PC treatment: Prostatectomy or Proton Beam Therapy

I regret having done anything to try (unsuccessfully) to Kill PC for 12 years now. But I guess I'd be dead if I didn't.

Do your research, talk to everyone (good call coming here), find a COE that you trust.

Some guys get 1 treatment and are done - then the rest of us.

Good Luck

I'm not a medical professional and I have no idea which treatment will be best for you. Picking a treatment path can be a tough decision. That said, what follows isn't a recommendation, but rather just my personal experience. In 6/2024 I had surgery at age 70. No incontinence (other than some minor releases until I figured out the new normal), ED gone at 15 months, urination actually better than before surgery. My biopsy results were 3+4=7, but pathology after removal found both Cribriform and IDC (not good, but at least I have that information going forward). I attribute my excellent outcome to a very experienced surgeon at a CCOE, a good penile rehab program, and some good luck. It is really important that you're comfortable with your decision of whichever treatment plan you choose so you don't have any regrets later on since it's impossible to know how things will turn out. Don't hesitate to ask questions, but also be aware you can click on my name and see my journey by reviewing my past comments in chronological order. Best wishes.

I had 60 gy of *photon* based EBRT to my prostate in spring 2022 (my cancer had already spread, but latest emerging practice per STAMPEDE is to radiate the prostate anyway if the cancer is oligometastatic).

Most people have few/no long-term side-effects from radiation (other than dry orgasms), but I fell into the unlucky few who took some permanent mild radiation damage to the bottom of the bladder and the rectum. Even then, not really a big deal any more.

Personally, I'd pick that over surgery any day, because I had a couple of months of complications after my first and only major surgery (to my spine) in 2021, and don't think I respond well to anaesthesia or pain killers. Radiation is easy, and — for most people — painless.

I would pick the one your team feels is best for you and gives you the best chance not worry about the side effects. There will be some adjustments in your life but your alive and can contribute pretty much the same. There are things that can be done to alleviate the issues with ED and incontinence.

What you’ll find is that urologists will usually (but not always) recommend surgery, and radiation oncologists will usually (but not always) recommend radiation. It’s nothing deceptive; it’s more like —> if all you’ve ever used is a hammer, everything begins to look like a nail. (Talk to a medical oncologist for an independent opinion.)

With success rates comparing surgery with radiation being statistically equivalent no matter what treatment chosen (https://www.nejm.org/doi/full/10.1056/NEJMoa2214122), 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.”)

One of the understandings I had with my doctors was that quality-of-life and successful treatment were equal priority for me. That set the basis for us working together and agreeing on a treatment plan.

At 65y, and With my localized PSA 7.976 and Gleason 7(4+3), Ultimately, I decided on 28 sessions of proton beam radiation, with 6 months of Eligard, and SpaceOAR Vue.

Prostate cancer has one of the lowest mortality rates of any cancers (< 12%), so no matter what you choose the odds are that you’ll be around for a very, very long time. So, quality of life does matter.

Your priorities matter. Much about prostate cancer diagnosis and treatment is about self-advocacy and shared decision-making. What you want matters. (Many times my argument was better than my doctors and we went my way; many times my doctor’s argument was better then mine and we went his way.) Learn all that you can so that you can self-advocate.

I had The same choice at 62. In my case, my father had radiation and died of prostate cancer so I decided to have surgery.

Much later I found out I was BRCA2 and surgery gave me 3 1/2 more years than radiation would’ve given me. That’s because 3 1/2 years after your surgery my cancer came back and I had to have 8+ weeks of salvage radiation. That only lasted me 2 1/2 years before my PSA started rising again.

You really have to make this decision on your own, however. You should realize that surgery, even if the nerves are spared could result in having ED issues for a long time. If you have radiation, it’s common to not have ED issues for a few years, At which time they start to occur. You do need to speak to a radiation oncologist and go over what the options are with them.

Do you have a 4+3 but are there any other issues?

Were any of these things found in the biopsy intraductal, cribriform, Seminal vesicle invasion, EPE or ECE. (Extraprostatic extensions extra capsular extensions). They can make the cancer much more aggressive. They also may make surgery more attractive because the chance of reoccurrence is higher.

You should get a Decipher score to see what your chance of reoccurrence is.

With my contained 3+4 case and high Decipher of 0.81, I looked at the situation much like @brianjarvis and also chose radiation as the side effects of an RP are pretty severe and immediate.

Some would say that as your odds of recurrence increase from having high risk factors like high Gleason scores, high Decipher score, intraductal, cribriform, PNI, seminal vesicle invasion, EPE or ECE then surgery is the better option because wide area radiation is still available to use if a recurrence happens. The counter to that is whether you think you could use radiation initially to get a clean wipe of all cancer both in the prostate and the greater pelvic region. Your best odds on doing that with radiation is to use a combination of something like 26 IMRT sessions (wide area radiation) and one SBRT or HDR brachytherapy session as a boost to the prostate. If your risk factors are low, you can also use a less aggressive radiation plan like 5 SBRT sessions and have low odds of recurrence. But as your risk factors go up, then it becomes harder for either radiation or surgery to have low odds of recurrence and the decision on surgery or radiation becomes all the more difficult.

If you and your doctors can come up with a radiation treatment plan that you believe has low odds of recurrence, then that approach will be the easiest to endure. If you have a recurrence after a primary radiation treatment then you will only have spot radiation like SBRT available to use again. But if you and your doctors believe that recurrence is almost inevitable after any initial treatment then surgery as the initial treatment leaves you both IMRT (wide area) and SBRT spot radiation available to attack a recurrence. Of course, there are drugs that can be used to fight a recurrence whether the initial treatment was surgery or radiation.

For me, I felt optimistic that an aggressive radiation plan could keep my recurrence odds low so I went with radiation over surgery. And so far so good. See my bio for more details.

I've expanded upon this elsewhere here, but I'm a big fan of surgery done by an experienced oncology surgeon (in my case, U. Wash Medical Center). It was a "nothing burger" with no pain or side effects (no incontinence). Back to my 1.5 mile daily walks the next day.

@wwsmith Actually, if there is local recurrence after initial radiation, choice of salvage treatment would depend on the nature of the recurrence; there are other options —> focal therapy (e.g., cryo), brachytherapy, and SBRT (because those are all very targetable), and yes even re-radiation in some cases. I personally know two guys who had their prostate recurrence re-treated with SBRT, because the recurrence was a single spot. (Plus, these days there are systemic treatments for recurrence - Isotope therapies, Immunotherapies, Checkpoint Inhibitor therapies, and PARP inhibitor therapies. So many secondary options.

Dr Geo Podcast 158 (What is HIFU)

I know very little about Proton Therapy. This Dr Geo podcast with Dr Cooperberg is very interesting and appears to have good information.

Dr Cooperberg is not slanting info and pushing any specific treatment(s).

He states Proton is not as good for prostate cancer and should not be selected. I do not know why? It was stated strongly enough, I would not select Proton without a ton of research.

I have not been a member of this forum long enough to post a website/youtube link. You can search youtube for the podcast.

Best Wishes.