Surgery or radiation?

@jeffmarc
The 3.4 uptake in the PET scan was at the left peripheral mid gland of the prostate. Unless my biopsy second opinion (in process) challenges the original pathology report, I may lean toward radiation as the primary treatment. Since the positive biopsy core was located just below where the scan lit up (at the apex) I’m a bit concerned if surgery can get clean margins in that location so close to the external sphincter. Another reason I’m thinking radiation.

If I was at that crossroads again, I’d find a highly regarded GU Medical Oncologist to help me decide. In the past only advanced cases ended up in their offices but more recently they’ve been consulted early. I think it’s great change!

@freed58 You have some good advice on checking focal, as there isn't just radiation or surgery. I have had focal therapy twice, tulsa pro and with some recurrence where the tulsa procedure ended I now had cryoablation at Mayo. I do NOT think Hopkins is the place to go for focal. At one time Hopkins had great pathology but they got rid of the guy that did that (Dr Epstein). So I personally (even though I am a Hopkins graduate) do not trust them. They seem money hungry, as why else did they get rid of Dr Epstein? Anyway, as a person who has had focal twice you really need to do a lot of the work yourself. You might get lucky and find a great one near you but chances are that won't be true, and you won't also get good advice from most academic places (not all) on focal. You often have to do a lot of work, like travel and so on, or you might find one near you if you are lucky. The push to over-treat is huge, they use decipher to push people toward over-treatment, they use pathology to push people to over-treatment, they use statistics and all kinds of push is all they know at most places. Only you alone can seek out and find places that do quality focal, because most places the push for over treatment is all they know. Even they hire a doctor who did focal in training, they push them to do non-focal. Just letting you know, as focal is a self found thing and it can be work. On the other hand some people like the idea of over treatment, they want max treatment to start as obviously it is easier to find and they feel since that is the majority opinion just go with it. Up to you where you are on all this.

@marlon
Hi Marion,
If your cancer is contained and there are no other extenuating circumstances I feel surgery is the best route. The one incision nerve sparing procedure the best. You are correct, if the surgery fails you always have radiation and ADT as a backup plan. Always a good idea to have a backup plan.

Dave 3+4

@bjroc
Hopkins. does have some really good doctors for prostate cancer

Bethesda Maryland
Sibley memorial hospital
Johns Hopkins, school of medicine
GU Oncologists
Dr. Channing Paller GU Oncologist One of the best in the country
Dr. Mark C. Markowski GU Oncology. A really good doctor
Dr Deville RO

I don’t know of any doctors there that do focal therapy, I would ask Dr. Channing Paller For advice

@jeffmarc Well that says a lot in your statement. Think about it a highly regarded medical center that got rid of the greatest pathologist in prostate, has nobody that does focal. Yet they are highly regarded in the prostate world. Sounds upside down to me. Look they want to hire top people in focal of all kinds, plus traditional things like brachy, and any option that isn't standard 2 treatment that would be great, plus of course re-order their pathology back away from politics and towards respect like it had. But till then your statement says a bunch, top rated, lots of doctors, none that knows a thing about anything but standard two treatments. You want top rated, well you have to be willing to, you know, kind of "boldly go where no man has gone before..." imho.

@bjroc

If you were to be treated by Dr. Channing Paller you would be so pleased with the resulting treatment that you could not believe how so many other doctors have done like you say.

I know a few doctors around the country that are that good.

@jeffmarc
I just want to second the recommendation for Dr. Paller, whom I am now seeing, based on a previous recommendation from Jeff. She is easy to talk to, and is a shining example of "shared decision making." She bucked her department and supported my request for the Estradiol patch, and walked me through the pros and cons of Nubeqa in my particular situation. She was willing to fight the insurance company to get me on Nubeqa before we jointly decided to go with an alternative,

I was diagnosed in early 2018 following a biopsy, with a Gleason score of 9 and a PSA of 90. I subsequently underwent what was called a treatment "triple-play", which was 1) ADT (Casodex + Lupron), 2) Low-Dose Brachytherapy, and 3) Seven-weeks of daily IMRT Beam Radiation. I have been cancer-free (PSA = non-detect) for eight (8) years ever since, until January of this year, when my 'rebounding' PSA was first detected to be 4.5.

Over the eight-months since, my PSA has slowly risen to its current level of 13.4, and a recent PSMA-PET scan shows recurrent 'localized' cancer, restricted to the gland itself and the right seminal vesicle. The potential for post-radiation surgery (partial or holistic prostatectomy), is unlikely, and I am actively seeking future treatment recommendations from several oncologists, including my original (treating) oncologist, the latter of whom is likely to call for Orgovyx, plus Abiraterone. There may in-fact be, no other treatment options available to me, and of course, I have no real idea what my newly projected life expectancy might be (could be months or years)!

Anyway, I'll hope that some of this information (surrounding my own journey), might be of help to you in your decisions going forward, but I'll close by noting two key things . . . 1) I did NOT need any outflow procedure(s) to undergo radiation back in 2018, and 2) Radiation treatment(s) MAY preclude you from any future surgical options, should recurrence take place thereafter.

Best of luck to you!

@toomany
Here are some other options

Recurrence after radiation, focal therapy and surgery

People who have radiation as their primary treatment have been told by doctors that surgery isn’t really an option if there’s a reoccurrence. Other options are not really mentioned..

This study shows that both salvage focal therapy (HIFU and cryotherapy) and salvage surgery were equally effective at extending the life of a patient that started off with radiation.

Those that had focal therapy had fewer perioperative complications.
https://jamanetwork.com/journals/jamaoncology/article-abstract/2844900