54M, “favorable” prostate cancer diagnosis — surgery vs. radiation

@jlhiggins01
I can give you the feedback I got in my particular case from the medical doctors I saw. I see you are at Mayo Rochester which is excellent care. I am at Mayo Jacksonville.

I was never given an consideration of active surveillance from neither my Mayo R/O, nor teh UFHPTI R/O that I dog second opinion. Based on all my tests Biopsies, Pet Scan, Bone Scan and Decipher (which gave me low risk) my treatment plan was radiation without hormones.

Active surveillance was not offered by either R/O and they both were working on my complete test results. The biopsies show I did have P.C. and both my R/Os, PCP and I agreed needed to be treated.

My doctors gave me the opposite of Decipher. It was to determine whether you cancer was low, intermediate, or high probability of metastasize and being aggressive. It had become an additional test back then at both institutions to determine the aggressiveness of your P.C. and thus risk level.

I hope this helped. I am glad to provide what my doctors told me. The diagnosis and treatment plans were the same at Mayo Jacksonville, and University of Florida Proton Therapy Institute.

@kjholz my doctor did offer focal treatment as an option, but the cancer elimination statistics for focal therapy for those my age and with my disease stage are not as good as nerve sparing radical prostatectomy or radiation therapy.

I'm sorry to hear about your diagnosis, but glad to see that your cancer is still very early and fully treatable.

Radiation vs surgery is probably the most commonly-asked question in this forum. As you probably already know, overall survival and progression-free survival are nearly identical for the two treatments, and while removing the prostate after radiation is a bit trickier, that's balanced by the fact that any cancer recurrence is more likely to be outside the prostate anyway (so there would be no point trying to remove it).

Side-effects are highly personal. Some people have almost none with either treatment, while others have permanent side-effects to varying degrees. So it's probably not worth spending too much time comparing them, because you might not get the common ones, or might end up getting the rare and/or permanent ones.

It might be worth just considering which will be easier for you: driving in for at least 5 separate 15-minute radiation treatments (plus at least one preparatory simulation) with a full bladder each time, or getting knocked out, having surgery, and taking a few slow days to recover. Also, who do you connect with better: the surgeon or the radiation oncologist?

Your surgeon is probably citing the long-running ProtecT phase III clinical trial for metastasis-free survival. At the 15-year point, it showed that for favourable Gleason 3+4 the risk of death within 15 years was the same for AS, RP, and RT at about 3%, but the risk of metastatic progression was 9.4% with AS vs about 5% for RP or RT ...

... however ...

... when ProtectT started nearly 20 years ago, risk stratification was much less accurate than it is now. It later turned out that 24% of the participants had actually had medium-risk cancer at the beginning of the study, while 10% had high-risk. If they were relaunching the study today, the metastasis gap would likely be much closer (if it existed at all), but that's just speculation. And note that I'm a patient sharing second-hand information, not a medical professional.

@brianjarvis Thank you for your comment and support. My PCP suggested the MRI following 2 years of steady climb in my PSA and an increase in nocturnal. I’ll look into the tests you mentioned. I’m working with doctors at the Mayo Clinic in Rochester, MN, and two tests have been ordered so far: Prostox and ArteraAI. Prostox predicts the likelihood of severe, long-term radiation side effects. ArteraAI predicts cancer progression and overall survival, and helps identify whether a patient would benefit from specific treatments like hormone therapy.

I was told Decipher is most useful for patients considering Active Surveillance, and less helpful if I’m planning to treat. Is there a good counterpoint to this view? Thanks again for your input!

@ireland1964 Yes, there is proton SBRT (few sessions w/high doses). I did not choose Proton SBRT due to reported increased risk of urinary bother. (See Dr. Rossi’s comments on this topic at the PCRI 2023 Mid-Year Conference: starting around timestamp 4:30:45 at https://www.youtube.com/live/WTqPnSRYtW4)

If you want to watch his entire presentation, Dr. Rossi has a lot of information about proton radiation treatments in his portion of that conference Starting at about 3:38:45 at that same link.

IMRT (intensity modulated radiation therapy) is photon-based radiation therapy. It utilizes high-energy X-rays (photons).

IMPT (Intensity-Modulated Proton Therapy) uses protons (heavy charged particles). Think of "proton radiation" as the overall category of treatment, while IMPT is a specific, technique used to deliver it.

My proton radiation was delivered (in 28 sessions @ 2.5 grays of radiation per session) with a Varian ProBeam Proton Therapy system. It uses pencil-beam scanning, and is accurate and precise at depth-dose control, completely eliminating "exit dose" radiation behind the prostate.

I did not use Proxtox prior to treatment. There are a dozen different biomarker (genomic) tests as well as genetic (germline) testing that can be utilized depending on what information you’re looking for. In my case, I had the OncotypeDx and Prolaris tests as well as the Promise genetic (germline) test.

My questions for the group:
1. Nerve-sparing prostatectomy vs. proton therapy with SpaceOAR (rectal spacer) — how do these compare for long-term (20+ year) outcomes, not just 10-year cure rates?
I did RALP in 2013 (age 42) and was cancer free until 2022 (age 51) when it resurfaced, and we did genetic testing and found out I was positive for BRCA2. If I knew I was BRCA2, I would have still done surgery, as my optimization of variable came to that conclusion, but that algorithm is very personal and the prior posted mentioned an excellent methodology of addressing it.
2. Real-world experiences with incontinence, ED, and any penile shortening after each approach?
Your physical health going into these next steps is a big factor (in my opinion) that influences these outcomes. In my case, I was quite athletically healthy for decades. Incontinence was a minor issue with tiny leakage with weightless leg movements, a drop here or two, for the first few years. No issues ever since. ED is interesting, it takes more work to get the arousal function activated, but after orgasm the blood flow remains strong (quite different than before surgery), this certainly has its benefits! Shortening, perhaps. I recently did 2 years of Eligard and Zytiga and that brought dormancy downstairs but now on Enzalutamide and biggest complaint is activation, but once activated, all is good.
3. Anyone with a similar Gleason 3+4 profile who chose one over the other and how it’s held up years later?
I was 3+3 going into Surgery in 2012 and the post-surgery upgraded to 3+4. I was cancer free for 9 years, but I attribute the biochemical recurrence to being BRCA2 positive (and dealing with lots of stress at work that triggered it, that is my take on why it came back).
…
Hope this helps! PCa is a tricky topic, I think Mayo published a study a few years ago that said something that 44,000 patients had over 2,000 different treatment paths. Regardless of exact numbers, it is quite telling that the decision matrix of the client is heavily influenced by personal choice and current standard of care.

@jlhiggins01 I used information from the OncotypeDx test (in 2012) in my decision to go on active surveillance, and the Prolaris test (in 2020) in my decision to go off active surveillance, I never had a decipher test.

@jlhiggins01 Hi again. I agree that focal treatment cancer elimination statistics are not as good as prostatectomy or radiation.

You're lucky. At least *your* surgeon mentioned there was such a thing as "focal".

Here's hoping that whatever you choose, you'd choose that again ---and it's your One and Done.

Cheers.

I was diagnosed as a 3+4, Only one core, But the doctor felt it to be treated, and I had the choice of radiation or surgery. I was 62 at the time. I chose surgery because my father had radiation and died of prostate cancer and I figured that would give me a better chance. That was 16 years ago. I’ve had four reoccurrences. I’ve had 40 sessions of radiation 12 years ago and had no side effects at all other than incontinent starting six years after the radiation. Of course, I had a prostatectomy before that so who knows what caused the incontinence?.

After surgery, I found out I was a 4+3. This is not uncommon about 1/3 of cases end up with a change to the Gleason score After surgery. That was 16 years ago, Four years ago I found out I have the genetic problem of BRCA2, which is why it keeps coming back.

At 54 you should definitely get genetic testing, That is way too young to be having prostate cancer. Do you have cancer in your family? Breast cancer prostate cancer, ovarian cancer, and a few more can be caused by genetic problems.

If you have surgery, you should have Retzius sparing surgery and also spare your nerves.

If you pick radiation you should also ask for a spacer like SpaceOAR, Barrigel, or BioProtect. Yes, it is possible to have long term issues as a result of radiation but they normally do not happen, Usually the urinary issues and diarrhea problems cease in a short time following radiation.

The chance of follow on cancers due to radiation is very low. Here’s some Information from a Stanford study.

In a study of about 145,000 men with prostate cancer, the team found that the rate of developing a later cancer is 0.5% higher for those who received radiation treatment than for those who did not. Among men who received radiation, 3% developed another cancer, while among those who were treated without radiation, 2.5% developed another cancer.
https://med.stanford.edu/news/all-news/2022/070/prostate-radiation-slightly-increases-the-risk-of-developing-ano.html

1. Nerve-sparing prostatectomy vs. proton therapy with SpaceOAR (rectal spacer) — how do these compare for long-term (20+ year) outcomes, not just 10-year cure rates?
I did 5 sessions of SBRT with SpaceOAR ~2.5 years ago followed by six months of ADT (G7 4+3). No surgery. PSA is still undetectable and I've been moved to six month monitoring from three.

2. Real-world experiences with incontinence, ED, and any penile shortening after each approach?

Developed fibrosis at the base of my penis. It does not impact sexual function but the first 1/2" at the base no longer expands when erect. It looks a bit weird to me but I've had no complaints. Had frequent, burning, urgent urination for about 3 months after treatment. 2 years later the frequency and urgency returned (but not burning). Currently being successfully treated with meds. Oncologist says it may or may not disappear in a 6-12 months. No bowel problems ever. Still on 5 mg daily Cialis but sexual function is good.