prostatectomy vs radiation?

@lcbc

I was 69 when I had 5 radiation treatments with the MRIdian linac which had a built in MRI so the margins of radiation exposure to healthy tissue, which impacts side effects and quality of life, outside the prostate, were 2 mm instead of 3-5 mm for most other radiation machines. The Elekta Unity is the only other machine that I know of that has a built in MRI. What they see, in real time, they can treat.

My side effects were limited to a slight reduction in urination after my third treatment, which Flomax took care of overnight. I had no pain, no bleeding in the rectum and was still able to have erections and orgasms shortly thereafter.

That was in February in 2023 and before treatment I had a PSA of 11.2 and a Gleason of 3+4: Low risk decipher. I did have spaceoar. Still all good today. I would do it the same way today except maybe a different type of biopsy.

Multiple opinions from centers of excellence or those trained at centers of excellence was also helpful.

I suppose if you have surgery and the cancer comes back, you wish you had gone with radiation. If you have radiation and the cancer comes back, you wish you had gone with surgery. The latter is my case. I was told surgery wouldn't be a good option, even though it hadn't spread beyond the prostate.

Oh well. In my next life, I'll get my PSA checked more often.

The history of the SBRT approval in 5 sessions by Medicare is new to me. I do know that UCSF Mack ROACH had mentioned he does it in four visits. (via PCRI.org YouTube video). One center of excellence in NYC is or has reduced SBRT to two sessions in an investigatory protocol. Roach said he was salaried by California and used the amount he thought necessary independent of personal gain. Incidentally, recent studies have shown that fewer IMRT visits are as equi-effective as more sessions over a longer period of time. Unfortunately there is likely less payment for the institution using the revised study. SBRT produces the least remuneration.

MiraDx has a PROSTox test ( mouth swab, 2 week turn around ) can categorize the risk of delayed urinary tract symptoms. They occur in several months to years later in up to 15% of those who test HIGH. The background rate is 5%. The test can calculate the risk for either SBRT or IMRT or both. Short term self resolving side effects with or without symptomatic medications are about the same for either technique. The SPACEOAR protects the bowels from the radiation effects. It should be emphasized that the skill of the physician is equally important. One commentator said the latest iteration is called SpaceOarVUE implying it was an improved version?

I got that from Dr. Walsh's book, IIRC. He (or one of his co-authors) wrote that SBRT can be delivered in more visits and smaller fractions to try to reduce side effects, but it's tricky because the Medicare fee schedule will cover only 5 sessions of SBRT.

If anyone thinks that sounds dubious, I can try to look up the refence and see if I'm remembering correctly.

In any case, I did have my 60 gy of SBRT to the prostate spread out over 20 fractions here in Ontario and still developed mild radiation cystitis (occasionally annoying) and proctitis (barely notice it except for a bit of tingling or "buzzing" after eating spicy food).

Personally, I don't mind the radiation spread: it means the radiation would have killed cancer cells near the prostate as well as those in it, giving me a much better chance (in my layperson's opinion) of long-term remission for my aggressive, stage 4b PCa. A bit of urinary-tract irritation seems like a very small price to pay.

For someone with a HIGH ProsTox test, suggestive of higher risk delayed urinary tract symptoms [15 vs 5%] the interval between sessions may be prolonged. Instead of 5 visits over two weeks (alternate days) maybe the 5 sessions can be provided over 5 weeks. The third party compensation may be the same regardless of time. I saw US$27K for SBRT and US$37K for IMRT. Moderate IMRT of 20 sessions was just as good 37 to 40. I know Medicare 'A' went to a DRG payment schedule for inpatient care. That is the institution prospective compensation. Physician visits are paid through Medicare 'B' and may still be a la carte fee for service?

My experience: I had five sessions of SBRT and six months of ADT (3 Lupron, 3 Orgovyx). I was G7 4+3, PSA ~7. Switched from Lupron due to episodes of tachycardia.

Minimal side effects from radiation: burning and slow urination for two months fixed by Flowmax and cutting out acidy food and drink (except coffee in the morning which I couldn't give up), and some tiredness for about four weeks (took an hour nap every afternoon).

ADT side effects were more severe: bad depression (this seems to be a less common side effect), osteopenia, joint pain, anorgasmia (but oddly no ED or drop in libido), insomnia, brain fog/forgetfulness, chills (but oddly no hot flashes which are common), muscle loss/weakness and some cosmetic effects (loss of all body hair and genital shrinkage but it all came back except about 1/2").

During ADT treatment my PSA was .01. Three months after stopping it was .at 4, .1 at six and .04 at nine months so still dropping. Was just moved for six month followups from 3-month. ADT is not wearing off very quickly--testosterone is in the low 200s. Brain fog has improved, still get chills but not as often, body hair about 50% back, no more joint pain.

I never had any urinary incontinence or any bowel issues at all. I'm now 13 months post-radiation.

Thanks, that makes sense, and aligns with the "trickier" part. So you can get your SBRT fractionated over more than 5 sessions with U.S. Medicare, but you need to provide medical justification?

71 had RARP
surgery is no walk in the park and incontinence is horrible. However I would do it again give what I and my team believe offers a better chance of survival. If a recurrence happens I can try radiation At least the side effects are here and now and luckily subsiding (incontinence and ED)
I keep hearing from those that had radiation that side effects crept up over time
not terribly scientific however in my case the chief of urology at a large teaching hospital recomended RARP over everything else

@edinmaryland
It has to be a personal decision. I would say also after exploring all pros and cons of each.

RP is a major medical procedure.

Radiation when being done had no pain. There is no recovery from surgery, etc. I had radiation 30 rounds of protron radiation. Other than the time to do the treatments was really nothing to deal with. I did have some minor side affects about 1 month in and about a year later. But they were minor and my R/O and PCP did not have to prescribe any medications for it.

I was 76 when I had radiation. I am 78 now. A major surgery at that age carries a much higher risk than someone younger. So if I was younger when I got PC say in my 50s I probably would chose RP.

Having said that I go to Mayo Jacksonville. I get a news letter and one of the recent articles is a research going on with a protein that can attack and kill the prostate cells only and leave regular cells alone. It would be a great breakthrough for PC patients if clinical trials are successful. So many new treatments coming that will drastically change the present treatments.

I may have misled you. I don't want to get over my skis as it were. I was merely referring to the interval between the typical 5 sessions to reduce 'potential temporary or delayed urinary tract symptoms. I believe some centers provide only 4 sessions on a daily basis most employ 5 sessions over two weeks on alternate weekdays. (The above formulae may apply only to the Cyberknife SBRT platforms?