63 yo, live in Europe, diagnosed w/ PCA in Aug 26 and hard to decide

@lojewski
You have too many positive cores with 3+4 to consider active surveillance. I know people with 3+3 that waited to be treated and ended up 4+5. Once cancer starts, it doesn’t usually become milder. It becomes more aggressive unless it’s treated..

You had a lot of of cores with cancer. You don’t show us your T score. Were you a T2b? That would mean it’s on both sides of your prostate so focal therapy doesn’t make a lot of sense. SBRT radiation does.

Thoughts (about each of your comments)…….

Even without access to genomic tests (such as decipher) or germline tests (for e.g. BRCA 1/2), they say that when a 1st-degree relative has prostate cancer, it increases the odds by 50%. (Plus other family solid tumor cancers probably increases the odds a little as well.)

Consider having your “Free PSA” tested along with your next “Total PSA.” PSA exists in two forms - attached to certain blood proteins and also unattached (i.e., “free”). % Free PSA is the ratio of unattached PSA to Total PSA in the blood. A higher % (above 25%) suggests more benign conditions, while a lower percentage (under 15%) indicates less benign conditions.

If you decide not to get treatment at this very moment, see what other (possibly inexpensive) biomarker tests they MIGHT offer: FoundationOne®Liquid CDx; Guardant360; Caris Assure; Prolaris; OncotypeDx; 4KScore; EpiSwitch PSE; Phi Prostate Health Index; SelectMDx; PCa3 (PC Antigen 3); MyProstateScore (MPS), ExoDx. Each provides information that might help in your decision.

Since you have a “4” in your Gleason score (albeit a small percentage), there is increased chance of metastasis (compared to a Gleason 6). Will they approve a PSMA PET scan? That information might impact your treatment management decision.
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a. I’m a supporter of active surveillance — when it’s appropriate. I was on active surveillance for 9 years (2012-2021), using that time to dig deep into learning about prostate cancer, and ultimately deciding on a treatment regimen just in case I ever needed to make that decision…..which eventually I did.

b. Can’t answer that one. I was not a candidate for focal therapy, having more than one lesion. Actually, though the risk of spread is certainly higher with not being treated (compared to surgery or radiation), recent data show that it’s not that much higher (see this study out of the UK: https://www.nejm.org/doi/full/10.1056/NEJMoa2214122). Plus, not jumping too quickly into treatment, and using the time to gather more information while still closely monitoring, buys you time to take advantage of medical advances before making that final decision.

c. With the success rates of localized prostate cancer treatments - no matter surgery or radiation - being statically equivalent, 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.”). The possible/likely side-effects of surgery didn’t fit my quality-of-life prifile.

d. MRI Linac is a good option. (Is that the technology that provides continuous, real-time live imaging of the prostate during treatment, and can even pause the beam if the prostate position shifts?) (If they administer the radiation well - and don’t overshoot the prostate, hitting otherwise healthy tissues and organs - the risk of side-effects is very low. What radiation doesn’t hit, it won’t affect. (I had 28 sessions of proton radiation, and had only 1 day of adverse side-effects, and none since; that was 5-1/2 years ago. My most recent PSA was 0.366.)

You mention that “ADT would not be necessary.” ADT typically isn’t recommended for a low-grade 7(3+4) without other significant risk factors (which you don’t appear to have). However, there is an ArteraAI Prostate Cancer test that looks at the biopsied tissue characteristics to determine if ADT would be beneficial (or not). Is that test available/affordable to you?

> If you choose radiation, will you be using a rectal spacer (SpaceOAR, Barrigel, or BioProtect)?

Choose well.

@lojewski It comes down to how you value quality of life vs. trying to get the best treatment now available for eliminating the cancer. With AS you just monitor, IRE is the middle ground where you get rid of current cancer and monitor it for recurrence. IRE recurrence is much worse with 4+3 than 3+4. Search for IRE posts. Some posters have had success with IRE for many years. Since you will still have a functioning prostate, a recurrence can be an entirely new lesion that developed.
Since SBRT radiates the entire prostate it has a much lower rate of recurrence. If the radiation was limited to the area of the lesion it might be close to the side effects of IRE; however, I have never heard of a RO do partial treatment of the prostate like they do with lungs, brain, etc. just focusing on ablating the lesion with SBRT.

@jim18 You wrote, "I have never heard of a RO do partial treatment of the prostate like they do with lungs, brain, etc. just focusing on ablating the lesion with SBRT." I too asked about that approach and was told that SBRT is given to the entire prostate and not focused solely on the tumor or lesion(s).

@jeffmarc

A single lesion was found (through mpMRT and subsequent targeted biopsy) in only the right side of the prostate. All 8 positive cores (out of 12 sampled) came out of this single lesion. So I guess the T score is T1c or T2a...

@lojewski
That’s either T1 or T2 a. The thing is, Many of the people in this forum, that have had their biopsy done, have found that the cancer was in area not seen on the MRI. If they didn’t really get a broad range of cores From both sides of the prostate, It is possible that they missed a lot. A biopsy only gets about 1% of the prostate. If they didn’t examine the other side you don’t know what could have been found, Unless you have a prostatectomy.

If it truly is on only one side, then it might be possible to do focal therapy.

@jeffmarc Missed: "Another 12 systemic samples taken from the prostate were all negative." So 12 standard TRUS + 12 targeted. So 16 with benign and 8 cancer all from targeted lesion.