Intermediate Risk Prostate Cancer Treatment Decision

You're correct, there is no "right" answer - you have to make the best, most-informed decision for your particular case and don't look back.

I'm 50, with Gleason 7 (3+4, 6/12 cores), Decipher 0.56, PSMA scan negative. After visiting several local surgeons and ROs, I was essentially in your position, so I went to MD Anderson hoping to gain some clarity. The RO and surgeon at MD Anderson thought radiation would worsen my existing urinary issues (frequency, weak stream). That helped me settle on RARP, but then I had to figure out where to go - ugh! In the end, I decided on the Cleveland Clinic based on discovering an insurance benefit that covers 100% of treatment/travel/lodging at CC for me and a travel companion. Overall, it's been about 5 months of agonizing decisions since my diagnosis but I'm comfortable with my decisions and ready for the surgery on 6/18.

Best of luck to you!

Former Gleason 7, Group 2.
Stage 2....IHad Da Vinci surgery. PetScan indicated no nerve involvement. Surgeon did nerve sparing surgery. That's the trick for maintaining sexual function. Peace of mind achieved!
(Pathology showed my prostate was 70% cancerous. )
Best decision I've made.

Just for starters, If you have one 4+4 you are a Gleason 4+4 Which means it is very aggressive. The other numbers are irrelevant.. As you know, the ductal issue means that it is more aggressive as well, but it doesn’t look like it is spread, That’s important to know, Something to ask about. It doesn’t really matter though, With proper treatment, you can probably go for decades.

Radiation and surgery work just as well in the long term, according to recent studies. With ductal “features”, you can have either treatment. Radiation is unlikely to cause incontinence or ED but results vary. Some people do have issues. And people report that a few years after radiation they have ED. It’s possible you could have SBRT radiation, five sessions, and you’re done. You have to make sure that you speak to a radiation oncologist that uses SBRT to find out if it makes sense.

Yes, there’s a much higher chance of having ED after surgery, Especially if they can’t save the nerves. Again, your results will vary some people don’t have a problem. I had no real problems with incontinence after surgery and the catheter was removed. Some people are incontinent for a long time, Others for a short time or not at all. Even if you have ED, there are solutions.

The fact is people who follow the treatments recommended live longer. I’ve been around 15 years with one treatment after another, 4 reoccurrences, and BRCA2. It’s meant being on ADT for eight years and other drugs for even longer. Sure, I have had side effects, but I live a normal life, You probably can too.

Hello @psychometric - How did you request getting a decipher score and who will be your surgeon at CC? Thank you

My original urologist ordered the Decipher test, presumably after he saw my biopsy results (we went over both at my follow-up appointment).

My surgeon is Dr. Christopher Weight.

My husband has only one core with 4+3 BUT it contains ductal component as well as cribriform. His PSMA was clean and he also had TRUS just the other day and doctor said that indeed lesion is fully contained inside the prostate gland (knock the wood).
We immediately decided to have RP but surgeon wanted us to have all of the options explained. During consultation with radiologist we were told that with aggressive features present he needs aggressive approach and RP would probably have better result. So for us decision is clear, both the surgeon and radiologist agreed that surgery is best way forward. There are also some studies that show that RP gives better results than RT for IDC, and cribriform also sometimes can evade radiation. For us the choice was RP before consultations and after them we had no doubt that RP is the best choice for our particular case.

I was 70 last year when I was diagnosed with 3+4=7 grade 2. I'm not a medical professional and I certainly have no idea which treatment would be best for you. That said, here's my story: The MRI indicated my PCa was contained in the prostate. During the consultation I asked my very experienced CCOE surgeon what he thought my odds were for incontinence and ED. He told me for my case he thought he could spare my nerves and that my odds at 1 year of being continent was 90% and 70% for sexual capability (assuming I was capable before surgery). I thought those sounded pretty good so I went with surgery. I was immediately continent after the catheter came out (except for some minor releases as I figured out the new normal). I did experience ED but daily 5mg Cialis (plus either a higher dose of Cialis or a dose of Viagra on days I want to have sex) has helped a lot and at this point (almost 1 year) I am able to have sex and the experience continues to improve over time. Without my old enlarged prostate, I urinate like a 30 year old. The surgery gave me the benefit of a pathology report on my prostate, which found both cribriform and IDC present. So I was pretty glad I got it out plus I do know if it comes back I want to aggressively treat it. All that said, it's impossible to really know what's best so you have to figure out what advice sounds best for you and then never look back. Best wishes.

Not just surgery or radiation with ADT but also radiation with no ADT as the third alternative.

Hi. I was a Gleason 7 (4+3) at 60 years old. Work out regularly with no other physical issues. My PSA was 3.46. Stage 2 as both lobes had PCa. I chose surgery as he did thousands of these and said my surgery would be nerve sparing. The biggest factor for me was that in case the PCa came back I could do spot radiation, where if you do radiation, surgery is more difficult. I've been very fortunate as I had no incontinence issues and am back to normal pretty much with ED side effects. Radiation possible side effects included problems with the rectum and going to the bathroom that way. Surgery does not have that possible side effect. It's a tough decision but you have time. Good luck and prayers for a quick recovery.

Others have given good advice. I will add:

Regardless of which treatment you choose, avoiding or minimizing ED means starting sexual rehabilitation ASAP. If you have radiation, that means concurrently. If you have surgery, you probably have to wait but I'm not sure how long (that's a question for a doctor).

I'm very lucky in that my cancer center (Memorial Sloan Kettering in New York City) has Dr. John Mulhall on staff. He wrote "Saving Your Sex Life: A Guide for Men with Prostate Cancer." (recommended reading!) The book is slightly dated but most of the information is still accurate.

For me, having had radiation, sexual rehabilitation involves taking 20 mg of Viagra every day for two years (one year to go), and 50-100 mg when I want to engage in sexual activity. The importance of getting regular erections was also stressed--at least 2-3x a week for 10-15 minutes, even if it's not for pleasure. There's a myth that you can't get erections on ADT but I was able to, though the ability to reach orgasm disappeared after 3-4 months. I see the doctor in person every six months, and, after stopping ADT, have a FULL testosterone panel every three months (T, free T, estradiol, FSH, SBGH, etc.) which the doctor reviews with me. I'm sure there's some kind of similar protocol if you choose surgery. INSIST ON A BASELINE TESTOSTERONE MEASUREMENT BEFORE STARTING TREATMENT SO YOU CAN SEE HOW WELL YOU ARE RECOVERING.

Whichever path you choose, you're going to have to be really proactive in your treatment. You might want to attend a couple meetings of a virtual support group to see what other guys have chosen. Here's a good site to find one: https://zerocancer.org/help-and-support/find-support-group

Also, don't neglect your mental health. I had severe depression and waited way too long to get help for it but am glad I finally did. Some sadness and grief (and anger) is normal right now, but if you start isolating yourself from people, sleep too much or too little, etc. you might want to ask a doctor about that, too.

Good luck! Give it lots of thought, talk about it with a partner if you have one and/or a close friend or family member, make your decision, then don't look back.