Surgery or radiation?

@freed58
My advise which is not a medical advise but what I did when trying to make decisions was to wait until you get your Decipher and your second opinion are important (because they were important to me in my decision making) and my suggestion is to wait until those test results come back and then explore your options based on the results of your test.

Then explore the pros and cons of all treatment plans with your doctors (and you by your post have had two opinions) of what is best for you. Only they know your full medical and mental health history.

Then for your own to help you decide do research on your specific cancer and test results on web sites that are C.O.E.s like Mayo, Cleveland Clinic, John Hopkins, to give you the lates research and studies being done at C.O.Es.

It is best to do those researches yourself as many times see research quoted on MCC that is old and not longer relevant.

Hi,
I went with surgery 11 years ago and don’t regret it. I’m about 70% on the old johnson scale and I do drip a drop every once in a while so I wear a light pad every day. No side effects from radiation, no secondary cancers from radiation, no ADT side effects. If my cancer does return I still have radiation and ADT as future options. Always have a backup plan if you need one. If you do go with surgery go for the new one incision version, heard nothing but good results as far as less ED and urine leakage. In the end do your homework and pick the best facilities+best doctors=best results even if you have to travel.
Dave 3+4

One of the understandings I had with my doctors was that quality-of-life and successful treatment were of equal priority for me. That set the basis for us working together and ultimately agreeing on a treatment plan.

> You’ll have to establish your own priorities in making this decision.

With success rates comparing surgery with external radiation for localized prostate cancer being statistically equivalent no matter which treatment is chosen (https://www.nejm.org/doi/full/10.1056/NEJMoa2214122), it all comes down to side-effects and quality-of-life (or as that paper concludes, “… the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer.”).

Based on my priorities and my understanding of each treatment’s side-effect profile, (at 65y with a localized 7(4+3) w/PSA of 7.976) I decided on 28 sessions of proton radiation (during April-May 2021), with 6 months of Eligard.

For me, that decision has worked out well. Quality of life was fully maintained and my most recent PSA test was 0.366.
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Regarding your urinary issues:
> are you on either Tamsulosin (Flomax) or Finasteride?
> in preparation for radiation, the ADT that’s given for a 4+3 shrinks the prostate; sometimes that reduces urinary issues.
> radiation itself also shrinks the prostate; sometimes that reduces urinary issues as well.

Lots of decisions to make; and much to discuss with your medical team so that your personal priorities are maintained.

@brianjarvis Thank you for your input. It appears a general consensus among the surgeons and radiologists that a pre-procedure (e.g., TURP) is a must, even with the recognition that ADT shrinks the gland.

I'm a big fan of surgery. You are in & out in one day. Mine (in Feb 2021) was a breeze, with 5 tiny bandages across my belly line, & no pain, then or after. Resumed normal activities immediately (then age 75). Wore a catheter for a week, & no incontinence when (or after) removed.

Have you got a second opinion on the pathology? How much was 4 is as much art as science. There is an aquablation PC trial going on that you might be a good candidate for at John Hopkins and a number of other places (there is a link on the aquablation site). That will be a focal therapy. There are other focal therapies such as HIFU, Tulsa Pro, IRE/Nanoknife, Laser that will ablate the PC area and wind up shrinking the prostate at the same time. You may or may not be a good candidate for some of these. Prostate size is usually in cc and if it is 73 cc it should be able to be radiated. Again, you may need a second opinion on this. I would be hesitant to get a surgical procedure (TURP) just to get radiated. If you do choose a RP, get the best surgeon you can that uses the latest technique to minimize the risk of ED and incontinence. A few on this board have had excellent results. Most have some period of ED and incontinence even with nerve sparing.

Based on the information provided, you need more info in order to begin “desired treatment” decision-making.

1. Did MRI show any lesion(s)?

2. As others have asked, from the one positive core, how much was Gleason 3 and how much was Gleason 4?

3. You will want a Decipher or similar test performed on the biopsy.

4. Active Surveillence may be your best option, at this time. More info will guide this decision/option. Some of this may be: Genetic testing to test for BRCA or other inherited gene(s), 2nd opinion on initial biopsy (Dr Epstein or similar), and Decipher.

5. With the information you provided, I would not be ready to make a treatment decision.

6. https://ancan.org/prostate-cancer/ Join Ancan and particpate in either the Active Surveillence or Low/intermediate group. Lots of great support and information. You will be able to introduce yourself and provide information you have. You will get lots of recommendations and information.

Best Wishes.

@readandlearn
I’d be delighted to have the successful outcome you experienced. Thank you for sharing.

@jim18
Thanks much for your input. I am getting a 2nd pathology opinion from Hopkins. It’s in work now. I’ll check out the focal therapy trial you noted. The Radiation oncologist I just saw concurred with the need for a debunking procedure like TURP or HoLEP.

You have a lot of options. You might consider focal therapy. You have a very limited case, which is only in one spot and maybe a treated quickly and easily without other side effects. Something like Tulsa pro could treat your prostate without having to reduce the size. The same may be true of other focal therapy treatments like NanoKnife, cryotherapy, HIFU, etc.

Five sessions of SBRT radiation could very easily resolve your issue permanently. I know a lot of people who have done it. Was such a mild case it’s pretty easy to treat. Because your prostate is so large they do want to do those other procedures first to reduce the size of it.

There’s a new surgery technique that makes incontinence a very short term thing and the same with erectile dysfunction as long as you can have the nerves spared. Here’s a couple of links discussing it. The prostate is quite large, so I’m not sure it is possible, but you could definitely investigate it. That would give you more time if it comes back before you have to do more drastic treatment.
https://connect.mayoclinic.org/comment/1548188/
https://www.mdanderson.org/cancerwise/how-retzius-sparing-prostatectomy-helped-a-prostate-cancer-patient.h00-159538167.html