1. < Prostate Cancer

Treatment Decision - Radical Prostatectomy versus Radiation Therapy

Posted by dougharris @dougharris, Oct 6 4:29pm

Recently diagnosed and now stuck in that frustrating "no man's land" between surgery and radiation therapy. Diagnosed after an increase in my PSA to 5.2 and concerns about family history of disease (father). Particulars are as follow: MRI showed 2 lesions, PI-RADS 5, with no evidence of seminal or lymph node involvement. Follow-up perneaural biopsy showed Gleason - 3+4 from biopsy; Biopsy showed positive in 9 out of 22 cores with perineural invasion present in one biopsy sample. Surgeon indicated that I was not a candidate for AS and recommended surgery (robotic). The surgery, however, would be somewhat challenging due to the location of one of the tumors near the apex of the prostate and based upon this he gave me a clinical staging of cT3a. This would require a wide dissection to maximize the probability of negative margins which might have a negative impact on the ureal sphincter. The imaging was inconclusive for extraprostatic extension, but suggest there might be local extension. Surgery would probably include a partial nerve dissection with nerve sparing on one side.

Due to these complications, the surgeon suggested that I also consult with a radiation oncologist. Radiation oncologist confirmed the diagnosis and also felt that the EPE would be rated at 1 - 2. No surprise, the oncologist recommended radiotherapy over surgery. This would be IMRT or SBRT with or without ADT (informed by Decipher test results). A sample of my biopsy tissue was sent out for a Decipher test to assess the genetic aggressiveness of the cancer. This would also inform my eligibility to participate in a clinical trial relating to RT with or without ADT.

So there I am...learned much more about PC than I ever thought I would have to. My doctors are at Mayo Clinic - Phoenix and they really seem to know their stuff. I am a retired Engineer with a background in statistics so I have reviewed at least 15 study results at this time. The survivability is relatively easy to quantify. The difficult part is the quality of life impact. I am 66, in good health (I cycle more than 100 miles/week) so discussions that sort of put an "end date" to your survivability are a bit unnerving. The difficult part of this process is the "joint decision making" with your providers when you are stuck in the middle between two choices with very similar statistical outcomes, but potential divergent and uncertain QOL impacts.

My initial thought going into this was that surgery would be my path. The idea of removing the "source" was appealing. The challenges with my specific presentation, however, gave me second thoughts and after exploring the RT options, I began to rethink the surgery approach. I am stuck in that state and looking for any insight that might help me move forward...

Thanks!!!!

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CancerFree | @cancerfreekevin | Oct 14 9:39am

I posted that response as I see many underlying themes and/or angst around sexual health and of course loss of length. Both areas appear to be somewhat diminished, especially length loss in the pre-op conversations and the resulting post op surprise. I suspect it can be a justified big shot to a man's ego when staying on this side of the dirt should be what matters contrary to our social norms in this area. My decision to jump on the Trimix train earlier than some was based upon a laymen's thought process that with a little early support I might be able to return to pre-surgery levels and hopefully have a relatively normal sex life. I suppose I was lucky, but I was also clear in my mind that if it didn't work, so be it as it was #2 on the priority list of outcomes. Best of luck to you and your wife as well!

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mesaaz7 | @mesaaz7 | Oct 14 11:59am
In reply to @chipe "I am 71 and found out in April that I had PC. MRI and Biopsy showed..." + (show)
@chipe

I am 71 and found out in April that I had PC. MRI and Biopsy showed PC in the prostate and seminal vesicles. Biopsy showed Gleason 7's and a 9, T3a, Score 5 and the cancer of the aggressive type.

My doc and I discussed the treatment options and since I have had many heart issues he said I might not survive the RP. I am in really good shape and I elected to go with the RP. My cardiologist said I was fine.

My thought process was that if you have radiation, you more than likely cannot have RP (but I learned recently that there are a few rare cases that you can). Yet, if you have RP you can have radiation and ADT. I thought of the RP/ADT/Radiation as a "triple antibiotic" type of treatment. We did the RP and now I am awaiting what the next steps are.

Yes, I have mild incontinence, and they had to remove one set of nerves which also had PC, which will make getting an erection extremely hard, but at my age that's not a big deal. I learned a long time ago marriage is not about sex, marriage is about love and mutual respect.

Jump to this post

I am almost 70 and have periodic AFIB and was also was told by a doctor specializing in radiation treatment that I was too high of risk for RP. He described 65-70 as a grey zone where over 70 generally should select radiation and below 65 RP was fine. Because of the combination of AFIB and age he strongly recommended radiation. However I have selected RP.

I am NOT sharing this to discourage people from the radiation option but instead to suggest you should consult with at least one radiation and one surgical specialist before making a decision. I feel most doctors are purely motivated by the desire to help you, not money and give their honest opinions. However in my case the RP specialist also with years of experience felt I was a low risk case for RP and in my specific case this got me back to work full time quicker. Only time will tell if it was the right decision . . . . my surgery is not until late November.

I appreciate your sharing as we are of similar age. Your comment "My thought process was that if you have radiation, you more than likely cannot have RP (but I learned recently that there are a few rare cases that you can). Yet, if you have RP you can have radiation and ADT." was the number one reason I selected RP.

I am lucky in that my cancer appears to be less aggressive than yours. Hoping you do not require further treatment and have a great life going forward. I share your feelings on what is important in life.

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3 replies
chipe | @chipe | Oct 14 12:42pm
In reply to @mesaaz7 "I am almost 70 and have periodic AFIB and was also was told by a doctor..." + (show)
@mesaaz7

I am almost 70 and have periodic AFIB and was also was told by a doctor specializing in radiation treatment that I was too high of risk for RP. He described 65-70 as a grey zone where over 70 generally should select radiation and below 65 RP was fine. Because of the combination of AFIB and age he strongly recommended radiation. However I have selected RP.

I am NOT sharing this to discourage people from the radiation option but instead to suggest you should consult with at least one radiation and one surgical specialist before making a decision. I feel most doctors are purely motivated by the desire to help you, not money and give their honest opinions. However in my case the RP specialist also with years of experience felt I was a low risk case for RP and in my specific case this got me back to work full time quicker. Only time will tell if it was the right decision . . . . my surgery is not until late November.

I appreciate your sharing as we are of similar age. Your comment "My thought process was that if you have radiation, you more than likely cannot have RP (but I learned recently that there are a few rare cases that you can). Yet, if you have RP you can have radiation and ADT." was the number one reason I selected RP.

I am lucky in that my cancer appears to be less aggressive than yours. Hoping you do not require further treatment and have a great life going forward. I share your feelings on what is important in life.

Jump to this post

I am NOT a medical doctor. Yet I feel you decision is the correct one, if you feel comfortable with it, I personally think it is the correct decision.

I had a bypass in 2000, then between 2000 and 2023 I had 8 stents placed and multiple angioplasties. Just between 2000-2008 I had 11 procedures.

Yet I made it just fine. I completely trust my cardiologist and my surgeon.

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jeffmarc | @jeffmarc | Oct 14 1:02pm
In reply to @mesaaz7 "I am almost 70 and have periodic AFIB and was also was told by a doctor..." + (show)
@mesaaz7

I am almost 70 and have periodic AFIB and was also was told by a doctor specializing in radiation treatment that I was too high of risk for RP. He described 65-70 as a grey zone where over 70 generally should select radiation and below 65 RP was fine. Because of the combination of AFIB and age he strongly recommended radiation. However I have selected RP.

I am NOT sharing this to discourage people from the radiation option but instead to suggest you should consult with at least one radiation and one surgical specialist before making a decision. I feel most doctors are purely motivated by the desire to help you, not money and give their honest opinions. However in my case the RP specialist also with years of experience felt I was a low risk case for RP and in my specific case this got me back to work full time quicker. Only time will tell if it was the right decision . . . . my surgery is not until late November.

I appreciate your sharing as we are of similar age. Your comment "My thought process was that if you have radiation, you more than likely cannot have RP (but I learned recently that there are a few rare cases that you can). Yet, if you have RP you can have radiation and ADT." was the number one reason I selected RP.

I am lucky in that my cancer appears to be less aggressive than yours. Hoping you do not require further treatment and have a great life going forward. I share your feelings on what is important in life.

Jump to this post

I’m 76 and have had 4 afib events in the last 2 years. Never had any comments about not having my hip and knee replaced in the last year. Both required I be put under for the length of the operations and the knee operation was many hours, a lot more than RP.

I suspect overall health is a lot more important than age.

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mark1952 | @mark1952 | Oct 14 8:42pm

I wanted radical prostatectomy thinking it could get rid of my prostate, my chronic prostatitis, and my BPH. Met with highly acclaimed Dr. Vipul Patel in Celebration, FL. Because of my recent unfortunate hernia repair (nerve damage) and my chronic constipation, he advised me against surgery. Decided on Image Guided Radiation Therapy with ADT (Orgovyx) to make cancer cells more susceptible to the radiation. 4 months of Orgovyx, 2 months of radiation ( 40 sessions). With surgery can have nerve damage, blood clots, urinary incontinence. With radiation can have various negative short/late term effects. Comparable longevity outcomes. Wish you the very best.

REPLY
kjacko | @kjacko | Oct 15 8:44am
In reply to @mesaaz7 "I am almost 70 and have periodic AFIB and was also was told by a doctor..." + (show)
@mesaaz7

I am almost 70 and have periodic AFIB and was also was told by a doctor specializing in radiation treatment that I was too high of risk for RP. He described 65-70 as a grey zone where over 70 generally should select radiation and below 65 RP was fine. Because of the combination of AFIB and age he strongly recommended radiation. However I have selected RP.

I am NOT sharing this to discourage people from the radiation option but instead to suggest you should consult with at least one radiation and one surgical specialist before making a decision. I feel most doctors are purely motivated by the desire to help you, not money and give their honest opinions. However in my case the RP specialist also with years of experience felt I was a low risk case for RP and in my specific case this got me back to work full time quicker. Only time will tell if it was the right decision . . . . my surgery is not until late November.

I appreciate your sharing as we are of similar age. Your comment "My thought process was that if you have radiation, you more than likely cannot have RP (but I learned recently that there are a few rare cases that you can). Yet, if you have RP you can have radiation and ADT." was the number one reason I selected RP.

I am lucky in that my cancer appears to be less aggressive than yours. Hoping you do not require further treatment and have a great life going forward. I share your feelings on what is important in life.

Jump to this post

I had RP at 71. My doctor said I was in excellent physical condition and a perfect candidate for RP. So I respectfully disagree with your doctor who based surgery on age. I guess I’m an example that there is not a “one size fits all” approach to RP.. After the surgery I had ZERO incontinence issues. My Gleason ended up being 4+5 and a high Decifer score. So far my last 4 blood tests indicate my PSA at < 0.01. Hoping and praying for more of the same in the future. Best to all of you who are members of our “Fraternity”.

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cmkeeley | @cmkeeley | Oct 19 10:23am

I had a Gleason score of 4+3=7. Dr. recommended removal as radiation hits off target tissue and down the road if I needed prostate removed it gets a little "sticky".
Best of luck to you, I hope all goes well.

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