Active Surveillance vs Radiation for Unfavorable Intermediate R. Grp.

Posted by tjpa444 @tjpa444, Apr 24 6:52pm

I am 74 yr old, in relatively good health & weight, except I also deal with RA. and have recently been given a diagnosis of unfavorable intermediate risk group (mostly from 1st biopsy in 2022 core scores and recent Decipher score)

PSA'S: 2024-5.3, 2023-5.9 &4.8, 2022-7.6, 21-4.9, 20-5.0, 19-4.3
Needle biopsies: 2024 - 12 cores, not MRI directed, 12 total, 7 benign & 5 positive( GS 2 - 3+3=6 and 3 - 3+4=7); 2 years earlier -2022 - MRI directed, 15 total, 4 benign & 11 positive ( GS 8 - 3+3=6 and 2 - 3+4=7). Decipher Feb. 2024 of 0.78 - high risk.

I have seen a Urologist for 2.5 years and recently a Radiation Oncologist, who gave the diagnosis based on my 1st biopsies and the Decipher results.

I am leaning towards doing RT because of my age and simply preferring the consequences of RT over surgery, but would appreciate any group comments on:
1. Is active surveillance still a possible option?
2. The type of RT being recommended would include: External beam radiotherapy delivered in 5 (SBRT), 28 or 44 fractions combined with 4-6 months of ADT.
Thank you.....appreciate the collaboration from this group and wishing you all well in your own Pc journey.

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The executive summary is : 68, fit, in good health (other than F*ing PC cancer), 1 - 3+3, 1 - 4+3, PSA 7.8, Decipher 0.86, PSMA PET showed confined to prostate. I had a Barrigel spacer placed, completed 5 SBRT on Dec 28th, currently on month 6 (of 6 total) of ADT with Orgovyx. Has a PSA at the 3 month post treatment point and my RO said " I don't know what you are doing in this cancer clinic, your numbers could not be any better." My PSA was 0.09. No SBRT side effects, mild hot flashes from ADT.

Stay Strong Brother!!


Why is this unfavorable intermediate? Because of the Decipher? Only 2 cores @ 3+4 on the MRI directed biopsy? If I were you, I would be an optimist and call it favorable….and certainly get a second reading of the biopsy.


@tjpa444: If it were me, I would go for a narrow margin (2 mm vs 3-5 mm) 5 treatment Mri Linac machine. This is what I did and I was happy with the results and recovery. Protect your healthy tissue from exposure, where you can. Have spaceoar or BioProtect inserted to protect your rectum. I did not have any ADT.


Is active surveillance still a possible option?

Sure it is in my opinion. Just keep an eye on your PSA levels. However you may not be able to do that. Once you get engaged on the message board, we already have you on the table ready for some kind of treatment. Think of it like meeting a new gal and deciding whether to stay single or get married. Both have their merits.

Just remember that prostate cancer is usually very, very slow growing and you can often wait a year or more and not dramatically affect your outcome.


I would definitely stay away from surgery at 74. Cyberknife type treatment would be my choice because the rectum is protected with gel spacer - not the case in IMRT.
I din’t think active surveillance is a good idea especially with high Decipher score.


Thank you all for your input. The oncologist gave the diagnosis based on my 1st biopsies which had more than 50% of cores positive and the high risk, 0.78 decipher results. However, he did mention that I was in a rather stable situation because of my consistent PSA scores and the second biopsy, 2 years later, being less than 50% positive.


I'm surprised your urologist is not recommending surgery. Why? Because you have cancer that seems to be widespread throughout the prostate. While it isn't that advanced in any of the places you've biopsied, it is widespread and then you have that decipher score, so it seems like removing it might be better than trying to kill it "all" in place without disturbing anything else.
I think for me, the hardest thing about making the decision was to be sober-minded about my actual situation as opposed to my preferred situation. So far I've been fortunate because while there were positive margins when it was removed, I'm over two years without evidence that the cancer is spreading. I was intermediate unfavorable because of a nodule that had more 4 than 3, so a slightly different situation than yours.
When I was coming to terms with my cancer, I was definitely first most enamored with active surveillance, and when that seemed inappropriate clinically, I was definitely inclined toward selective ablation, and in that category, preferably using something other than radiation, but to the urologists I was just one more person in a range of situations and they saw my situation fitting most appropriately in the RP camp. In hindsight, I'm fairly confident they were right and I'm glad I listened, though reluctantly.

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