Why do some people have surgery at stage 4, while others don't?

It used to be the doctors felt that removing the primary (prostate) was an essential thing to do even with somebody that had extensive cancer spread, Because it would reduce the amount of spread long-term.

For years Rick Davis over at ancan.org (he is the founder) Promoted removing the prostate for people that were in the advanced prostate cancer online group. Then a study came out, about nine months ago, showing that removing the prostate was not an advantage for people that had extensive prostate cancer. That completely changed the tune at ancan.org. Now they no longer promote removing the prostate for advanced cases. That study concurred with what your doctor told you.

For a long time, people who had spread outside the prostate were told not to have a prostatectomy as the initial treatment, They needed radiation that would also radiate the cancer that had spread. You seem to be in the right place when it comes to treatment. Another thing about cancer that is spread a lot is that chemo really is beneficial for long-term remission. This is based on how many metastasis have been found outside the prostate.

For people who have not had the cancer spread outside the prostate a prostatectomy makes sense. Even a very small amount of spread, to the lymph nodes, can be handled during a prostatectomy.

So it makes sense to do either technique based on the extensiveness of the diagnosis.

Yes, they used to think it was too late to deal with the prostate once cancer had spread beyond it, but thinking has changed with evidence from studies like STAMPEDE.

Radiation is less invasive than surgery, and can also be designed to go beyond the prostate to the surrounding area to catch local spread, but what matters is going after the primary (the "mothership") *somehow* to reduce the overall cancer burden.

In my case, I also had the large lesion on my spine at T3 surgically debulked and then radiated. That was primarily to restore my mobility after spinal compression and paraplegia, but it also had the benefit of further reducing my cancer burden, so that the cancer was already reeling when we hit it with systemic therapy (ADT+Apalutamide) for what may 🤞 turn out to have been a knockout blow.

Time will tell (4½ years and counting…)

@northoftheborder

Why did they only offer me palliative care then? None of the doctors suggested targeting the tumor with radiation therapy.

I completed eight cycles of chemotherapy with docitaxel and ADT, and six months later they added apalutamide, which dropped my PSA to 0.

Now I'm very afraid that the cancer will become resistant.

I asked my doctor about radiation therapy, and he said radium and lutetium would be used later. But I still don't understand why radiation therapy can't be used now?

@denis76 I can't answer for your oncology team. It could be because the evidence isn't as strong for benefits of going after the "mothership" with polymetastatic PCa as it is with oligometastatic, it could be that they're not convinced that this (new) approach is best for you, or they might just not be ready to adopt it yet.

On the bright side, the TITAN study showed that starting Apalutamide early with ADT can significantly delay castrate-resistance (when the study ended after 4½ years, nearly half of the participants *still* hadn't developed castrate resistance, and many of those had had PCa for years before the study started). So you're getting latest/best standard of care on that side.

I hope things go well.