Surgery or Radiation if large cribriform found in biopsy?

I believe both cribriform large and small have in some cases been more resistant to radiation, however that being said due to that higher aggressiveness it is approached not just with radiation but with ADT. I think there is a member on the board here who first went radiation and then on relapse was fortunate to find a surgeon which their are some that due salvage surgery which it is well known surgery after radiation is difficult and most Surgeons will not attempt. I think his position is that if it was likely to relapse regardless , get the surgery first (certainly all your factors go into surgery needing to be a favorable treatment) and then wait if BCR happens then proceed to the radiation and ADT. I believe he feels he should have gone surgery first. I have cribriform not stated large or small pattern and went surgery. These are all things to discuss in your consultation’s. Their is not going to be one right answer.

Surgery is recommended as the best treatment for large cribriform. If you were to get radiation, you would probably want IMRT and brachytherapy.

If you have metastasis outside the prostate, then they usually don’t like to do surgery As the primary treatment.

There is recent research that has meaningfully changed the landscape w/r/t cribriform and a lot of the conventional advice is being revisited.

This paper from last October concluded that in a retrospective review of the 15-year outcomes from the PROTECT trial, men with cribriform-positive PC experienced markedly lower rates of metastasis after radiotherapy combined with ADT, as compared to surgery or AS.
https://jamanetwork.com/journals/jamaoncology/article-abstract/2840006
"In this secondary analysis of the 15-year outcomes of the PROTECT trial, the cumulative incidence of metastasis was 25%, 26%, and 8% for men with cribriform-positive prostate cancer assigned to active monitoring, surgery, and radiotherapy with neoadjuvant androgen deprivation therapy (ADT), respectively."

However, these researchers also published a follow-up paper showing that the adverse outcomes for cribriform-positive patients were highly concentrated among men with higher-risk staging or grading:

"Of 480 men with RP specimens reviewed, 143 (30%) had cribriform-positive disease and 337 (70%) had cribriform-negative disease. All 21 metastatic or lethal events occurred exclusively in the cribriform-positive group (15-year cumulative incidence 14%). Within the cribriform-positive cohort, risk was concentrated in patients with pT3b stage and/or GG ≥3 (15-year cumulative incidence 27%). In multivariable analysis of cribriform-positive patients, pT3b stage (hazard ratio [HR] 8.19, 95% confidence interval [CI] 2.39–28.10; P < 0.001) and GG 3 disease (HR 5.12, 95% CI 1.59–16.40; P = 0.006) were independent predictors of adverse outcomes. Conversely, cribriform-positive patients with GG 2 and ≤pT3a had a 15-year event rate of only 3%."
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Source: https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.70261

There are valid cautions regarding the overall statistical validity of these conclusions and more studies will surely seek to verify, but this has absolutely changed the calculus of treatment decision-making for cribriform-positive patients: if you are cribriform-positive and also either GG3 or higher and/or stage pT3b or higher, then this would argue for radiotherapy + ADT as your first-line treatment.

@jeffmarc wrote "Surgery is recommended as the best treatment for large cribriform."

This is no longer unconditionally accurate given the results of the studies I cite in my prior comment. For men with >=GG3 and/or >=pT3b cancer, the weight may now be shifting in favor of radiation + ADT over surgery as a first-line treatment, given what the PROTECT trial showed in terms of lower incidence of later metastasis. There won't be a clear-cut answer without additional studies, of course.

There can be other considerations too and every man should work closely with his team of doctors. But this does show how quickly our understanding of prostate cancer treatment can sometimes evolve.

@notpetecrowarmstrong
I wish it was that simple. Other tests have shown that surgery works better with cribriform. UCSF had a seminar about cribriform and specifically said there was a problem using radiation. That’s why I mentioned adding brachytherapy to IMRT.

Here is the link to the UCSF webinar were they discussed the fact that radiation is not effective enough.
https://www.urotoday.com/video-lectures/a-journal-club-for-patients-with-prostate-cancer/video/mediaitem/4452-unfavorable-histology-classification-aims-to-reduce-unnecessary-treatment-journal-club-jesse-mckenney-cornelia-ding.html

@jeffmarc I'm certainly not suggesting anything is simple. I think my comment was clear that this is the potential start of a shift but not definitive.

That UCSF webinar predates the studies I cite by a full year, so they were unaware of the findings. The studies also reference RT+ADT, not RT alone.

I've spoken directly with three oncologists who've all said that the findings published in the past several months have had a real -- but preliminary -- impact on how MOs think about treating cribriform.

And for what it's worth, I had surgery myself and then had cribriform glands identified in my post-op slides, but they were not previously IDed on my biopsy and so that didn't factor into my decision-making.

@notpetecrowarmstrong
You should come to an ancan.org Advanced prostate cancer Meeting. They are held the first four weeks Of every month.

The next one will be on 6 July at 5pm Pacific time.

There were five doctors last meeting one is a specialist in prostate cancer.

The study you are referring to finished in March 2023. More recent information has shown that surgery actually works better just like the UCSF doctors said.

You can ask about this at the meeting.

They’ve been helping people with prostate cancer treatment for about 15 years. There are a lot of experts that come to the meeting that really know what’s going on.

@jeffmarc Thanks for that ancan.org info. I'll try to join!

@jeffmarc Th link you provided is for a discussion on modifying the grading system. I see nothing in that article on the benefits of surgery versus radiation for prostate cancer with Cribriform. Please post the proper link so that we can see the evidence.

@overage
Well, that link discusses grading systems it also Discusses cribriform and They do say during that discussion that radiation does not work fully on cribriform.

Did you listen to the whole thing?