Nearing decision time: what treatment?

I suppose you’ve already been told that they won’t do radiation because your prostate is so large. As a result, your decision to do The ablation will probably reduce the size of the prostate so they can actually treat it with Radiation or focal therapy. I was at a recent UCSF conference where they talked about results of Hifu. The biggest problem was reoccurrence in over 54% of the cases, you are grade group 2 so there is a better result expected.. Hifu leads you to be able to have radiation next, a real benefit. Here’s some information from that conference.

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

At 80, there is a time factor involved in the decision using quality of life as part of the strategy as you will be impacted by two sets of treatments. Many of the guys on this site have had medications to reduce the size of their prostate and then have done targeted radiation when the prostate was reduced in size. I bet they will chime in. If it were me, I would find the medication with the least side effects and shortest time to reduce the size of my prostate followed by an MRI guided radiation machine (with spaceoar inserted a week or so before).

@jeffmarc Thanks, Jeff. You are right about my thinking post hi-fu. Most docs rule out most treatments because of my prostate size. Right now, EBRT has been suggested by one RO but he also says it would be much more effective if my prostate were smaller. Some kind of ablation will also address BPH symptoms and pre-empt possible post treatment urination issues. I'm not experiencing any significant BPH-related problems, but those too are down the road if I don't address the issue.

@bens1 I've considered meds to reduce prostate size but most forecast a modest reduction--114 cc to about 60cc is the most optimistic prediction with most suggesting about a 20% reduction to about 80-85ccs what would be expected. Or less than that. Tried tamsulosin a few years ago and didn't like the SEs. Maybe I'll go back to it. Also considering finasteride, but leery of those SEs as well. Appreciate your advice!

@tdgillett

As a layman, that does not seem so modest as the size of my prostate was just under 60cc so if you could get to that level options can change. It may be worth exploring the radiation options and the likelihood of a "strong response" possibility.

@tdgillett
At a recent monthly Mayo Clinic Meeting the radiation oncologist said that he doesn’t like to do radiation on prostates larger than 75 cc. 60 would be no problem.

I'm wondering why its decision time. You've consulted with some top flight doctors. What is their reasoning?

The factors that go into a decision like this are very likely more complex than the description you've given about your case.

It looks like they are going to upload videos of all the presentations at the recent UCSF Patient conference Jeff Marchi mentioned. Here is the webpage where all the videos will eventually appear.
https://www.uctv.tv/prostate-cancer-conference/
Some are already up.

Here is a video of the Cooperberg presentation:

@tdgillett, how goes the decision making? What did you decide and why?

@colleenyoung Still undecided. Have another couple consults with IRE, Ho-LEP and HiFu practitioners scheduled. Also reviewing possibility of TULSA-PRO since I learned that my hip replacement might NOT disqualify me from consideration, depending on the center doing the procedure. Because my MRIs do not actually show the cancer lesions, focal therapies would need to either be total gland ablation or be PET-guided.
When we have these consults, my wife and I leave them thinking, "Well, that seems like a good possibility." Eventually, the last doc I talk with will probably be the one we go with!