Your PSA isn’t bad (1.9-2.3):

> With such a low PSA, what led you to get an MRI?

> Do you know your % Free PSA?

> Since you have a “4” cell type in your Gleason score, have you had a PSMA PET scan?

> Have you had a biomarker (genomic) test (Decipher, Prolaris, OncotypeDx, or one of the many others)?

> Have you had a genetic (germline) test?

With that additional information, you’ll be better equipped to make this treatment decision.

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As for which treatment —> 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.”).

Your choice of treatments will depend on your priorities. 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 an appropriate treatment plan. (My disease was not unifocal so, that quickly eliminated some options.)

> You’ll have to establish your own quality-of-life priorities in making this decision.

When comparing risks of surgery vs external radiation, I made a list of side-effects of each, then scored and ranked them. Then through personal introspection I made a list of quality-of-life issues that were important to me, scored them, and ranked them. Then, I compared my quality of life introspection ranking with the side-effect rankings of the surgery and radiation. Ultimately, proton radiation ranked best, IMRT second, then SBRT, and finally surgery as a distant last place.

Take the time to figure out for yourself what’s best for you.

As for “long-term effects of radiation (10-20 years down the road),” remember that what radiation doesn’t hit, it won’t affect. If you do choose external radiation, work with your external radiation team to use the latest technology and expertise so as not to overshoot your prostate in order to avoid hitting nearby otherwise healthy tissues and organs (i.e., minimize entry-dose, scatter, and exit-dose).

If you use a rectal spacer and practice consistent full bladder/empty bowel protocol, your risk of GU, GI, rectal, and bowel issues will all be minimized.

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Looking at your Radiation Therapy Risks:

> Potential longer term risk of secondary cancers caused by radiation?: That only happens if they overshoot your prostate. We spent much time talking about how to avoid radiation overshoot.

> Longer term risk of bowel complications?: Again, only happens if radiation hits your rectum; use a rectal spacer (and tell them to still not overshoot).

> Longer term risk of bladder complications?: a bit more risky if they have to treat the prostate near the bladder. Though the risk is small, you can always ask them to “cool” the radiation as they approach your bladder.

> Makes salvage surgery very complex if cancer returns to the prostate?: Though that does have some truth to it, it’s very old-school and doesn’t consider modern treatment techniques. With modern radiation, if there is local recurrence following primary radiation you have many options - focal therapy (e.g., cryo), brachytherapy, and SBRT (because they’re all very targetable), and even re-radiation in some cases. Salvage surgery would still be my far (far) distant choice.

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Additional questions:

1. I’m only 5yr3mo post-proton radiation (w/SpaceOAR Vue) and have seen no 20+ year data. (However, if I do have a recurrence after 20 years, I’ll simply get the appropriate treatment; no differently than I did for my knee surgery for which I had to have surgery again 23 years later.) When my urologist/surgeon told me that with surgery I had a 50/50 chance of ED, “but we won’t know for sure until we get in there,” those odds weren’t good enough for me.

2. My proton radiation treatments were relatively uneventful and I’ve had no lingering adverse after-effects. My wife later told me that if she hadn’t known I was undergoing radiation treatments, she wouldn’t have realized it from any change in me; the short amount of time that I was gone each day for treatment were no different than any other time when I simply left to go shopping or to the gym.

3. I had a localized, Gleason 3+4, w/PSA of 7.976 and chose 28 fractions of proton radiation and had the SpaceOAR Vue rectal spacer. However, a second opinion upgraded the 7(3+4) to a 7(4+3); not knowing which was “right,” we simply added Casodex (Bicalutamide) and 6 months of Eligard to the treatment plan.

For me (5yr3mo later), that proton decision has worked out very well. Today, life is back to the way it was; quality of life was fully maintained.