Gleason7(3+4) - treatment options recommendation

@ireland1964 you still could be a candidate for a focal treatment HIFU, Tulsa or Nanoknife depending on location of your cancer. Less invasive treatments then surgery and SBRT but from what I understand a little higher chance of cancer reoccurring or of not removing it all

@davidz26 my preference moving forward is surgery but only if I can find a facility that practices nerve sparring techniques instead of just “uses robots”. Still wrapping me head around how I went from AS to unfav inter risk requiring treatment within 1 month. Throw in the fact that change was only due to genetic testing results which I had to ask for doesn’t promote confidence in my Dr

@davidz26 I just haven’t heard reassuring results from any type of Focal or hormone therapy. I don’t love the idea of surgery but want to take my best shot at being C free.
Perhaps I’ve read too many stories about long term side effects, scar tissue along with not providing a more definite answer surgery can provide. At 62 and decent health I feel like now is my best shot. Still trying to learn and hoping to find a facility that offers better direction and best options

@ireland1964 don't know what part of the country you are in but if I was going to do RP surgery I would try to find a really good surgeon who has done hundreds of these surgeries and from what I have read get in the best shape of your life and do lots of Kegels prior.

@ireland1964
Here are some information about focal therapy from ancan.org and the actual links to the original articles.

Among US patients who received focal therapy for prostate cancer in the most recent decade, half were outside guideline-recommended care.Clinical practice guidelines currently recommend focal therapy for use in intermediate-risk disease only in clinical trials or prospective registries, not routine clinical practice. In low-, high-, and very high- risk disease, no level 1 evidence is available to guide treatment decision-making about the use of focal therapy.

To better understand contemporary treatment trends, investigators analyzed data from the 2010-2023 National Cancer Database (NCDB) including 1,179,384 men aged 50 years or older with nonmetastatic prostate cancer. Inappropriate focal therapy use was defined as receiving focal therapy for low-, high-, or very high- risk prostate cancer.

Overall, 15 672 patients (1.3%) received focal therapy, but 51% of these cases had low-, high-, or very high- risk disease, Quoc-Dien Trinh, MD, MBA, of the University of Pittsburgh Medical Center in Pittsburgh, PA, and colleagues reported in JAMA.

From 2010 to 2023, focal therapy use increased among men with favorable intermediate-risk cancer (2.1% vs 2.9%; P <.001) and decreased among those with unfavorable intermediate-risk disease (2.5% vs 1.9%; P <.001). The investigators were unable to assess the appropriateness of focal therapy in intermediate-risk disease because the NCDB does not specify whether patients were enrolled in
clinical trials or registries.

Focal therapy decreased among patients with high-risk (2.1% vs 0.9%; P <.001) and very high risk disease (1.8% vs 0.5%; P <.001), respectively.

Groups with higher adjusted probability of receiving focal therapy included men with older age, greater comorbidity burden, non-private insurance coverage, and treatment at non-academic facilities or higher volume facilities.

Focal therapy modalities shifted over time. Cryotherapy use decreased (79.8% vs 19.1%), whereas laser ablation (14.6% vs 45.8%) and high-intensity focused ultrasound (5.6% vs 35.1%) use increased.
This study was limited by a lack of data on adverse effects, treatment outcomes, retreatment rates, and costs. “These findings underscore the importance of distinguishing selective investigational use from routine adoption of focal therapy ahead of appropriate evidence,” Dr Trinh’s team concluded.“

These findings underscore the importance of distinguishing selective investigational use from routine adoption of focal therapy ahead of appropriate evidence.

In an accompanying editorial, Spyridon P. Basourakos, MD, Jonathan E. Shoag, MD, and Daniel E. Spratt, MD, from Case Western Reserve University in Cleveland, Ohio, compared real-world focal therapy use for prostate cancer to Hans Christian Andersen’s tale, “The Emperor’s New Clothes.” “Group think,” in the form of professional societies, opinion leaders, reimbursement incentives, and market competition, appears to have influenced clinicians’ decision-making even in the absence of clinical trial evidence. They cautioned that just because a technology is available and lucrative, it may not be in individual patients’ best interest.

“Clinicians in this field need to commend colleagues who openly report findings that raise awareness and question practice trends, especially when those practices are being adopted ahead of the evidence…,” the editorialists wrote. “It is to be hoped that academic leaders and professional societies pause to ask whether endorsing, promoting, and offering unproven and potentially harmful treatments outside of clinical trials truly serves the best interests of patients with cancer.”
https://www.renalandurologynews.com/news/half-prostate-cancer-focal-therapy-cases-inappropriate-treatment-risk/
Focal Therapy in Spotlight: Could Landmark Study Rewrite PCa care in UK? What About US?
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

@davidz26 thanks…at 62 I have no chance of getting in best shape of my life but I’m trying and only know this is probably a better shot than kicking the can.
I’m in Michigan and have met with Karmonas cancer already and looking into U of M. Problem I’m having is trying to find specifics about what type of nerve sparring techniques they use other than just pointing out they do Ralp and try their best with that.
Brought up things like Retzius and non-cutting of pubo ligaments with Karmanos and got nothing

@davidz26
I agree that you should consider SBRT which I finished 3 months ago after a 3+4=7 Gleason. Prior to my decision, I did a decipher and ArteraAI test which were very helpful and reassuring that I was making the best choice. So far so good; minimal side effects in all areas. My initial urologist strongly recommended surgery, prompting me to find a more objective provider. Given my status, the research on surgery did not feel like a necessary or good choice. Good luck on your journey; you’re not alone.

I have learned a ton in my 5 weeks since my prostate cancer diagnosis and first and foremost I have learned that you have to be your own advocate and sites like this are helpful, but the information out there is overwhelming. If I recall that with the surgery, you have potential side effects of incontinence and erectile dysfunction. With SBRT the biggest side effect risk is erectile dysfunction and not as much with incontinence. 1 in my opinion is better than 2, but there is also the possibility of not being able to have the surgery later if you do SBRT and cancer reoccurs so that is something to consider. The focal therapies HIFU, Nanoknife and Tulsa if you are a candidate, the side effects appear to be even more minimal, but the chance of recurrence or not getting all the cancer out I keep reading is greater. You can do a second focal treatment if needed and an MRI prior to focal treatment would be helpful. I have also learned the importance of incorporating a better diet with little to no sugar, eating certain foods and taking supplements that cancer doesn't like, eliminating or greatly reducing alcohol, consistent exercise, reducing stress and getting 7 or more hours of sleep consistently can help recovery and with long term health and prognosis. Intermittent fasting has also been recommended to me, and most days I try to not eat after 8pm or before 8am and sometimes go longer based on how I feel. @Dekeset glad your SBRT went well. I have heard mostly good stories regarding SBRT and a lot of good ones with surgery too, but of course that is not always the case with any of the choices we have. A consultation with one or more Doctors for each procedure you are considering is helpful with making the right decision and make sure to ask good questions. AI can help with that and probably YouTube also. For @ireland In MI it looks like you have a couple great choices regarding surgery Henry Ford Vattikuti Urology, U of M Rogel Cancer Center and Cleveland Clinic in Ohio. All 3 of these facilities also come up highly recommended for SBRT as well. Weiser Center for Prostate Cancer came up with good ratings for focal therapies. Hope some of this helps you and others reading this and of course do your own research as this is based on my conclusion from 5 weeks of diligent research.

I had a similar situation in 2023 with a 3+4 Gleason Score and the surgeon advised IRE as it was minimally invasive and he promised no side effects. In terms of recurrence he said data is same for 5 years vs surgery or radiation. I’m in Canada so I paid $23000 out of pocket as this new procedure is not covered by the government unlike surgery or radiation which are covered. Long story short the cancer came back within 6 months and 3 months ago I had to go through open radical salvage prostectomy as robotic surgery wasn’t possible on treated prostate. So please avoid IRE for sure. All the best to you .

@ireland1964 If they have not heard of Retzius go to another center/surgeon. UM is probably the best choice where you are. Nerve sparing is always on a best-efforts basis. The nerves run on the outside of the capsule and if there is no cancer there the tissue gets peeled away and that preserves the nerves. Sometimes it is full, other times partial. Ask the surgeon how successful they have been with the technique. See the Wheel1 post where he went through his Retzius surgery.