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Considering Tulsa Pro or Proton radiation (full gland)
I was diagnosed with stage two prostate cancer a year ago. Biopsy showed 11 cores of 3+3 and one core of 3+4 )less than 5% of 4). Bilateral No perineural invasion . That biopsy was an ultrasound. Decipher of 0.32. So I went on Active surveillance.
I had a repeat biopsy This year.
It was an MRI guided biopsy (not sure why I didn’t get an MRI guided biopsy last year ??) and I had an additional core of 3+4 (35% of 4) and the urologist re-sampled one of the tumors and it came back 3+5 (but less than 5% of the 5). On this biopsy I also had perineural invasion. No cribaform. I am sending the 3+5=8 for another decipher test
I’m afraid that my cancer didn’t grow in that year, but it was due to the better sampling of the MRI guided biopsy.
PET scan showed no escape
ED an incontinence is very important to me.
I had a consult at a newer Tulsa pro site and they stated that since I needed a whole gland ablation that I was not an ideal candidate due to the possibility of recurrence in 2 to 3 years. I like the advantage of Tulsa pro gives with reduced side effects and the availability of further treatment, including another Tulsa Pro procedure or radiation.
I am considering getting a second opinion from the Texas Prostate Institute, which is a higher volume Tulsa Pro site
I am also considering proton radiation consults at the university of Cincinnati . (I think they use a Varian machine with gantry) at the University of Cincinnati. I am leaning towards the proton radiation and the 28 sessions to reduce effect on the rectum and bladder and other organs . I have severe diverticulosis and generate many polyps during each colonoscopy. The downside of radiation seems to be in 2 to 3 years some of the same side effects start to appear as surgery.
I just read about getting the Prostox test for sensitivity of radiation
My questions
1) is it worth it to get a second opinion from the Texas prostate Institute on full gland ablation by Tulsa pro or is it too risky?
2) I’m considering 28 sessions of proton therapy. What is your opinion of that for my cancer
3) and is it worthwhile for me to get the Prostox test for radiation sensitivity?
4) any other advice?
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Hi,
Yes I think it’s worthwhile to get a second opinion especially from a different doctor/hospital network who specialize in Prostate cancer. Proton is a very good form of radiation since it has a fixed beam length which does not go past the cancer sight thus no damage to bladder or rectum. Proton radiation uses photons where traditional radiation uses X-ray based beams. So on your last answer about Prostox, make sure the test also is valid for photon based beams.
Here are some information and recommendations from doctors that are at locations that do focal therapy like TulsaPRO. In your case, I think they would tell you to avoid focal therapy completely.
At the 11/1/2025 PCRI conference the following was said by Matthew R. Cooperberg, MD, MPH Urologic Oncologist UCSF
What about focal therapy?
* The energy modality matters much less than the accuracy of the imaging - which is not there yet.
* Overall focal therapy is associated with minor side effects, but high rates of recurrence both in- and out-of-field.
* Focal therapy is not really a replacement for surgery or radiation; it is better considered an adjunct to active surveillance
Af the UCSF prostate cancer forum on 4-17-26 Dr. Cooperberg had slides with this information
UCSF Results: first 135 HIFU patients
• 54% recurrence (41% in-field)
• 4% progression by 1 year, 16% overall
• IPSS (urinary obstruction) 6 before, 6 after
• SHIM (erection function) 16 before, 13 after (p=0.11)
• Major drivers of recurrence: GG3, high Decipher
Trade-offs
• Overall focal therapy is associated with minor side effects, but high rates of recurrence
• Inadequate energy delivery?
• Inadequate field of treatment?
• New cancer development?
• Others?
• Understanding the high recurrence rates and trying to improve them is a major area of research focus.
• Focal therapy does not burn bridges: RP, RT, even additional focal therapy are possible if necessary
Summary thoughts
•Focal ablation has a growing role for very carefully selected cases.
• Side effects rates are low but recurrence rates are high. GG3 and high Decipher are warning signs, as are high PSAD and bilateral disease.
• Focal therapy is an adjunct to active surveillance; additional treatment may well be needed down the road, but these treatments are still possible after focal.
University of California Consensus
1 Focal therapy must be acknowledged to be investigational
2. Focal therapy should be done under trial or research protocols as much as possible
3. Candidates should have at least 10 year life expectancy, GG2 or low-volume GG3, stage T1 or 2, and PSA < 10 or PSA < 20 and PSAD < 0.15
4. Candidates need an MRI-guided confirmatory biopsy before treatment
5. Follow-up biopsy at 12 months is essential
3+5 puts you in Grade Group 4. Tulsa Pro is not the standard of care for GG4. While you did not give your age, proton therapy with ADT would likely be a good choice for you. If it were me I would not waste my time with a Tulsa Pro consult.
Stay Strong Brother, We Got This.
@toolbelt thanks so much. I am 66 years old. Which is probably why the consult didn’t recommend it. The only reason I considered it was I have less than 5% of grade group 5 my prostate is very small at 22 mL and it seems like Tulsa pro lend itself to more available. Repeat treatment treatments but I certainly see your point.
@jeffmarc Jeff. Thank you very much. I am 66 years old. My PSA is 5.99. And I am sending my 3+5 = 8 biopsy sample out for another decipher test.
The only reason I even considered Tulsa pro is due to my less than 5% of grade group 5. It will be interesting to see what my decipher is on this sample and whether that impacts my decision on continuing with Tulsa pro consult or just dropping it.
I’m leaning towards the university of Cincinnati 28 session of proton therapy using a Varian cyclotron proton instrument with a gantry.
I’m considering a 28 sessions of proton versus five session SPRT or 28 session I MRT to keep bleed over of the rectum at a minimum. Especially with my diverticulosis and polyps.
Of course I will use the SpaceOar gel.
@jaygk Thanks. Given your age I think some sort of radiation is appropriate.
Look at my profile here and at
https://www.inspire.com/m/Toolbelt/posts/
to read about my SBRT treatment of 4+3 with Decipher of .81.
You may want a second opinion on the biopsy since grading is subjective. A lot of difference between 3+4 (35%) vs. 3+5. Get an expert opinion to see where you stand.
The Prostox test was developed/tested on photon radiation (IMRT and SBRT for ultraProstox). Probably a lot of overlap but the test developers do not claim any prediction for protons. Definitely worth it if you decide on IMRT.
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You might want to send out your biopsy for a second opinion.
This doctor is a real expert in the field of second opinions and while he does charge $500 after the biopsy is complete you can talk to him on the phone and go over all the issues involved. He’s very responsive.
Dr. Epstein biopsy
https://advanceduropathology.com
Jeff thanks.
For my biopsy last year I did send samples out to Dr Epstein and they came back very similar. Slight changes in % but no grade changes.
The < 5% of the grade 5 really could change my direction of treatment
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