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54M, “favorable” prostate cancer diagnosis — surgery vs. radiation
Background: Diagnosed via MRI-fusion biopsy — Gleason 3+4=7 (Grade Group 2), 50% of one core involved (10-25% pattern 4), plus a smaller Gleason 3+3=6 (Grade Group 1) area, 5% involvement. No cribriform or intraductal pattern. Staging clean — MRI shows intact capsule, CT urogram shows no nodes or bone lesions. PSA 1.9–2.3 ng/mL. Clinical stage T1c/T2a N0M0.
Surgeon’s input: Recommends treatment over active surveillance (says it can cut 10-year metastasis risk in half). Considers surgery and radiation+hormones roughly equivalent for long-term cure, differing mainly in side-effect profile. Mentioned focal therapy as an option for patients prioritizing quality of life if disease is unifocal.
Surgical risks discussed (robotic prostatectomy):
* Overall complication rate ~12%
* <2% DVT/PE, <2% major cardiac/stroke event, <1% rectal injury
* 5–10% urinary leakage at 1 year (pad use); initial leakage common for 3–6 months
* 0.5% risk of needing sphincter surgery
* ED risk depends on age, baseline function, nerve-sparing extent
* 1–2 weeks with catheter, 6-week lifting restriction, 1-day hospital stay
Radiation Therapy Risks:
* Potential longer term risk of secondary cancers caused by radiation
* Longer term risk of bowel and or bladder complications
* Makes salvage surgery very complex if cancer returns to the prostate (<5% chance)
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?
2. Real-world experiences with incontinence, ED, and any penile shortening after each approach?
3. Anyone with a similar Gleason 3+4 profile who chose one over the other and how it’s held up years later?
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@ireland1964 ADT is not standard for G6, unless there are other significant risk factors indicating that something more serious may be lurking unseen.
As you can see (in the attached NCCN guidelines) ADT is not recommended for treating G6.
I was on active surveillance for over 8 years with a G6; it wasn’t until my 4th (& final) biopsy showed 7(3+4) that I sought treatment (without ADT). It wasn’t until a 2nd opinion came back a 7(4+3) that we considered ADT.
With no way to know which Gleason was “right” - the 3+4 or the 4+3 (because both were educated, experienced pathologists’ opinions) - I made the decision to add 6 months of ADT before starting proton radiation.
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3 ReactionsI had 1 tumor that was a Gleason 3 +4, 5 percent tissue area and 40 percent was pattern 4; I also had 4 tumors that were a Gleason 6, 5 percent tissue area.
I did request a Decipher test and a second opinion of the biopsy from a center of excellence; the Decipher score was low risk and the second opinion came back as 10 percent pattern 4; Active Surveillance the past 2 years.
I switched Urologist and had my 2nd transperineal biopsy in June, (my PSA went up and he insisted on a biopsy) a recent MRI was done in March which did not show a change which is why I pushed back on the biopsy.
The Biopsy showed no cancer with the exception of one new Gleason 6.
My advice would be to take your time deciding next steps; get a Decipher or Prolaris test; get a second opinion on the biopsy.
Best of luck to you and please keep us posted!
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4 ReactionsMost people would say that treating Gleason 3+3 is not a good idea. This type of cancer according to PCRI and other experts does not metastasize. You have probably had that cancer for many years. Treating it opens you to serious risks that will last you the rest of your life.
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1 Reaction@robertov I have one 3+4 core, one 3+3 core, and one HGPIN core. There is a 10-15% chance that if I do nothing the cancer will spread and become incurable. It will be treatable, but I would lose the privilege of being able to eradicate it. I recognize that there is a 85-90% chance that everything will work out fine if I wait. I am now awaiting results from ArteraAI to determine the likelihood the cancer will likely become more aggressive. I’m awaiting those results, along with Prostox results to determine next steps. Thanks for your input, but I wanted to ensure you had all the details.
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1 Reaction@jlhiggins01 I’m sorry, somehow I missed the 3+4. I had to look up HGPIN. My thoughts: You can evaluate long-term studies with better context by watching the PCRI & ASCO prostate cancer recent conferences.
As you know, PCa is slow growing. The studies necessarily include treatments that have changed significantly since those cohorts were treated. I am suspicious of the stats. 100 people must be treated for the few whose results you are looking at. What else was different?
I am surprised that HGPIN was brought up. It is ‘pre-cancerous’ and I’ve never heard it mentioned in the years since I joined this club. Why was it mentioned?
I was diagnosed with Gleason 4+4. It was localized and PSMA scan was clean. I had no intention of having surgery. Radiation is more precise than in the past. 4+4 precluded focal therapies. I chose Proton Beam (with spacer). I was also on Orgovyx because I wanted to do more research and travel and it stopped any progression while I studied my options. It’s now been a year since treatment. PSA is undetectible. The ADT took it’s toll, but I feel pretty good now. You should take your time. Treatments continue to improve. I’ll bet on that before betting on a few percentage points. Sorry for being so long-winded.