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

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

@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.

@jeffmarc Fabulous summary! And to my knowledge, about as accurate as one can get. I too had genetic testing done when first diagnosed 8-years ago. It took almost 6-months to get the results, but I was told by that specialty group, that I too, lacked the two BRCA-1 and -2 mutations of genetically induced prostate cancer, and that my specific case, was strictly a "lifestyle disease" (i.e., I did not "inherit" the disease, nor could I pass it on to male children). My radiation oncologist later concurred with that genetic assessment, and notably, my own father died at age 80 of bladder cancer (never having had prostate issues).

As for the incidence of secondary cancers occurring to non-target tissues from radiation treatments later in life, again, my oncologist fully agreed with what's been said here. He stated that the reported incidence of such "secondary" cancers, was well below 3%, and that the vast majority of that 3% did not occur for 10 or more years. For what its worth, he had also stated at one point, that the radiation level of IMRT (external beam radiation), was roughly twice the strength of an average x-ray.

@jeffmarc Fabulous summary! And to my knowledge, about as accurate as one can get. I too had genetic testing done when first diagnosed 8-years ago. It took almost 6-months to get the results, but I was told by that specialty group, that I too, lacked the two BRCA-1 and -2 mutations of genetically induced prostate cancer, and that my specific case, was strictly a "lifestyle disease" (i.e., I did not "inherit" the disease, nor could I pass it on to male children). My radiation oncologist later concurred with that genetic assessment, and notably, my own father died at age 80 of bladder cancer (never having had prostate issues).

As for the incidence of secondary cancers occurring to non-target tissues from radiation treatments later in life, again, my oncologist fully agreed with what's been said here. He stated that the reported incidence of such "secondary" cancers, was well below 3%, and that the vast majority of that 3% did not occur for 10 or more years. For what its worth, he had also stated at one point, that the radiation level of IMRT (external beam radiation), was roughly twice the strength of an average x-ray.

@toomany @jeffmarc
Dr Patrick Walsh book also had an interesting discussion that men with the defective Brca2 tended to have cancer with more aggressive features. Unfortunately it appears the lab which performed my biopsy is still trying to locate my saliva sample for this

@brianjarvis Thanks for the link and time bookmark. I’ve been reading about higher dose presenting better outcomes so it was very interesting to hear his input on the SBRT vs more treatment sessions at lower rad level.
My Pet scan should help provide some clarity on whether I should search out a good Rs-Ralp or look into this type of rad treatment.
It did seem like many of those studies from the video also involved ADT even for the G6 group. Is that fairly standard procedure and something you also had done?

@toomany
Just to let you know about one point You were making.
“ nor could I pass it on to male children”

Unfortunately, this comment from the doctor is not true. A father or brother having prostate cancer more than increases the chance of the child/brother having it by More than double over a normal Chance of getting it. This is not me saying it. This is something that’s been presented by doctors at multiple prostate cancer forums I’ve been to..

My father died of prostate cancer. I got it at 62 because of him and because my mother gave me BRCA2. My brother got it at 77 because my father died of it and he did not get anything from my mother. You’ll find many generations of families that have prostate cancer passed from father to son. If there’s a genetic issue, then the child can get it younger.

@jeffmarc Greetings Jeff, and as always, my thanks for your continued contributions to these various threads.

Let me start by saying that I am no trained or educated Geneticist, so I can't really speak to the validity of what was said by those who are, including any difference between 'genes' themselves and 'mutations' of those same genes, or whether such mutations can be congenital (i.e., passed-on, etc.)? I'm afraid all of that is well above my own pay-grade.

However, I do wish to clarify that it was not my oncologist, or a "doctor" of any kind, who had conveyed that information to me. Rather, it was a senior researcher of the genealogical group at the Huntsman Cancer Institute, entitled the Utah Population Database (UPDB), which links multi-generational family trees to medical and public health records. My "doctor" (or oncologist), simply concurred with it.

@ireland1964 Some guys want their G6 treated; I didn’t. (I was on active surveillance with a G6 for 9 years.) Like any other disease, illness, or injury, I don’t get treatment unless it’s medically necessary. Rarely is treatment for a G6 medically necessary.

The issue with moving too quickly to treating a Gleason 6(3+3) is that there’s some debate in the medical community as to whether a G6 should even be called “cancer.” Some in the medical community say that a “3” cell structure can’t metastasize and therefore shouldn’t be considered cancer like a G7+. (That a “true” 6(3+3) is a harmless benign tumor - that it shouldn’t necessarily be treated.) Others in the medical community disagree. So, the debate continues.

This is a presentation by Dr. Scholz referencing a study involving 26,000 cases that concluded that a “true” Gleason 6(3+3), never metastasizes: https://youtu.be/NV8QHzbgamI