Second opinion for husband's stage 4A prostate cancer? And update

My prostate cancer was already stage 4b (distant metastasis ) when it was discovered, so I never had the opportunity your husband has now to decide.

From where I am now, I'd suggest being as aggressive as possible as early as possible, because knowing about it earlier is a gift, but I don't know what I would have chosen for real in your husband's situation.

Sorry for your husband’s diagnosis. I have stage 3 PCa with lymph node involvement so my opinions are only based on my experience. As I understand it the standard of care TYPICALLY involves in order 1.) surgical removal of the prostate (RP), 2.) first and second generation androgen deprivation therapy (ADT) and 3.) radiation (RT) to the prostate bed and lymph node basin. A decipher test or other genetic test may be valuable yo understand what other treatment options are appropriate.

Best wishes for success on your journey together.

I would definitely want two more opionions One from a radiation oncologist and one from a proton radiation oncologist. The surgical oncologist I spoke with wanted ADT for two months before surgery to halt the advance and to shrink the tumors. Because the "sweet spot" (terrible terminology) for ADT is at two months I think that aggressive treatment without delay will give you two months on ADT to decide between surgery and radiation.
I think the best way to get the second and third is with teleconference in the comfort of your home. It can be good to record the call instead of taking notes. Best wishes.

My case was somewhat similar to your partner's. I insisted that the prostate be removed even though a specialist at a major cancer center said it was a waste of time and effort.
I found another specialist at another major cancer center who agreed to remove it. No regrets.
I am a major advocate of second and third opinions.
Daniel

I was diagnosed with stage 4a. Gleason 9 like your husband. Mets to pelvic LN. This was after robotic surgery. Great response to ADT and radiation. My PSA was 13.4. With a Gleason 9, he definitely needs aggressive treatment. I was diagnosed six years ago. He should be ok. Best wishes.

So you had surgery then ADT and radiation? Thank you for the information.

(layperson, again)

This study is pretty old now — radiation therapy, surgical techniques, and pharmaceutical treatments have all advanced massively in 20–25 years — but for *localised* prostate cancer (below stage 4), it found no significant difference in 10-year overall survival among patients who received radiation, surgery, or active surveillance.
https://www.nejm.org/doi/10.1056/NEJMoa1606220
As far as I know, there's still no major evidence that surgery gives a better survival outcome than radiation at any stage — that's what my onco team (researchers who teach at a med school) told me — but each approach comes with a different collection of potential side-effects, and that's probably where you need to focus. And your partner may end up with radiation after a prostatectomy anyway, since their cancer has already escaped the prostate.

You are so correct. At 75 they said RT/ADT would suffice. Prostatectomy would result in same outcome. No difference. I’m < .01 PSA 18 months down the road. Two pelvic lymph nodes were affected. Also had it in seminal vessels. You won’t believe me but I felt the cancer fall off the wall of the seminal vessels in bed last week. It was dead- no more testosterone to feed it. Thru the process of phagocytosis the body will destroy this dead tissue. That’s my opinion only, just as me eating mushrooms keeps my PSA at 0. Lol. Hope you enjoyed my info???

When you meet with the 2nd opinion docs, be sure and do a deep dive into side- and after-effects as well as chances for survival. I suspect with the extensive involvement of cancer throughout the prostate that nerve sparing surgery is not possible, which will probably mean a loss of erectile function. And the increased likelihood of bladder neck involvement raises the chance of long-term incontinence issues.

I strongly support talking with both a radiation oncologist and medical oncologist who specialize in prostate cancer, even if you need to pay out of pocket.

Yes, I am also aware of those studies. However, I followed the advice at the time of Dr. David Samadi, a renowned prostate cancer specialist who advocates removal even in cases where the cancer has spread outside the prostate.

You can find studies of all types that show different outcomes to support your decision. The truth is that prostate cancer studies often take many years to develop. Having helped design studies in the field of psychology, I can tell you that scientific studies have so many variables that it can be mind spinning and different outcomes can be arrived at with one change in one variable. Plus, we are also all individuals and not statistics.