I have been diagnosed with intermediate non-favorable risk prostate cancer. Currently, we are conducting Decipher testing along with PSMA PET and genetic testing. My father is a prostate cancer survivor; he had brachytherapy 12 years ago, then experienced a recurrence at 78 and underwent intensity-modulated radiation therapy (IMRT) with androgen deprivation therapy (ADT).
In July, I had an MRI-guided biopsy, during which 18 cores were taken. Eight of them were graded as 3+3 and one as 3+4 with 10% involvement, with concerns that it could be more aggressive.
My process has involved starting with a surgeon and then getting referrals to radiation oncologists. Both Surgeon Stanford Alan Thong and UCSF's Carissa Chu are advocating for surgery. I also met with Jessie Alexander at UCSF, who suggested external beam radiation and 6 months of ADT.
Tomorrow, I have a meeting scheduled with Hilary Bagshaw.
In 2024, when both options are available, why choose one over the other (aside from peace of mind about having it removed)? Many intermediate surgery patients are having radiation as well. It seems that a lot of radiation comes with ADT. Brachytherapy allows for radiation and ADT for recurrence.
Radiation after surgery leads to bladder and rectal exposure, as those organs end up in the prostate bed.
I wonder what options men in their 50s are choosing and why.
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Seat15c
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I am on the east coast but have not heard much about UCSF. But in any case I always believe in getting a second opinion like maybe from Stanford or UCLA possibly. Also suggest you have your biopsy report sent off to Johns Hopkins Baltimore for 2nd review.
You've read a lot here already I am sure and the key is to take your time, don't be rushed, get a second opinion from another great facility. Once you feel comfortable, then move out.
I had a RP but most here will advocate SBRT with ADT. Both have issues and every person seems to go through the process differently and have different side effects, some more some less. PCa is not a death sentence at all but decide your path, have a great Doc that has done thousands who is at a great facility.
What tipped you into unfavorable intermediate? the number of 3+3 cores? your PSA? Other factor?
I think there are legit arguments for either of those treatments.....I guess 3 options actually, including brachytherapy or external radiation, and there is LD brachy or HD brachy.
Have you checked the PCa nomogram that MSK offers for helping you better understand the statistics for men like you who have had surgery at MSK. Just Google prostate nomograms MSK.
IMHO, ADT for 6 months will probably be little problem for you. All options have salvage options BTW. Salvage typically 50% successful.
As a younger man with PCa, more emphasis on sexual side effects......compare the 2 for that, and I worried about higher risk od long-term incontinence with RP. There may be a risk of slightly higher number of scecondary cancers after radiation......I thinks there is still a debate about that......maybbe research that question a little more, ask the Docs about that.
Beleieve it or not, quite a few studies have found that your long-term expected "cure" rate will be about the same whetehr you have treatment now or 6-12 months from now!!!
i am heading out to proton radiation treatment. It will be my 3rd time. I was steered this direction by surgeon, radiologist and a lot of reading. After the fact a found out it had moved to my lymph node and was told surgery was not a option.
At age 53 in 2021 I chose RALP because I believe in removing tumor burden so the mothership (prostate gland) can not develop a higher grade of cancer, less chance of nerve involvement (supposed to be contained), and easier to understand future BCR because if you do not have a prostate the only meaningful PSA (> .010) on face value is cancer.
I was having great healing even given the poor quality of care and lack of penile rehab until month 8. I had a BCR at month 8 that was .1 and went to .4 in nine weeks. This led to 33 rounds of EBRT and hormone treatment for 24 months. All that I know now is that Kaiser Permanente does not use the best diagnostic tools, which may have missed the iliac obturator lymph node.
IF you choose RALP be sure to line up a progressive and robust penile rehab program with a pump and meds soon after. And don't be afraid to ask about injections if needed.
You write: “Radiation after surgery leads to bladder and rectal exposure, as those organs end up in the prostate bed.” Rectal/colonic exposure can be negated by SpaceOAR. True about radiation but those with surgery often struggle with incontinence, whereas those w/ radiation might have flow issues. Comparing today vs dad’s time, the adverse effects have lessened, an in the case of SpaceOAR obliterated (my opinion) as related to lower GI effects.
Do not relate to dad’s brachy history—twelve years makes todays risks entirely different. Remember PSMA-pet only started being used a few years ago.
As far as surgeons: “To a hammer everything is a nail.”
“Peace of mind about having it removed.” Now, consider that (I cannot remember the source) a large group of surgically removed prostates were tested for cancer in the margins, and in many, yes there “be cancer.” This means that surgery, in fact, may not remove everything, so much for, “…having it removed.”
“It seems that a lot of radiation comes with ADT.” Yes, the two are clearly synergistic, possibly as a multiplier, meaning not 1+1 =2 but 1 + 1 has a greater than two effect.
I’m much older than you but I am opting for, 3 months ART to shrink my 71cc prostate, hopefully to something more like 50’ish, then 5 weeks IMRT + 1 week IMRT to pelvic nodes, (continuing w/ ART out to one year, possibly more depending upon Decipher results) then I’ll have brachytherapy. But what is ideal for me, is not ideal for you.
You have (unless someone tells you otherwise) plenty of time to choose your path wisely. Do remember that this is a business, and you are the profitable product, and remember too that if you had a hankering for lamb chops for dinner, but the butcher is out of lamb, you’ll likely hear a lot about the great beefsteak.
Consider sending your biopsy results out to one of the cancer centers for a 2nd opinion.
I think that ten years from now, almost all RP’s will be history. G’luck.
Just met with 2 radiation Oncologists, one suggests surgery for me, then met with one from Stanford who got my Decipher back and it's .25. they suggest high dose brachytherapy along with 13 treatments of imrt no ADT, going to do a PET scan shortly
Lots of good advice given - one thing I see missing here. A medical oncologist. They often aren't called in until everything has gone to sh!t.. the surgeon/radiologist feel they can handle any medical issues that come up - like ADT.
That's in my experience - a big maybe.
My radiation doc was quite good and attentive. He got to know me and followed my illness until he's got it back to an annual visit (we probably should just meet for coffee and bill Medicare.)
I went through several urologists - my first one was competant, but a bit greedy and he had awful office staff who missed entering appointments (and when called on it would usually say - the soonest I can get you in is about 9-10 weeks..). Fired him for several reasons I won't go into, went to another guy highly recommended by a friend. I was having pee problems and his answer was "Green Laser" - that was the wrong answer - I'm still dealing with that today. Fired him. Using a big-city urology team - 3 excellent MD's - each with a particular skill that I need.
The doctor you're missing in your description of doctors is a medical oncologist. They don't have a dog in the race between surgery and radiation. They do know what the side effects of each really is/are - and they're the guys to ask about it.
Anyone have a great MO in his area who can take over managing his treatment?
Perhaps inevitably, a radiation oncologist will recomend some form of radiation plus varying lengths and types of ADT, and a surgeon, surgery of some type. I saw both and was undecided. So I saw the head of department, a surgeon, who said that if I had surgery then he would strongly recommend radiation as well because of the involvement of the seminal vesicles, so why not just have the radiation? I had Gleason 4+3 stage 3b cancer. Seemed sound advice - but could it be be because of budgets? He was HoD in a public health facility, so another conflict of interest perhaps?
Anyway that was in 2021 and PSA/Testosterone has bounced around a bit but that's par for course I'm told.
As you are only G6 and newly G7, but the good kind (3+4), what do you need ADT for? Has it broken out of the capsule or moved into the seminal vessels?
You also mention "concerns that it could be more aggressive". Have you done any genomic testing to see just how aggressive it is?
All of the doctors believe it is still contained on the prostate, and the 3+4 10% 4 is in the lower Apex near the nerve bundle my Decipher is .25 low after getting the Decipher score back; two docs who also do HDBT and cyber knife suggest BT vs external beam SBRT due to the amount of radiation and my younger age of 57 the thought being lessing the chances of other cancers down the road
Nearly ten years ago, 57YO at the time, mpMRI and genomic testing played big roles in my decision for RP. Today, I would be adding liquid blood biopsy and PET CT findings to my decision process.
I would chose RP again, this time with extended pelvic lymph node surgery with frozen section pathology method. And I would know to not give this beast time and obscurity.
My biopsy samples missed the worst bits. My initial Gleason of 3+3 was upgraded to 4+3 with RP pathology.
Based on my experiences, and now with melanoma as well, no doc can be certain your cancer is contained.
Also, based on my experiences US docs can be biased in their recommendations by their revenue streams, financial incentives, volume requirements, etc. I base this on my experiences here in US and Europe.
Here is a good website to compare odds of cure for the major treatment paths. You have to determine your stage, low risk, intermediate, or high risk (risk of recurrence). So if you are intermediate, pull up the intermediate chart and you can see the odds of 10-20 yr survival, etc. based on the treatment you pick.
It is best viewed on computer or just print it on paper. Not so viewable on phone.
To make the graphs easier to read, i drew a dot on the endpoints of the elipses, and then drew a line through the dots. This turns the elipses into lines.
Also be aware the the graphs don’t show any salvage radiation benefit. This would boost the surgery odds up a bit.
And, this is a very dysfunctional industry from my view. Loads of bad info mixed in with the good info. Same with the docs. Some of them are more dangerous than the cancer.
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Just diagnosed with prostate cancer
Treatment: Unfavorable Intermediate Risk PCA
New to group; very high PSA; headed for da Vinci surgery
Ultrahypofractional RT and ADT for Int. Risk PC 
