prostatectomy vs radiation?

Your age and the severity of your prostate cancer is important in determining your treatment decision.

Short/quick answer that others that may echo: When discussing my options after biopsy revealed my cancer, my urologist said that you never want to do radiation "first" if you have the option for prostatectomy. He said that radiation turns your prostate into "concrete". If the radiation does "not" work, you are no longer a candidate for prostatectomy. A radiation therapy treated prostate is not suitable for prostatectomy. He said "you have no choice...I am taking your prostate."
So...I had my DaVinci robotic assisted radical prostatectomy. While there are several unpleasant outcomes to radical prostatectomy, I was glad I had the surgery. Here is why:
I was diagnosed in January after December biopsies revealed: Gleason 3+4 = 7 with only 10% being 4's. My urologist assured me that I'll be alive in 15 years. But...I think urologists fall into the trap of "since everyone's prostate cancer grows slowly, we can wait a couple months for surgery and/or radiation." And of course, nothing is known after biopsy except Gleason score. It was only after surgery that my surgical pathology report revealed slight invasion into my left seminal vesicle (both seminal vesicles and vas deferens were removed as part of the surgical procedure). I was one of the unlucky 10-20% that have "surgical margins" (cancerous tissue left behind by the surgeon). I also had cribriform glands. Taken together I am classified as a "pT3b" with a much poorer long term outcome. I've gone from a "sure thing 15 year or greater survival, to something that the literatures says is more like 5-10 years. Even though the prostate, seminal vesicles, and vas deferens were removed, a pT3b cancer just always seems to "come back." "Lucky me."

@rlpostrp
I have read and been told it is very hard to find a urologist who can do surgery on prostate after radiation and cited the reasons you did.

However they are out there but very hard to find as takes some exceptional skills to do it.

I think MCC posters will agree the statement of urologist that you will die of something else or you will be alive in 15 years and assume everyone cancer is slow growing. They should just be honest and say we will do everything to keep you cancer free.

Can I asked did you have the Decipher test done after your biopsies? That test gives a more precside diagnosis of the risk level of your cancer.

I had proton radiation done (30 rounds) in 2023 with a PSA of .10 just done 2 years later.

Has your urologist referred you to a R/O? Can they not do radiation on the others areas where cancer is.

I know if my cancer would come back I would look at new treatments even clinical trials. I know Mayo is working on a type protein that attaches to prostate cancer cells only and kills them leaving healthly cells alone. I am unsure if in clinical trial basis yet.

I think what a urologist and R/O should give is the options for treatments and the pros and cons of radiation and RP.

The idea that “if you choose radiation first, you cannot have surgery later” has some truth to it, but is old-school and doesn’t consider modern treatment techniques.

If there is local recurrence after initial radiation, these days choice of treatment would depend on the nature of the recurrence; there are other options - focal therapy (e.g., cryo), brachytherapy, SBRT, and yes even re-radiation (w/rectal spacer) in some cases. Dr. Rossi answers a question about this in his presentation during the 2023 Mid-Year PCRI conference: https://www.youtube.com/live/WTqPnSRYtW4?feature=share
—> Starting at time: 4:53:00.

(I personally know two guys who had their prostate cancer recurrence re-treated with SBRT, because the recurrence was a single spot.)

So, I wouldn’t let the old school “no options if recurrence after initial radiation” philosophy change an initial radiation treatment decision.

There are many different types and doses of radiation, of course, but I'd hazard a layperson's guess that if your PSA starts rising again after a large, "curative" dose of radiation to the prostate, the culprit is more often outside the prostate (so it wouldn't make sense to try to remove it anyway).

More often, but not always, unfortunately *sigh With cribriform and IDC things get dicey.
https://www.sciencedirect.com/science/article/pii/S0893395222002629
Also :
"Herein, we analyzed radiorecurrent cases of PCa in patients who underwent salvage RP and proceeded to demonstrate that tumors without treatment effect are enriched in both cribriform PCa and IDC-P, collectively referred to as cribriform morphologies, and exhibit genomic alterations that are often seen in advanced PCa. Our observations suggest that these recurrent tumors are likely driven by treatment-emergent clones that are either absent prior to the initiation of treatment, or present with an increased survival advantage relative to the pretreatment state. Understanding the phenotypic and genotypic diversity of recurrent PCa following RT is critically important to understanding radio-resistance and facilitating optimal patient management."

If the cancer is inside of the Prostate and they did a scan to confirm it, They could take it out but you will still have the urinary issues. if you choose Radiation those issues may come on later. if it’s outside of the Prostate in the lymph nodes, then Radiation will be done to the lymph nodes and the Prostate. If you remove the prostate the lymph nodes on the outside may still need Radiation very soon. If not your may be on hormone treatment for a while

Good info. And also bear in mind that small micrometastases and individual circulating tumour cells won't show up on any radiology scan (even PSMA-PET), so the oncologists never actually know for sure that the cancer is still confined to the prostate; instead, they take a highly-educated guess at probabilities based on things like Gleason score, Decipher score, germline genetic testing, location and type of known cancer cells (as @surftohealth88 mentioned), etc.

When the cancer "recurs" after a prostatectomy or full dose of radiation, that often actually just means that their educated guess was wrong (despite best efforts), and the cancer *was* already outside the prostate but not yet detectable.

@northoftheborder
Hope you guys are still our friends up there! I took several cruises out of Vancouver and loved Canada.

I agree with you. I sometimes crinch when I hear posters post they only had radiation on certain areas of prostate. My R/Os at Mayo and UFHPTI stated they radiate all areas of prostate and will add margins.

Why I asked? Because a biopsy will only show the cells where taken. It is almost impossible to take a biopsy of all cells in prostate. So you might miss a part of prostate that has cancer so we radiate all of prostate and margins regardless of the specific areas found by biopsies.

I researched this to find we are talking about cancer at a cellurar level. So my little prostate got radiated along with my margins. It seems to have worked as my PSA last test was .10 when before treatments was 3.75.

I agree with your assumption of the culprit being outside prostate when PSA rises. I think that is one of the things my urologist, PCP, and R/Os looked at when we all thought radiation was best treatment for me.

@brianjarvis
I am glad you posted this.

I have read post where if you have radiation you cannot have surgery. That is not correct.

What the issue is that radiation causes a lot of damage to prostate and margins. It does not make a good surgical organ to remove after radiation damage to it and the margins. What I was told a Mayo and my own research is the bottom line not many urologists out there experienced and expert enough to do the surgery and thus most do not want to do them.

However there are (per Mayo) urologists that do do surgical removal of prostate and other tissues after a patient has had radiation treatments. They are just hard to find as requires some really expert ability.

Again I am glad you posted your post as it echos what I have been told by my medical care team.