at the TRIP study. For patients with localized PCa of any risk group as long as there was no proof the cancer was outside the prostate, if they had external beam plus brachy boost, there was no difference in any measurable outcome between the group who had 30 months of ADT and the group who had 6 months. Dr. John Sylvester, who is one of the most experienced brachy docs in the US, tried to run a study comparing 6 months of ADT with no ADT for patients treated like this but couldn't get patients to enroll - patients didn't want to be randomized to ADT or not as they were either willing to take or they weren't. He wonders if any ADT is useful in patients treated like those in TRIP.

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jime51 | @jime51 | 5 days ago

I totally understand. I turn 75 in a couple of weeks and have recently finished 18 months of Orgovyx and had 44 IMRT treatments in spring, 2025. Sex hasn't been possible, I've gained weight, hot flashes and a good dose of fatigue remain along with radiation proctitis for which I'm taking hyperbaric oxygen treatments. When I told the doctor that I really was just hoping to get to 80 without dying from prostate cancer (there was node metastasis), he was more concerned about eliminating it entirely. Treatment takes a toll. I would recommend having the best diagnosis available, with a second opinion to confirm, and taking the least severe treatment that statistically will give you the years you'd like to have remaining. Hopefully, that can be some localized radiation without additional ADT. Take the disease seriously, but choose wisely. I heard the word "cancer" and was off to the races.

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copyman | @copyman | 5 days ago
In reply to @brianjarvis "When you mention a “negative PSMA PET” scan, did anything light up at all? “Watchful Waiting”..." + (show)
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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.

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@brianjarvis Hi, You posted you knew of several people who didn't have success with Brachytherapy and had urinary & ED issues. Since you said that was back in 2019 I'm assuming the brachy these men had was "LDR" Brachy (seeds implanted)? The "HDR" brachytherapy as a boost with short course of RT or as mono therapy is being done at most COE's with 85%+ success rate and way less than 5% +2 late term urinary toxicity. Reason why many COE's are no longer doing "LDR" is late term side effects and much better success rates with "HDR". The ED may be an issue with any treatment along with most men are older and would be getting age related ED anyway.

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clevelandguy | @clevelandguy | 5 days ago

Hi,
If it was me I think I would go with some form of external beam radiation and possibly a short term of ADT drug before and after the radiation. Your right, quality of life does count so make it easy on yourself but effective. Some of the newer type of ADT drugs like Orgovyx seems to have less side effects and are easier on your heart than say Lupron.

Dave 3+4

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oldgreenpaint | @oldgreenpaint | 5 days ago
In reply to @climateguy "I was diagnosed earlier this year. I'm 76. My PSA had gone from just below 3..." + (show)
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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.


External beam with brachy boost also appeared to me to have the best chance of allowing safe reduction of ADT time compared to any other treatment aimed at a long period of freedom from recurrence. Dr. Nelson Stone presented convincing arguments at that same symposium about this.

I did my best to figure things out prior to actually being treated. In retrospect I was stumbling around in the dark. Now that I've had the 20 sessions of external beam and one session of HDR, I don't regret the choice. I feel there was a lot of luck involved.

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/

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@climateguy Man, did you really nail it!

Especially this excerpt, because the technicians said nearly the exact same thing to me. I was telling them that I was in pain, not feeling well, 3 sessions into a five session sbrt. If I had it to do over again, I would spread the radiation out over a longer period.

Your words below……..

“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.”

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