Prostatectomy vs Photon radiation vs Proton Beam Therapy

@jeffmarc you have the right mindset and must be very strong emotionally. The generics are what they are. I am doing a test and waiting on decipher score. This all sucks to be frank. But I’ll glad the survival rates are much longer. And it seems like I have options. They all have their trade offs. Thank you again and stay positive and healthy.

@bdouglas67

My PSA has steadily declined since 2022 from 10.29 before I was treated to .61 a few months ago with the exception of a one month slight rise, which was more my fault. I still test every quarter even though my RO says every 6 months would be ok.

My urination flow is better than before I was treated and I was surprised. I have no pain or blood anywhere, which was true before and after treatment.

I do work out regularly in a gym and play golf and all good (although my game is a work in progress).

By the way, I would have picked Proton if it had a built in MRI. I respect all the studies being done in this direction as well as patient experiences in this direction BUT none of the studies compare Proton DIRECTLY with MRI guided photon such as the Mridian or the Elekta Unity. As two RO's said to me, what you can see in real time, you can treat.

Many RP's end up in salvage radiation too. That was a friends viewpoint in doing radiation instead of RP. A 50-50-90 roll the dice thing 🙂

I was considering protons. I'm 75, Gleason 4+3, cT3b by virtue of seminal vesicle invasion. I was surprised when discussing treatment options at my recent appointments at an NCI designated cancer center. This center has a proton facility. Management is heavily promoting it for prostate cancer therapy. I can't listen to local sportscasts without hearing advertising about this fantastic game changing therapy.

The urologist I saw there to talk over RP didn't think surgery was the best given my particular case. So this is a surgeon recommending radiation therapy. When I said I liked what I had read about the theoretical characteristics of protons, he was very negative. The senior radiation oncologist he referred me to, this is at the same NCI facility that is heavily promoting protons for my type of case, was also negative. One of his comments was they should stop aiming all these ads at prostate cancer patients. His proposed treatment plan was photons.

Some things to consider when making your decision.

With radiation and a Gleason 7 unfavorable, your radiologist will most likely recommend ADT. There is a lot of information regarding the effects of ADT on this website.

If your in a sexual relationship, radiation will allow you to continue, (no semen) while surgery usually results in ED for an extended period of time following the procedure.

I found that the urologist want surgery and the radiologist want radiation, so they're not much help in the decision process. It comes down to what you are most comfortable with. Good luck!

@climateguy
This may help explain things:
So why would a radiation oncologist recommend IMRT (photons) over protons?
Because treating the seminal vesicles requires wider, deeper radiation fields.
And in that situation:
IMRT often provides better coverage and fewer risks than protons.
Specifically:
Seminal vesicles are long, thin structures that extend upward and outward.
They are harder to target precisely.
IMRT handles complex shapes better.
It can “wrap” dose around anatomy more smoothly.
Proton beams can be more sensitive to motion and tissue changes (like bowel gas or bladder filling).
For deep or irregular targets like seminal vesicles, this can reduce accuracy.
Several major cancer centers prefer IMRT for prostate cancer with extracapsular extension or seminal vesicle invasion (SVI) for these.
I summary: For prostate cancer that has spread into the seminal vesicles, IMRT is often the safer, more reliable option to cover all cancer areas fully while protecting organs as much as possible.

@bdouglas67

It is a good idea that you requested a genomic test like Decipher or GPS. That is because not all 3+4 or 4+3 cancers are the same. For exmple, my initial biopsy report showed 3+4, and only 1 out of 18 cores. But a GPS genomic test before surgery came at 47 (very aggressive and high risk cancer), indicating that my initial biopsy report did not detect the wolf in sheep's clothing. A Decipher test after surgery came up with a score of .75 exposing again the wolf in sheep's clothing.

Once all your tests are completed, and your initial risk profile is determined you have multiple treatment options. And like you suggested, you will have to weigh many factors before selecting the best treatment options for you. These factors include insurance coverage (or not), efficacy, side effects, convenience etc.

Fortunatley, you are in an excellent forum where you can weigh these options by learning from the experience of others.

@chippydoo

Yes, but as "many" can have BCR after RT and than have no choice of RT and need to do RP that is almost impossible to do and IF it can be done than it causes MUCH higher incidence of permanent incontinence and definitely ED.

Younger patients are almost always unanimously advised to have RP as the first line of defense and there is a reason for that - life expectancy is much longer and so is than possibility of eventually having BCR and need for RT as second line of deffence. Also, RT can cause secondary cancers and for young patients it is better to avoid radiation if possible.

For older patients and patients with low grade cancer it is 50-50 decision, for younger ones or with aggressive cancer it is different situation.

@johnernest
the RO wasn't enthusiastic about protons for any prostate cancer patient.

@johnernest
I’m not sure the comments were accurate so I did some searching, And the information I found does not confirm what was said.

The assertion that IMRT provides better coverage and fewer risks than proton radiation for prostate cancer with extracapsular extension (ECE) or seminal vesicle invasion (SVI) is not consistently supported by medical evidence; studies generally indicate that IMRT and proton therapy offer comparable outcomes for high-risk prostate cancer.
Both IMRT and proton therapy are effective and safe treatment options, with the primary difference often lying in the specific side effect profiles and costs, rather than the overall efficacy or coverage for advanced features like ECE or SVI.

Here’s 2 links that discuss this
https://www.redjournal.org/article/S0360-3016(25)03372-3/fulltext
https://www.astro.org/news-and-publications/news-and-media-center/news-releases/2024/astro24efstathiou.