RARP vs RT plus ADT for Gleason 8 with cribiform and high Decipher

@larrypt3b I personally agree with your choice of treatment. Even though radiation as a primary treatment has really evolved into an incredible modality, it is STILL radiation.
A very high Decipher score and cribriform cells are known to be somewhat resistant to radiation - even HDR as some on the forum have pointed out and suffered through.
High doses may preclude retreatment in cases where bladder incontinence is a factor (there’s a test for this- the name escapes me).
I will be the first person to say that surgery sucks - even the uneventful kind; but with all those negative factors - and the fact that post surgical pathology can be assessed for the true extent of disease - I would do as you have done and go with surgery as primary treatment. Your SRT should be fairly uneventful - Best of luck!
Phil

Your description of your priorities post-treatment reminded me of my quandary in choosing the initial treatment option. I am 71, was GL 7 (4+3), with possible EPE, cribiform, PNI and .89 Decipher. Negative PMSA. I bike and/or go to the gym almost six days a week--definitely not in your category, but physically active. So it was pick your poison--incontinence and sexual dysfunction or radiation and ADT and all that entails. My feeling was with those characteristics, the odds of avoiding recurrence were not in my favor. So I chose surgery (on 9/22/25) because I would be back on the bike quickly (3 weeks, but only short/indoors to start) and back to "normal" quickly. I wanted to do all I could before any recurrence and (to me), what sounded really terrible: a month of radiation and 6 months/year of ADT. Surgery pathology was pretty good: clean margins, removed lymph nodes were negative, confirmed EPE. My first PSA was non-detect and I just returned from a great bike trip to Tucson. I do have incontinence (and likely will for a long time or forever because surgeon could not do nerve sparing surgery in my particular case), but I don't find it to be much of a problem; I just have adapted to it. So I feel good about my choice, but this and a lot of the other discussions on Mayo Connect only confirm there is no "right" answer and you have to choose what makes sense for you and what you value, after learning all you can. Good luck with whatever option you choose!

@brianjarvis It's great to hear that you were able to continue to lift weights, run and swim while on ADT. Hope your PSA continues to stay low!

@bikeman1 Thanks for your perspective! This is going to be a hard decision trying to balance cancer control and quality of life. I've got a consult with a medical oncologist coming up and hopefully he can help me sort this out.

@klw23 The way I pushed through to the treatment decision was through introspection…. what did I want out of this?

I had told my physicians early-on that quality-of-life and successful treatment were equal priority for me. (They are not mutually-exclusive; you can have both.) That set the basis for us working together and agreeing on a treatment plan.

I wanted to balance quality of life with survival (of course!) along with the possibility of treatment in the future if needed (as medical treatments progress). This was about utilizing the best treatment techniques to get the best outcome while still surviving and maintaining my quality of life. (Every medical-related decision I ever made I made the same way; why not this?)

With success rates - between surgery and radiation - being statistically equivalent, it all comes down to side-effects and quality-of-life.

So, I put together a spreadsheet and listed across all available treatment options. Then listed down all possible & possibilities (%) of side-effects from each type of treatment, and gave each one a numerical score. The one with the lowest total “score” ranked highest. We then took that list, and narrowed it down based on the preventions available related to each individual type of treatment.

I then “scored” the quality of life priorities that came out of my introspection, and compared that final score result with the treatment options score result.

The score that was closest matching was my 1st choice, 2nd closest was my 2nd choice, etc.

Surgery ranked last —> SBRT next to last —> then IMRT —> finally, Proton ranked at the top.

I wound up having 28 sessions of proton radiation + 6 months of ADT. It wasn’t a difficult decision, just time-consuming.

If you do the analysis, the numbers will clearly show the pathkla The way I pushed through to the treatment decision was through introspection…. what did I want out of this?

I had told my physicians early-on that quality-of-life and successful treatment were equal priority for me. (They are not mutually-exclusive; you can have both.) That set the basis for us working together and agreeing on a treatment plan.

I wanted to balance quality of life with survival (of course!) along with the possibility of treatment in the future if needed (as medical treatments progress). This was about utilizing the best treatment techniques to get the best outcome while still surviving and maintaining my quality of life. (Every medical-related decision I ever made I made the same way; why not this?)

With success rates - between surgery and radiation - being statistically equivalent, it all comes down to side-effects and quality-of-life.

So, I put together a spreadsheet and listed across all available treatment options. Then listed down all possible & possibilities (%) of side-effects from each type of treatment, and gave each one a numerical score. The one with the lowest total “score” ranked highest. We then took that list, and narrowed it down based on the preventions available related to each individual type of treatment.

I then “scored” the quality of life priorities that came out of my introspection, and compared that final score result with the treatment options score result.

The score that was closest matching was my 1st choice, 2nd closest was my 2nd choice, etc.

Surgery ranked last —> SBRT next to last —> then IMRT —> finally, Proton ranked at the top.

I wound up having 28 sessions of proton radiation + 6 months of ADT. It wasn’t a difficult decision, just time-consuming.

If you do the analysis, the numbers will clearly show the path.

My biopsy in July 2024 listed me as 4+3, and I chose surgery after talking with maybe 10-15 people. The surgery in November 2024 showed my cancer was more aggressive - 4+5, and the surgeon said it could have been fatal if we had waited. I had a number of adverse factors, including bladder neck invasion, cribriform and multifocal. My PSA remained low (0.04) but we decided to move ahead with radiation because it was trending in the wrong direction. I had Lupron in October and started radiation in December. I've had 35 treatments with 4 to go.

I found the process of deciding on a treatment frustrating because I had to make the decision as the least-qualified person at the worst time in my life. I'm confident this will work but after 18 months it's hard to know anything for sure.

@anosmic1 Well, you DID make the right decision, as evidenced by your surgical path report; radiation alone might not have done the trick and where would you be then?
Sometimes we DO get lucky!
Phil

Hi, Klw23, my husband opted for RALP, with a PSA of 12.1 on the basis of it being contained in the prostate. He was 64, fit and active at the time.
He recovered fantastically from the operation no incontinence or ED post op. Unfortunately pathology revealed his cancer was infact Large Cribriform which had already spread outwards from the prostate (not seen on MRI pre op). The margins were all clear. His post op PSA being 1.9. and his Gleason 4+3. PSA rapidly rose over the following months but 2 PMSA CT scans were negative as he is one of the unfortunate people who don't react to the radioactive material. The cancer was eventually found in a rib by taking HT to cause a 'flare', to show the location. SABR was excellent in sorting out his rib.

He had a torrid time on the HT and ended up with heart and kidney problems (no history prior). Once the HT was out of his system his problems went and he is feeling fit and healthy again. The flip side is now his PSA is around 30, but they can't find the cancer again though they suspect its possibly in a lung (scan results due in 4 weeks). He knows he has to try HT again, aand is debating which one to try. He wants quality of life verses quantity which I understand.

We are pleased he had RALP as we wouldn't have had the hystology otherwise as it hadn't been picked up.
Ultimately its a minefield and only you can decide which option to go for its a difficult decision for everyone but I wish you the very best for your journey.

@cher60 thanks for sharing this info about your husband's experience. Hope things go well with his scan and follow-on treatment. I've got an Axumin PET scan scheduled this week and then hopefully can make a decision on a primary treatment.

Why go through surgery and it's aftermath when you know you'll need radiation also. Go with radiation and ADT.
Keep exercising and lifting weights and eat a healthy diet! Your QOL won't be perfect, but you'll be around to keep plugging away.