Treatment options and cribriform

I'll let the guys with localized disease (unfortunately, I am not one) comment further but just wanted to say welcome and sorry you had to join our little group. Lots of great info here and my sincere best wishes.

My husband had cribriform and IDC and was advised by both surgeon and RT doctor to have RP. His decipher score was also high (1). With aggressive cancer there is a high chance of recurrence and my husband wanted to have that second option of salvage RT available. At the time (last year) all research showed better results with RP for cribriform patients. However this year they published new analysis that found that RT actually delayed BCR better (by about 15% better, as far as I remember). BUT, again, once you had primary RT, salvage RT is not easy to accomplish, and salvage RP is almost never done and is tremendously complicated with much higher incidence of ED and incontinence.

For younger patients RP is almost always suggested due to long life expectancy, so patient has salavage available and there is less chance of developing secondary cancers caused by radiation.

All in all, it is very tough choice to make and depends of many factors but one that is the most important is "what you see as better choice " for yourself. You will have almost the same results regarding cancer control and regarding side effects they are also almost the same , they just happen in reverse order. With RP you will have surgery that will effect your ED and continence but you will slowly recover ( and some people have zero SA ), and with RT side effects usually develop over time (also ED and incontinence) since nerves are effected by radiation as well as urethra that becomes stiff. There is also chance of chronic proctitis or cystitis .

All side effects are usually manageable via different modalities and medications regardless of the treatment.

Wishing you all the best and complete eradication of PC regardless of what technique you choose.

I came across this post on another forum and wanted to share it because I found it helpful: It was advice to me..
"please hear me out take it from me i was in your postion ..CRIBIFORM …i did radiation and i regret it .not only did radiation mess me up bad and it did not work ..6 years PSA started creeping up .. after mri and biopsy all the cancer that remained was gleason 4 and the same tumor right next to the targeted marker ..i had 2 too surgeons tell me they are seeing as of late that cribiform seems to be radiation resistant..the cancer was fortunately contained to the postate still and i had salvage surgery done at ucla and i just celebrated 1 year cancer free .. dont even think about radiation..find an expert surgeon get it removed ..i was soo worried the first time around ..for nothing the surgery to me was a piece of cake ..2 hours on the table 1 night in hospital 1 week catheter ..onky side effect i have is a leak but thats only because i had salvage surgery if you do radiation you are taking a hugeeeee riskkkk ..thats my opinion from the horses mouthA"
another one
May 2025
"do it trust me nobody was more worried than me and the surgery was nothing and if you’re the decifer test came back that low your chances of beating this thing a really good find a good surgeon go and get it done and don’t look back. I can’t even see my scars anymore, I can still get an erection and I don’t even leak that much and that is after salvage surgery get it done"
and last one,
"well like i said if it was me i wouldnt mess around with any radiation type treatments at all if you look it up the gold standard treatment prostrate cancer for men that expect to live 10 years or surgery is plan A…..if it ever does come back radiation is plan b and then you have the dreaded Plan c which would be hormone treatment Don’t be like me and skip a step you might regret it. It’s just my opinion. Good luck with your choice.
I had cribriform and I follow his advise and also from wheel1...read his post "Newer surgery technique" on this forum
I am 6 weeks post–radical prostatectomy. I have no urinary leakage at all and feel almost like I didn’t have surgery. It’s still too early to say much about erectile function, but it really depends on your priorities—health or ED recovery. For me, health comes first. I want to spend the next 10–15 years living well with my best friend, my wife with full support from her to do my surgery and to get rid of this demon from my body.
We’ve been together for 47 years. I am 67. My first PSA was 0.05 ...
You have probably heard that you can still have Radiation after surgery if the cancer returns but not surgery after Radiation. This keeps Radiation as a back up. That why we all here to share and give to each other best information
I just wanted to share this detailed post with anyone considering surgery as an option from my experience

My biggest concern with RP is a Dec '25 article in JAMA Oncology by Nikita Sushentsev, "Active Monitoring, Surgery, and Radiotherapy for Cribriform . . ." Indicates RT + ADT 15-year metastasis at 8%, RP was 26% and active monitoring was 25%. Based on secondary analysis of PROTECT trial.

One major question is, Did they find large cribriform? That is cribriform that is larger than .25 mm.

Surgery should take care of it easily if it’s small cribriform. Large cribriform Can still cause problems, even if you have the prostate removed. You probably want ADT after.

@jeffmarc
I have a question for you...small cribriform or cribriform that is larger than .25 mm ?
If your surgeon take out prostate...checked margin...send it during surgery to hospital pathologist department and all margin came negative ...Why is large cribriform can still cause problems after....cancer was inside prostate all test confirmed...How to determine the reason for us..
perhaps it was a bad surgeon... or a poor pathology department... or maybe our body simply reacted that way genetically.

@mozir
All I can do is give you the Technical information about the chance of reoccurrence with large cribriform.

Large cribriform pattern in prostate cancer is a significant adverse feature, highly associated with increased risks of biochemical recurrence (BCR) after prostatectomy. Studies indicate large cribriform patterns correlate with higher Decipher scores, 16-fold higher risk of BCR, and, in cases of severe cribriform, recurrence rates can be as high as 75%.

This could be because some of the cancer gets out of the prostate before it gets recognized. Like dormant cells that get sent to many different places in your body, and hide out so they can’t even be seen, but if you get stressed, they can pop up and become cancerous again.

Prostate cancer has weird ways to propagate.

They do not know(surgeons..) and you do not know... until they get down there

So many choices and things to consider.

If you do decide on primary RT, in case of recurrence, salvage RP would not be your first salvage option. (Many years ago, yes that would’ve been your only salvage option.)

These days, if there is local recurrence after primary radiation, choice of treatment would depend on the nature of the recurrence; there are other options - focal therapy (e.g., cryo), brachytherapy, SBRT (because they’re all very targetable), and yes even re-radiation in some cases. Salvage RP would be a distant finisher.

As for the possibility of secondary cancers, those sometimes occur due to overshooting the prostate and hitting otherwise healthy nearby tissues and organs. (Whatever radiation doesn’t hit, it doesn’t damage.) Choose a type of radiation or radiation technology that minimizes overshoot.

As for other possible RT side-effects:
> the possibility of late ED may be minimized by not hitting the penile bulb with radiation. (Again, related to radiation overshoot.)
> the same with radiation-induced proctitis, cystitis, and enteritis - avoid overshoot. Use a rectal spacer (SpaceOAR). SpaceOAR has demonstrated protection against rectal tissue damage, and is also said to protect from late GI and GU toxicities, and provides urinary, bowel, and sexual quality-of-life improvement. (Other rectal spacer options are Barrigel and BioProtect.)

Whatever treatment you choose, go into it fully informed. Whether there are success stories or failure stories, dig a bit deeper and find out the details of what safety protocols they did (or didn’t) follow with their choice of treatment.

(At 65y, I had 28 sessions of proton radiation + 6 months of ADT for a localized, 7(4+3), PSA 7.976, with no other known risk factors. Radiation treatments were relatively uneventful; never experienced ED. We’re now 5 years since treatment; most recent PSA was 0.314 ng/mL.)

I think @jeffmarc provides a reasonable perspective. Cribriform does not make surgery “better” than radiation, nor does it make radiation “better” than surgery. Cribriform has its own risk scenario. I did not have it but did have 5 MRI guided radiation treatment in 2023 and would do it again even with Cribriform, as my side effects to this day were low. Many of us, thanks to the helpful folks with real life experiences on this web site, understand the risks and rewards of radiation vs removal. I never saw any high-quality randomized trial for comparisons for those with Cribriform.

I was interested in quality of life and side effects and felt that for me, the risk of side effects with removal, were greater than I was willing to accept. When, and if I encounter BCR, I felt it was more likely, from expert discussions, to be outside of the prostate and as much as catheters do not thrill me, I would accept the cold/heat/electrical BCR solutions currently on the market.