Thoughts on treatment options?

radiation- prob 10-15 sessions and then 6 mos ADT. I dont think I would go thru the surgery for what you describe. you dont have high risk at the moment and prob radiation will destroy what you have and ADT will suppress any spread. I doubt either will upset your life too much at all. Just my opinion.

In brief, diagnosed Gleason 4+3 at 59 in Dec 2025. Retzius, single incision RALP Jan 2026. I chose the surgery for a few reasons. I am working and radiation would be most disruptive for work and I would need ADT with my risk being higher at 4+3. Wanted to avoid ADT. Otherwise, I would likely have had radiation. Surgery was very successful. Currently undetectable. No real lack of continence, except a bit of stress incontinence which resolved in less than two weeks after catheter. Natural return of erectile function progressing 7 mos post surgery. Utilize Trimix for sexual intercourse. I have zero regrets and am very grateful 🙏🏽. There is no right way, but this was best for me. Hope this helped a bit.

Currently waiting to see Urology surgeon on Sept 28th, saw oncologist last week waiting for decipher test to make decision diagnosed with 2 cores 3+4 taken from .8cm lesion, oncologist recommended 5 sbrt treatments with a 90% cure rate or 95 % with adt, to me the extra 5% is not worth taking it. Would rather do radiation but not with high decipher score, will see what happens.

Check to see what your insurance will cover. If the MRI does not show additional lesions (easy to miss with random biopsy sample) you could continue with AS for another year, or do any of the focal therapies (HIFU or Tulsa Pro (both ultrasound), IRE / Nanoknife, Laser, or Cyro). All of these are ablative and will target the lesions within the prostate. If MRI and another biopsy identify a lot more lesions you may not be a good candidate. All of these have the least side effects. Nothing is free. All focal therapies have higher recurrence rates than either RP or RT. Can do any other treatment if there is a recurrence. Most commercial/employment insurance plans will not cover the focal therapies even though they are less expensive.

RP and RT are about equal in percent/time without recurrence especially with 3+4 group 2 disease. RP has much higher incontinence, RT has much higher proctitis. At 3+4 you should not require ADT with the RT treatment. See what your insurance covers. It may limit how many IMRT sessions you can have and may not cover SBRT (these are always 5 sessions). IMRT will be 20-40 sessions. The dose per session is adjusted up with fewer sessions so effectiveness will be about the same with any. More sessions tend to have fewer side effects. Should probably get PROSTOX test to get prediction on chance of late Geno urinary side effects. May want a Decipherer test to predict chance of aggressive disease and if ADT is useful.

If you want to do RP make sure you get a good surgeon that uses the latest technique. See Wheel1 post on this board.

@jmgpdx68 My diagnosis was 3+4=7. Because of my age (and this is my coordination with my urologist, R/Os, and PCP) and medical and mental health history was given radiation treatment with no hormone treatment due to low Decipher score interpret as low risk.

My PCP asked me to get a second opinion to help me know the diagnosis was right and treatment right for me. I did and same diagnosis and treatment was given. Although the second opinion wanted a Pet Scan which I had with negative finding.

I don't see you mentioned Decipher test. Did you have one? It is a test (genetic) to determine if you cancer is low, medium, or high risk. That helps your urologist and R/Os determine what is best for your treatments.

I had the Decipher test, bone scan, and Pet Scan so passing on the test I had and why they were done on me.

I had 30 rounds of proton radiation because wanted the type radiation that stopped at the calculated spot and not pass through body like photo does.

Neither of my R/Os I met with recommended the short term high does just the long term low dose. I respected what they were telling me and the research they had along with doing thousands of these treatments and seeing those patient in person and what they were seeing with both types of low and high dose side affects.

Did you consider a second opinion.

5 sessions of SBRT radiation would probably resolve your cancer problem. Usually, the least side effects of the easiest to get done.

You might consider focal therapy, something like Tulsa Pro. It would be worth speaking to a doctor that does it to find out if you are a good candidate.

You could also find a surgeon that does Retzius surgery with nerve sparing. That could eliminate the chance of having long-term Incontinence or ED.

Here’s a link to a discussion about it
https://connect.mayoclinic.org/comment/1548188/
Some more information
https://www.mdanderson.org/cancerwise/how-retzius-sparing-prostatectomy-helped-a-prostate-cancer-patient.h00-159538167.html

@jmgpdx68
I had five radiation treatments with the Mridian radiation machine in February 2023. I chose the machine because it is Mri guided and so the margins were 3 mm instead of 5 mm for most other Radiation machines, including Proton. That meant less exposure for healthy tissue and fewer side effects. I too had 3+4 and my PSA was 10.2. So far so good.

If kicking the can is what you want - and honestly, it’s ALL kicking the can - then HIFU, TulsaPro or any of the PROVEN focal therapies is what you want.
Since you are young you might be able to defer more invasive treatment for a few years - or many.
Side effects are much less and you always have the option of radiation or surgery in the future.
IMO, the most important aspect of focal therapy is being an ideal candidate for the treatment; you want to ask your doctors why they WOULDN’T use focal treatment.
Also, you want a doctor who does this a lot! Many ‘can’ do focal therapy, but you want someone who ‘specializes’ in it. Many on this forum have had TulsaPro (search it here on the forum) and can tell you a lot more than I can…Best,
Phil

I did Tulsa Pro for my 4+3 in July 2024. Like you I wanted to avoid the side effects and I was OK with a newer treatment that offered that lower risk. I’m 27 months out and have no evidence of disease. The procedure itself was painless and I was back to normal activities in two days. You have lots of variables to sort out. Your urologist is likely to recommend procedure they know, which may not be the best for you. Research all your options and choose what is best for you.
I talked to seven doctors before I made my decision. I am fortunate that I am 90 minutes from the MAYO , and when I talked to them about Tulsa Pro, they said I was an ideal candidate, given my single lesion and where it was located. I just had a good friend with 3 lesions treated with Tulsa at Mayo. If you choose to go focal, the big benefit of Tulsa is it is done in a real time MRI environment and offers a level precision most of the others do not. One thing you may run into though is insurance coverage. Medicare does cover and I heard that some insurance companies have now come on board because of that. You can read more about my story by clicking on my profile.

ASCO-GU 2025 Abstract 388 10 Year Follow-up: Surgery or External Beam Radiation Therapy (EBRT):

you-tube brachytherapy 101 PCRI.org video - Avast Yahoo Search Results

and then this:
https://video.search.yahoo.com/yhs/search