Deciding: Surgery vs. Radiotherapy 64yr old Gleason 3+4

Apologies and thanks, copyman, I found this video while searching for the MRI guided video. It's pretty interesting, too. https://www.youtube.com/watch The link i meant to send https://www.youtube.com/watch, mainly for the portion starting at 21:24, showing how much the prostate moves during treatment.

@gently
Thanks, appreciate that.

@marlon
First time I heard somebody being told that at 67 they shouldn’t do surgery. I know an awful lot of people that have done it in their early 70s. One’s health could be a factor.

Your experience with it being found worse after surgery is not uncommon. I was a 3+4 before surgery and a 4+3 after. I know a few people that found they were 4+5 after being told they had lower Gleason scores before surgery. A biopsy only gets about 1% of your prostate, Hard to figure out what’s in the other 99%.

Lots of good advice posted by the very knowledgeable crew here.

My decision process boiled down to this: My doctors said that since both radiation and surgery had similar 10 year outcomes for someone with my profile (3+4=7, contained) that I should choose based on which side effects profile are the least agreeable to me.

To me, that is the wrong question. My decision was based on which procedure gives me the best options if there is recurrence. This is cancer and recurrence is a very real reality. For that reason, I chose surgery. It leaves open all the options for radiation and hormone therapy.

Now, with that, you've got to find a surgeon who has done more than 250 surgeries and centers of excellence are your best bet. You want a surgeon familiar with the latest techniques.

I had my made my decision, but I did explore radiation. I got a Decifer test, which showed my cancer was somewhat agressive (.61), which meant the radiologist recommended ADT therapy with the radiaton. That sealed the deal for me toward surgery. I did not want ADT unless absolutely necessary.

The question in my book; "Based on my imaging and cancer profile, which procedure provides the best options for followup treatments if there is recurrence."

I had surgery 3 1/2 months ago and progressing well. The post surgery pathology was very, very good. I am fortunate. My incontinence is so much more manageable. My ED response is very promising.

Quick bits of advice: If you do surgery, get signed up with a pelvic floor therapist. Even though my incontinence is not terrible compared to others, the therapy has been incredibly helpful. Also, get signed up with a sexual function/ED therapist as well. My ED recovery is WAY ahead of schedule. Still a ways to go, but, having good advice and a treatment path has also been super helpful.

My surgeon didn't offer these automatically, but as soon as I asked, he wrote out both referals with no delay. You just have to ask....so make sure you ask and set these up BEFORE surgery so that you don't get delayed by scheduling issues (another story).

I will say this, post surgery incontinence is largely stress incontinence (leakage on exertion), but because of bladder irritants, I deal with urge incontinence. I find the urge incontinence to be much worse. I'm no expert, but what all the doctors told me is that radiation induced incontinence is largely urge incontinence, which I feel is very challenging.

Tough decisions, but you're smart and whatever way you go, embrace the choice and know that it is the right one for you. There is always second guessing, but getting educated and then just own it. You're on the right path.

Thanks so much for the advice and I have taken all on board. I'm definitely leaning towards surgery as I think it leaves all options open. Thanks for the replies and hearing about others in the same situation has helped greatly. Tim.

Thanks for all the good advice. Tim.

I was diagnosed 2 1/2 years ago at age 70 with 4+3=7 Had all the tests Parametric MRI & Fusion Biopsy, PSMA PET scan, my PSA had gone from 4.24 to 6.29 in 6 months, hit a high of 7.29 3 months after. I chose Active Surveillance, I cut out all sugar, low carb diet, exercise, my PSA dropped to as low as 3.59 last summer 2025 and since has stabilized at 4.40 Big factor was my Decipher score was only .38 so low risk of metastasis, and my PSMA Pet scan showed my very small tumor, .12 CC was contained to the prostate, which is 50.4CC. I will be 73 in October, so far I am happy with my choice, and I feel great, no side effects from the cancer and zero side effects from the Active Surveillance. If I had only a 3+4 instead of 4+3 the choice would have been even easier. BTW I entered all my info, Gleason score, number of cores, percentage of 4 and 3, prostate size, PSA density, tumor size, results of PSMA Pet scan, age, decipher score into AI Grok, ( I assume Gemini would be about the same) really got an excellent answer, my chance of dying from PCa vs something else in the next 10 years is very small. It was my personal choice to have no treatment and just rely on AS, each person has to make their own decision. Quality of Life was my main priority, not longevity. I'm sure there are some that have no side effects ED, Incontinence, bowel issues, etc from either surgery, radiation or hormone therapy, you are the lucky ones. As I read all the posts on this forum, there seem to be quite a few that deal with some kind of side effects

@tm1a, how goes the decision making? What did you decide and what criteria helped you make the decision?

Tim,
I much wanted radiation at first because the side effects are not up front but come on later and I was hoping I'd be lucky and not experience them. I ended up going with surgery as I explain in this copy and paste from a post I made 2 weeks post prostatectomy:

"First of all, I'd like to convey my sincere and heartfelt thanks to all of you on this forum for helping me come to my treatment decision. Your knowledge, advice, and experience that you’ve shared with me either directly, or just by my reading through all your posts have been a great resource to me. And thanks to the Mayo clinic and moderator of this forum for making its existence possible. And also a special thanks to my wife for all her help, without which this recovery would be much more difficult.

After years of steadily rising PSA, a couple of biopsies that found nothing, and then leveling out at a PSA around 12, my urologist said it was time for a new MRI. The MRI done in July 2025 found a larger PI-RADS 5 tumor, and a smaller PI-RADS 3 tumor, followed by a biopsy in August, which found that the larger tumor was a 3 + 4 = 7 with perineural invasion, and the smaller one was a 3 + 3 = 6.

I started researching prostate cancer, and its treatments in July, using reputable sources such as Mayo Clinic, John Hopkins, Harvard, NCI, the health services of Canada, the UK, Australia, and the Prostate Cancer Researchers Institute which has lots of excellent videos. I came to the conclusion that SBRT would be the treatment for me. I also took the advice of a lot of these sites and got second opinions. I got a second opinion on my biopsy pathology from a center of excellence, University of Wisconsin Madison Carbone Cancer Center, and also talked to one of their docs for a second opinion. They pretty much jived with what I was getting in my own local area. I got the decipher test on which I scored high. I also had a PSMA PET scan performed on me, and it showed no spread outside the prostate capsule. Then I heard about the Prostox test that can predict future serious genitourinary complications from radiation treatment. There's one for SBRT and one for CFRT. Unfortunately, I scored high risk on both, so I had to rethink my treatment, and I decided I'd go with prostatectomy. A 3 + 4 = 7 tumor contained within the prostate would normally mean I could even qualify for active surveillance. But because of my high decipher score and the fact that I had perineural invasion, I decided I better just get it out before it did spread. Just to note, the tests like Decipher, PSMA PET, and Prostox, I had to ask for. Maybe my doctors would have mentioned them to me, but I guess because of my research, I was on top of it, and got to it before they did. So, as many other people have said in this forum, you got to be your own advocate.

I scheduled my prostatectomy, and I had it two weeks ago today. It was a RALP, using a da Vinci machine. The surgeon said it went well with no complications except one which showed up on the post prostatectomy biopsy. The biopsy report said there was one positive margin. So that worried me at first, but my surgeon said that when he was pulling the prostate out, the region where the margin is stuck to the prostate capsule tore, so hopefully that is just, you know, a little hiccup in the process and not a true cancer margin. But we'll see on my future PSA tests if the PSA declines to undetectable. He was able to save most of my nerves, so ED hopefully won't be a long-term problem, and he said he was able to do something with the urinary sphincter that should make continence come back faster."

I'm now 7 months from surgery, fully continent, able to do all physical activities as before, got about 50% erection with steady improvement, and most of all- no detectable PSA.
Hope that helps and good luck.