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RARP vs RT plus ADT for Gleason 8 with cribiform and high Decipher
I’m new to prostate cancer, having been diagnosed in December 2025 with Gleason 8 (4+4) with cribiform architecture, stage T1c, PSA 4.7, and Decipher score of 0.97. MRI, biopsy, and PSMA PET suggest that the cancer is localized, but PET scan doesn’t have much diagnostic value given my very low PSMA expression. I have a family history of cancer: mother (breast), brother (small cell prostate), brother (brain), brother (skin)). I had genetic testing in 2023 and it was negative. Had second opinions by a major cancer center on the MRI, biopsy and PET scan and they all confirmed the original findings.
I’ve received second opinions from both the chief of urologic surgery and the vice chair of radiologic oncology at a major cancer center. The surgeon told me that I should assume multimodal treatment will be required and recommended RARP (fascia-sparing, nerve-sparing on the right side) so to avoid ADT now and perhaps have more flexibility of treatment upon recurrence. However, in a subsequent conversation he told me that both surgery and radiation are good primary treatment options for me. The radiologic oncologist’s recommendation was EBRT (45 fractions with BioProtect spacer) plus 24 months of ADT, and he wants me to consider participating in the High Five clinical trial (NRG-GU013 - comparing SBRT to EBRT in high-risk patients). I asked the RO what he would do if he were in my shoes, and he was adamant that if he had my cancer he would go with radiation plus ADT.
I’m 69 years old and in excellent health (except for prostate cancer), work out 10-15 hours per week, and compete in triathlon and gravel bike events. I’d like to be able to continue to maintain fitness and to swim, bike, run, strength train, and do yoga (even if I can’t compete in triathlon and/or gravel bike racing at the same level or at all). Urinary incontinence is the side effect that worries me the most, although the side effects of ADT are not too far behind. Cancer control is important, but so is quality of life.
I’d be interested to hear from others in a similar situation and how you weighed the pros and cons of these treatment options, and how it’s working out for you. Also, would be interested to hear from others with low PSMA expression and how you are staging / monitoring your disease without the benefit of the PSMA PET scan. Thanks! Ken
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@shelby29
Because radiation with aggressive cancers sometimes does not give full result.
My husband was diagnosed with 4+3 and cribriform and IDC , Decipher 1 , PSA 5.6 before surgery and was recommended by both, the surgeon AND the radiologist, to have RARP as initial treatment.
RO said those words : " You have aggressive cancer and it is best to have "aggressive" approach in those cases and the most aggressive approach is surgery."
After RARP it was discovered that his gleason was actually 4+5 !!! So - if he was treated as having 4+3 which would require just 6-12 mos of ADT and "regular" RT , you can bet it would NOT be successful treatment ! Besides, PSMA is never all telling.
My husband is extremely happy that he had RARP, recovered very fast and is living a normal, very active life, already skiing and hiking full speed and working 3 jobs. If anything was "left" it would be something that is of lower grade and would be easily zapped with RT if necessary since it is not hidden inside the gland and possibly resilient and mutating even further O_O !
Every case is different and aggressive cancers require very specialized approach.
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7 Reactions@surftohealth88 wow, so good to know...and you are spot on...everyone is different, no cookie cutter treatment. My mayo Rochester docs did not recommend surgery....not 100% sure why. But doing well with the treatment the recommended.
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3 Reactions@klw23 thanks. We find the waiting around for the results the worst part of this process. Good luck for your scan too.
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2 Reactions@surftohealth88 thanks for sharing your husband's experience with RARP. That is great that he had a quick recovery, and encouraging for men like me who are trying to decide what primary treatment path to take.
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2 Reactions@shelby29 That is the issue I am struggling with. I am waiting on the results of the ArteraAI and Prostox tests and have an Axumin PET scan scheduled for February 6. I am hopeful that my consult next week with a medical oncologist will help me pull all of this together and make a decision.
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1 Reaction@shelby29
My urologist and radiation oncologist both said surgery after radiation is more problematic and difficult due the the damage the radiation does to the prostate. You might want to ask your medical some more questions about that.
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2 Reactions@ddavid I was told once you have radiation, no need for surgery. Prostate is reduced to mush.
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1 Reaction@shelby29
Surftohealth88 explains it well. His is a story similar to mine. If there is a chance the cancer is aggressive, you need an aggressive approach. Surgery first is the more aggressive path. I'm happy I went that path, they found specific details about the my aggressive cancer from the pathology report of the removed prostate.
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3 ReactionsThanks to everyone who commented. I was able to get an Axumin PET/CT scan last Friday. There was strong tracer uptake in the prostate at the site of the biopsy-proven cancer, but no evidence of tracer avid nodal or distant metastatic disease. Based on that, the biopsy results, and the prior MRI, PSMA PET scan and bone scan, we think that the cancer is localized. Decided today to go with surgery and, much to my surprise, was able to get it scheduled for February 20 at Siteman Cancer Center in St. Louis. It's been a long road to get to this decision but I think it's the right one for me.
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