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.)