Time to decide what treatment is best

I assume your PET scan being negative means that the cancer has not spread outside of the capsular prostate? That was the case with my PC last year (3+4 Gleason, 2mm and 3 mm lesions at time of biopsy). I was 61 at the time. I chose robotic assisted laparoscopic proctectomy (RALP) last December. My margins were not clean of cancer and my pathology post surgery showed 4+3=7, Grade group 3 with 3 masses of cancer. My surgery was 6 months post biopsy. In my case, my cancer had progressed to the point if I had waited another 6 months, I may not have had as successful of surgery. My decision was to get rid of the cancer BEFORE it spreads. I have not had any long term issues post surgery (ED and incontinence). My PSA at 9 months post is .2 ng/ml and is rising so I am in discussions with my Urologist and surgeon. Salvage radiation my be in my future. At least I still have the option of radiation. If I had started with radiation and that did not remove all cancer, it would most likely be too late for surgery. If you haven't already, get a copy of Dr Patrick Walsh's Guide to Surviving Prostate Cancer. Good luck with your decision.

@gfeaglefan
I am so sorry to hear that you have detectable uPSA of 0.2 which points to definitive BCR.

My husband had BCR in May. He started his salvage when uPSA reached 0.2 since starting at that number salvage gives the best long term results.
All studies show that salvage should start no later than 0.2, so please do not wait too long. Your doctors will need couple of months just to organize it all and do all additional scans and your PSA might continue rising in that period : (. I hope that you are treated in Cancer Center of Excellence and that they will start with your treatment soon.

Wishing you the best of luck 🍀.

I would ask why the sbrt comes with ADT. My numbers were PSA of 17.5, 4 +3 and visible lesion of 12mm on MRI. My doc said ADT wasn’t needed. He said that the research didn’t support it. I was ready to do 6 months if required. I am in Japan however and largely covered by insurance so they don’t tend to upsell.

Thoughts…..—->. Would recommend letting the numbers and test results guide your treatment decision.

For a 3+4, you have options. (See attached NCCN guidelines for favorable intermediate risk prostate cancer.)

> regarding your 3+4, what % was the “4” cell structure?

> a 3+4 typically doesn’t require ADT unless there are other risk factors (perhaps the high Decipher score?) or they’re just being extra cautious. There’s probably no harm in it (and I would prefer to be slightly overtreated rather than slightly undertreated and have to go through this again). Still, it’s worth the discussion.

> did your MRI report or biopsy report mention anything about extracapsular extension, seminal vesicle invasion, perineural invasion, cribriform pattern or intraductal carcinoma?

> when you mention that the PSMA PET scan results were negative, did any non-cancerous areas light up?

> don’t worry about the “if you have radiation first you can’t have surgery later.” That’s 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.

> have you had a genetic (germline) test to check for any inherited gene mutations related to prostate cancer?

As for which treatment —> with success rates comparing surgery with external radiation for localized prostate cancer being statistically equivalent (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.”).

(With a localized 3+4 & PSA of 7.976, I chose 28 sessions of proton radiation.)

@brianjarvis 2 cores 3+4 10% and 40% component .8cm lesion pet scan was negative and mri didn't show any invasion. The .86 decipher score is what worries me down the road even though now it shows it being contained so ralp seems better in my situation if there was reoccurance.

@ginger38314 Yes, the 0.86 Decipher score signals an increased probability of disease progression or metastasis, typically requiring multimodal or intensified therapy regardless of which primary treatment path you choose.

> If you choose external radiation for primary treatment —> they’ll consider treatment intensification, likely using the combined approach (EBRT + ADT). Then if rising PSA levels later occur, you’ll have options —> focal therapy (e.g., cryo), brachytherapy, or SBRT (because they’re all very targetable), or even re-radiation in some cases.

> If you choose prostatectomy for primary treatment —> they’ll also consider treatment intensification if rising PSA levels later occur — likely using the combined approach (EBRT + ADT).

I’m not sure which option is more likely to play out. This is one of those tough decisions…..

Thanks for your comments I just want more treatment options if reoccurance happens.

I’m still right behind you and waiting on f/u to discuss Pet but summary of report appears encouraging.
Did your surgeon consult provide any insight for you?

After years of steadily rising PSA, a couple of biopsies that found nothing, and then leveling out at a PSA around 12, my urologist said it was time for a new MRI. The MRI done in July 2025 found a larger PI-RADS 5 tumor, and a smaller PI-RADS 3 tumor, followed by a biopsy in August, which found that the larger tumor was a 3 + 4 = 7 with perineural invasion, and the smaller one was a 3 + 3 = 6.

I also had a decipher of .85. I initially wanted SBRT, but a Prostox test revealed that I was at high risk of complications from radiation treatment, so I chose surgery and its been a success. 8 months out, I'm continent, get erections, and most importantly, have undetectable PSA.
Research the Prostox test.