Surgery or radiation, looking for some advices

[Healing1826]

Hi everyone, I’m looking for some advices for my father. He was recently diagnosed with prostate cancer. He probably already had it for a long time. Quite high PSA (way over 20), and spread to multiple lymph nodes. The surgeon said surgery is still doable, followed by radiation. Radiation oncologist recommended hormone therapy followed by radiation. We feel so much pressure trying to make a decision asap, as there is already spread outside his prostate.

My father is otherwise healthy, a few years from 70 years old, Gleason scores were 7 and 8 (majority is 8). Besides the couple pelvic lymph nodes there is no spread elsewhere according to PSMA scan. I’m not sure if all these makes him a better candidate for surgery or radiation.

I’ve seen many posts and watched videos but still cant really make a decision between the two (my father is okay with either approach). To add more details, his prostate has been enlarged and he has some issue urinating sometimes, because the enlarged prostate or the tumor itself has been impacting the urethra. There is only one tumor and quite large (about 4 cm I believe).

Would really appreciate any advice you could offer. Surgery vs. radiation, any specific type of radiation, specific type of HT, etc. Thank you.

[RyderLake2]

Hello,

Keep in mind that doctors (surgeons) get more money for performing a prostatectomy than they do for brachytherapy or radiation. You often hear doctors say if we perform surgery first, then we can always try radiation afterwards. If you do it the other way around and start with radiation then surgery is very difficult because your prostate is "cooked". Like operating on porridge. That might be true but if radiation is done correctly you won't need surgery. Both methods have serious risks like incontinence and impotence. I still have an intact prostate because, in my case, the cancer had metastasized to my bones and the "horses were out of the barn". However, I have many friends who opted for brachytherapy (radioactive seeds around the prostate). None of them regretted that decision. Good luck with your choice.

[Seasid]

I did irradiation of my prostate and it is failed. Now I am having a meeting with the surgeon to see if he can remove my prostate because a radiation oncologist is refusing to radiate my prostate again. Usually they will refuse the radiation if you have difficulties with urination. Best is to talk to both, to the surgeon and to the radiation oncologist.

I like the idea to get rid of the prostate so it can't produce Mets in the future. Prostate has a high DHT environment very good to spread the cancer. Plus if you remove your prostate than you know that any PSA produced is from the prostate cancer. If your prostate stays then you could still have some PSA produced by the prostate and not the prostate cancer.

[Healing1826 in reply to Seasid]

May I ask what is considered a failed radiation? Is it not reducing the PSA, causing other issues, side effects too bad or something else?

[Seasid in reply to Healing1826]

When you have surgery they also remove some of the pelvic lymph nodes. Therefore you may get rid of the cancer that way, again I am not a doctor but that is how I understand the situation.

You may don't need ADT after surgery if the surgeon removes the cancer. That would be a big bonus if you ask me. If you get ADT after radiation it is a big question if he will get back his natural level of testosterone. The best is to clarify this important question with the surgeon and the radiation oncologist before you commit anything. Radiation is also not good for the immune system and for your bone marrow.

I agree that radiation is less risky, you can't bleed out like after the surgery. Ask your doctors. I just know that I wanted radiation and now I have to think again about surgery. Try to contact some excellent cancer centres for advice. I can't advice you, only trying to explain you the upside and downside of each selection.

Surgery could results in lasting incontinence that is a big downside of the surgery. You may be able to put an artificial sphincters and it could last 7 years maybe. With radiation you are losing your bone marrow function plus you may never regain your natural testosterone levels. After long ADT.

For older people I would probably prefer radiation as they will lose their natural testosterone levels anyhow. You need good doctors to advise you. I am not a doctor and I don't have medical experience treating prostate cancer. I wish you luck

[Tall_Allen]

I don't see any upside in having surgery, other than it immediately removes his enlarged prostate, since you already know radiation will follow. And there is a lot of downside - the side effects of radiation after surgery are much worse than starting with radiation. Add on top of that, the risk of incontinence from surgery.

He can start ADT now. This will stop any further spread. The SOC is 3 years of ADT+2 years of abiraterone. The hormone therapy is usually given 2 months prior to the start of radiation. It will shrink his prostate, making peeing easier. In fact, he might want to start hormone therapy for longer to improve his urinary function. He might want to ask for a urodynamics test now to establish a baseline and in a few months when his prostate shrinks.

The kind of radiation that has the best results is called "brachy Boost therapy." This would entail whole pelvic external beam therapy with a brachytherapy boost to his prostate.

[Healing1826 in reply to Tall_Allen]

Thanks so much for your response. I got the impression that removing the prostate drops the PSA more quickly, which means additional spread would be less likely (or it makes the spread slower); on the other hand radiation reduces PSA slowly so spread might happen at the same time. Is this true? Perhaps that is the reason to start hormone therapy before radiation?

[Tall_Allen in reply to Healing1826]

No, PSA is just a biomarker, not his cancer. Either way, he will have cancer in his lymph nodes too.

It is true that if the cancer were only in his prostate, surgery would make his PSA undetectable immediately. It is also true that after curative prostate radiation his PSA takes time to go down. But that has nothing to do with active cancer, only the biomarker.

[Seasid in reply to Tall_Allen]

"the side effects of radiation after surgery are much worse than starting with radiation" what are the side effects of the radiation after surgery and why are they worse?

Could you please explain this in more details? I am really interested.

[Tall_Allen in reply to Seasid]

Without a prostate blocking some of the radiation, the anastomosis and the cut urethra get the full brunt of the radiation. The urinary adverse effects are much worse.

[Seasid in reply to Tall_Allen]

That's what I was afraid of. Thanks for explaining.

[Lizzo30]

My husband was dx with prostate cancer at 70yrs and chose surgery he has never regretted his decision

[Mgtd in reply to Lizzo30]

Thanks for joining in on the discussion but it would help immensely if your bio had details of your husband’s diagnosis so that the original poster could evaluate apples to apples.

[God_Loves_Me]

One important advice: Listen to   Tall_Allen . Please build a team of Medical Oncologist, Radiations oncologist and Urologist, Write down all questions and prepare for longer meeting. I hope it will help you to make better decision.

[Healing1826 in reply to God_Loves_Me]

thanks, I found it weird that my dad’s urologic surgeon is only offering 15 mins appointment. Haven’t been able to get much out of it.

[God_Loves_Me in reply to Healing1826]

Woow

[j-o-h-n]

6 of one and a half a dozen of the other. Whatever your dear Dad chooses NEVER look back and say "should have, could have, would have".

Make sure you see good competent doctors who have performed many many of the procedures your Dad has chosen. Check out the doc's credentials and post their names here and ask if any members have used them. Don't be shy to ask. Best wishes from all of us. (keep us up to date)

Good Luck, Good Health and Good Humor.

j-o-h-n

[j-o-h-n]

Oops............. Please update your Dad's bio on your login ID. (Age, Location, Doctor(s) name(s), meds, treatments, treatment center and etc.) All info is voluntary but it helps him (and you) and helps us too. Thanks! Keep posting here.

Good Luck, Good Health and Good Humor.

j-o-h-n

[Izzysdad]

I went with surgery because my low Psa and the MRI suggested it might be contained. It wasn’t so I needed radiation and ADT. TA is correct about a prior RP making subsequent RT potentially worse. At least it was in my case. I had a nasty year of bleeding, urinary retention, catheters, cystoscopies and a TURBT to address radiation cystitis. However things straightened out and it’s been good for over a year. Last night I went the whole night without having to get up to pee. I went for the touchdown when maybe I should have gone for a field goal but I have no regrets. Both treatment courses are a crapshoot. Radiation damage is possible either way. I never give advice. Just relate my experience. I wish your dad all the best with whichever route he chooses.

[Healing1826 in reply to Izzysdad]

Thanks for sharing your experience.