Proton, Photon, or Cryotherapy?

@abrero1947
A lot of questions. You have already gone through the biopsy process. Do you have an experienced urologist? If so, and you trust his/her experience/knowledge, please confer with him about your questions and or asked for a referral consultation to R/O. If you don't feel comfortable with answers seek a second opinion.

I can comment on personal experiences with some of your questions but those questions on treatments that I did not have personal experience with can be best answered by those that did.

1. Proton versus photon: I had proton radiation, 30 rounds low dose 7 weeks. I did consultations with Mayo Jacksonville. Mayo PCP. And per my Mayop PCP got a second opinion at UFHPTI.
Per those medical experts: There is no significant difference in successful outcome between photon and proton radiation treatments. The difference is that photon radiation enters body full dose, treats your treatment areas and continues through the body. Proton radiation can enter body at lower dose, treat your treatment area, and does not continue through body. Thus the possibility of proton radiation not causing as much damage to surronding organs and tissues.
2. The 5 high dose is usually done over a two week period. My R/Os and PCP discussed the options with me and stated their research was showing increased side affects with high dose. However the treatments are over quicker and you are on the recovery time period quicker. Low dose is usually over a couple of months (I had 30 rounds of low dose proton).
The success rate for prostate cancer is very high if not diagnosed as high risk (per my R/Os) level and has not spread already outside the prostate. Have you been advised about additional tests that can help define your treatment options. Those tests are Decipher, PSMA, bone scans, etc. Again if these have not been discusses with you already ask. I had all those mentioned above. Both my R/Os stated would treat my entire prostate and margins to treat all cancer present. But yes areas could be missed and cancer show up again and additional treaments needed.
3. Did not have the radiation treatments in this question so cannot provide my personal experience with it.
4. This answer should come from your R/O (radiation oncologist)
5. Again no experience with this so cannot pass on my experience with it.
6. Is a good question and knowing the answer would be beneficial for all of us. If you go to an major medical facility (Mayo, Cleveland, Clinic, John Hopkins, UFHPTI, and many others) you are going to have experienced and knowledgeable specialists. If you are not comfortable with your R/O seek a second opinon at another medical institution.
I hope this helped. I am sure those on MCC that have personal experience with the questions you asked can help you with their personal experience.

1. I think you get the answer to your first question here

3. Same Answer as #1

4. Your doctor will decide that based on what your treatment is going to be.

5. Getting a 2nd opinion is something you should absolutely do. You can go to a different doctor/facility To get that second opinion, It may just matter what you are insurance will cover.

If You don’t want to go on ADT or you could take Darolutamide alone. It has the least side effects of the drugs that are available and doesn’t reduce your testosterone like ADT. It also doesn’t cause cognitive issues. I know a lot of people taking it alone, including me

Interesting. My oldest brother is 78y, was recently diagnosed with PC with similar numbers as yours. They’re going with 28 sessions of IMRT (70 Grays total radiation) + ADT. (In 2021 at 65y, I was diagnosed with PC with similar numbers, and had 28 sessions of proton (70 Grays total radiation) + 6 months of ADT.)

ADT is usually recommended for 4+3 due to the severity of disease and the risk of metastasis. But, you have your reasons for not using ADT. It’s your call.

(1). Technically, Proton with its Bragg-Peak characteristic, should provide fewer QOL side-effects than standard IMRT/photon. (That is why I chose Proton.)
There are two clinical trials looking into this; COMPPARE and PARTIQoL. (You should look up these studies.)
—> The PARTIQoL trial showed that both therapies achieved similar tumor control rates and patient-reported quality of life outcomes. Specifically, there was no significant difference in progression-free survival or patient-reported outcomes like urinary, bowel, and sexual function
—> The COMPPARE trial is another large-scale study also comparing proton therapy and IMRT, but with a different focus on patient-reported outcomes. The COMPPARE trial is still ongoing,

(However, was your question comparing Proton SBRT vs Photon SBRT???)

(2). Regarding getting 5 proton treatments. In this 2023 Mid-Year PCRI conference, Dr. Rossi has a lot of information about proton therapy in his presentation starting at 3:38:45 at: https://www.youtube.com/live/WTqPnSRYtW4?feature=share

Dr. Rossi specifically talks about Proton SBRT and Photon SBRT during a Q&A session at 4:30:45.

As for needing more radiation if there is a recurrence —> following any external radiation, if there is local recurrence you have options (depending on the nature of the disease), such as focal therapy, brachytherapy, and sometimes even re-radiation (if the rectum didn’t receive too much radiation the first time). Are you planning to use a rectal spacer (SpaceOAR, Barrigel, or BioProtect)?

@abrero1947 I cannot add much to the good information given above other than I had 5 sessions with the Mridian linac sbrt machine with a built in mri vs other machines that use fused images. They used 2 mm margins instead of 3-5 mm for most other forms of photon radiation, including proton. This meant less exposure of healthy tissue. The machine had dynamic ability to adjust, in real imaging time, any changes in your body during treatment that might cause one to be re-mapped. They can do it in real mri time. What they see they can treat. The Mridian, and I believe the Elekta mri guided machine as well, has gating technology that stops automatically if the machine detects radiation going outside the mapping area. My side effects were a slight lessening in urination after the 3rd, of 5 treatments and Flomax took care of that overnight. I was treated in February of 2023 and my psa has been declining reaching my nadir of .66 in March of 2025.

No. 2 - the same total amount of radiation is delivered in all primary RT treatment of the prostate; just in different "fractions".
My salvage radiation treatment was delivered in 1.8 gy fractions over 37 treatments for a total of 66.6 gy.
Larger doses are delivered each session for fewer sessions in the other protocols, such as the 5 session.
I may not be accurately addressing your Q.

No. 6 - there is a long educational curve for ROs, and a team of specialists that calculate and configure radiation treatment.

ADT - I received a 4 mo short course of ADT starting shortly before radiation to " weaken" the cancer cells and make them more susceptible to the radiation.

I hear your ADT concerns, and agree that it might not be my choice if in your circumstance; however I would listen to and evaluate any recommendations of adding a short course of ADT to your treatment.

There seems to be a lot of thought being given today over who, when and why receives ADT, and more instances of short term or no ADT.

Best wishes from this PCa surviving layman.

Believe it or not, a 2024 meta analysis was inconclusive for cognitive impairment in men undergoing ADT; even those already diagnosed showed little change.
In fact, there is some evidence that estradiol, delivered thru a transdermal patch, improved memory loss in post-menopausal women.
Yes, I know, apples and oranges, but the patch has been shown to mitigate SE’s such as cardiovascular events and liver toxicity in men; no studies have been done on cognition.
Just something to be aware of as short courses of Orgovyx (4-6 mos) are unlikely to cause further decline. Really need to speak with a KNOWLEDGEABLE oncologist about this. I emphasize this since many RO’s are not up to the newest research.
Phil

I think you’re right 4 to 6 months doesn’t matter at all. Those of us who’ve been on ADT for many years are almost universally, saying they have brain fog. I know I sure do struggle with it after eight years of ADT,, I’ll sit here for a minute or two, trying to remember the best word or a word, Sometimes I’ll just go to the web and type in the concept so I can get the word.

Remembering facts about things is pretty easy, but remembering the names of people, drugs, and similar type of things can just be painfully slow. If the name does come to me, finally, then even more facts related to it also come with it. It can be very frustrating, I hear the same complaints from others on the multiple online chats I attend.

I just wonder what group of people they studied to find there wasn’t a definite problem with brain fog.

https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/cncr.35210#:~:text=Open-,Access. Here’s the study -if you can get through the whole thing…,from my reading, it seems that there is a greater ‘perceived ‘or ‘objective’ recognition of cognitive decline, and not an actual one.
Also, since most of the patients studied were men of an advanced age, cognitive decline, and lower testosterone were already baked in.
Personally, before I was on ADT, I was searching for certain words. Now being off ADT I am still searching, but feel no worse.
I do think, however, that being on ADT long-term has to affect something in the nervous system. For that matter any chemical that reverses what you are genetically supposed to be, i.e. male or female, has to have some long lasting consequences.

Very thoughtful. I have the same sense. Struggling for words both before and after ADT. Personally I think my age and other life habits are having more of an effect than the ADT.

Hi jc, I follow your comments studiously. Just started a discussion on why Proton Therapy is almost entirely ignored in these discussion. Further looking at PCRI and other YT videos, it probably is the most dated in what is being produced. Do you have any idea why this is? I’m starting next month on that process but am becoming concerned that it is not mentioned any more?