Decision Time - Why do younger men choose surgery?

Hi Hobster. Welcome to the site, but sorry you have to be here. There are a lot of very knowledgeable people here and it's a great place for information and support.

There are a number of reasons that younger guys tend to favor surgery. Assuming you are otherwise in good health, younger guys have a longer life ahead of them. Surgery is the only method that gives you a complete pathology report and the knowledge of what you are really dealing with. The random biopsy can miss something more serious lurking in there. If your cancer is actually confined to the prostate, surgery offers a cure. Some say that radiation offers the same chance for a cure, but with the risk of causing secondary cancers later on. The younger you are, the longer time you have for those cancers to develop.

Others here are proponents of radiation and will weigh in as to why they think radiation is a better choice.

Best of luck as you work your way through this. It is overwhelming at first, but once you make a decision about treatment, it will be manageable.

The main reason younger men have surgery is historical. 10 to 20 years ago radiation was not as accurate as it is today. To get to the higher rad doses to kill PC cells normal cells were also damaged so only those men who couldn't have surgery for co morbidity reasons were sent to radiation, which were normally men over 70. This thinking is still prevalent today and younger men are steered to surgery while older men are steered to radiation.
With today's modern radiation the side effects you have at 2 years are the ones you will most likely have for the remainder of your life and this also holds true for surgery. The younger you are the more able you are to recover from surgical side effects such as ED and incontinence, so surgery is still hard on us older guys. Radiation has improved to such an extent with IMRT, HDR Brachy and SBRT that the longer term SEs are no longer the problem that it was two decades ago. Younger men can have radiation and expect similar results as to cure rates and better results as to ED and incontinence than those electing surgery.
Secondary cancers are not an issue anymore and radiation patients of all ages, especially those who have had Brachy or SBRT have much better quality of life issues at any age than surgery patients. Reoccurrance for radiation patients is rare at the local level because radiation not only treats the prostate, but the seminal vesicles, nerves and up to 15 mm of prostate bed, so the main reasons for local reoccurrence is eliminated.
with your stats I think a combo of HDR and IMRT is overkill and is only used on higher risk patients. A mono therapy of HDR or LDR or SBRT should be more than sufficient to cure you, especially if it is shown to be contained. The only reason to add any external radiation is to treat a wider area if extra capsular extension is suspected.

I chose surgery because, after speaking with the RO, two urologists, and my PCP, I felt it was my best option to be cancer free. I had had major surgery before, and came through without issues. Thankfully, the same was true of this surgery and I am not suffering major SE. If, like many others, I was experiencing continued SE (and I'm only 5 weeks post-op) then I might feel differently.

Ultimately, it's a personal decision. Weigh all the options, make your decision, when you are ready, and don't look back.

Hi Hobster5,
Stunning news at age 52. I know the feeling. My urologists recommended surgery as option 1, and brachytherapy as option 2. He indicated that since I am young and relatively healthy, recovery from the surgery would be quick, although with my stats, either option would be equally effective. Also, he indicated that surgery has radiation as a back-up, but radiation doesn't have surgery as a back-up, and additionally, problems post surgery can be fixed, while problems post radiation can't be.
Second opinion with the multidisciplinary prostate cancer team at JH, and they also indicated that surgery or radiation would be equally effective, but recommended surgery because my age and relative good health would offer quick recovery. It seems that the push is more towards surgery when you're in your 50s because being younger helps with recovery. I'm currently trying to decide, but surgery scares me more than brachytherapy.

Hello Hobster and welcome. Gotta say that I agree 100% with what JohnT wrote so I will not repeat any of that - I'll just suggest that you read it again.

With your stats it is highly likely that the cancer is contained and that any of the major treatments will cure you. Beyond cure, the major value proposition of surgery is the immediate knowledge you gain from post-op pathology. The major value proposition of a mono-therapy such as HDR Brachy, LDR Brachy or SBRT is a lower likelihood on onerous side effects like incontinence or ED. Each man has to do their own trade offs since the cure issue is really not a factor.

Re the argument that you can have radiation after surgery but not surgery after radiation...that is largely true BUT is only part of the story. There are EQUALLY EFFECTIVE salvage options for a failed radiation treatment as for a failed surgical treatment...they are just different. So please don't buy that argument as a reason for a surgical choice.

What I would recommend is that you meet with specialists in HDR Brachy, LDR Brachy and SBRT who are NOT associated with your urologist. Obviously you should also meet with an experienced surgeon to get that perspective. Get yourself educated and then make a studied decision.

BTW, speaking of education, I would suggest reading the sticky thread at the top of our forum that is designed for new patients. I would also suggest two books, "Guide to Surviving Prostate Cancer" by Dr. Walsh and "Invasion of the Prostate Snatchers" by Dr. Scholz. Between the two books you should get a broad perspective.

Good luck and let us know how we can help.

Jim

I'm currently trying to decide, but surgery scares me more than brachytherapy.

Windsor,
While I was not so young as you and Hobster when I was diagnosed, I was still considered relatively young at 56. Because of all that I had witnessed and researched, I too had a very strong aversion towards surgery. If anything, I have moved even farther in that direction these 7 years later. I was able to do Active Surveillance for two years before mine became a 'significant' cancer. At that point, I chose LDR brachy because I was much more afraid of life-altering side effects than I was of the disease. Brachy gave me at least as good a chance of beating the disease with a lesser chance of the SE's that I dreaded. Five years after treatment, I could not be happier. My oncologist uses the 'cure' word, and my sex life is as good as it has ever been. I could not be happier with my decision, and I would have made the same one regardless of what my age had been at the time.
There will certainly be differing opinions, just sharing mine and wishing both of you guys the best.

As someone who is three weeks (today) since RALP, I can share my reasoning. I chose surgery because (a) I wanted to know beyond a doubt what my real pathology was, (b) because I'm planning on living at least another 30 years, and the extreme long term effects of radiation treatment are unknown, (c) because I watched my father have the following treatments for PC and later on general urinary tract cancers: initial cryotherapy when it was new, HT, pinpoint radiation (he was proclaimed 'cured' after that) and finally spinal mets that killed him less that 6 months after he was "cured".

Some guys talk about being afraid of surgery. I get it. I get the willies when I think about radiation.

I seem, by the way, to be on track for the trifecta. My surgical pathology was great, I'm declaring myself 95%+ continent, and no ED at all. PSA blood draw today.

Frack,
I can say that because it is backed up by many studies which found there is ZERO incidence of secondary cancers in Brachy and about a 1% difference in external beam when compared to a similar group of surgical patients. The older ERBT radiation was about 5%.

Like halbert, I chose surgery because I wanted .the final,pathology so I knew what I was dealing with. And in fact I was upstaged from g6 to g7. And because I plan on being around for 20 more years at least.
And frankly, with an MRI showing that the Cancer was likely contained, I wanted it out. Some will say it's not the best most logical reason. And it may not be. But it was for me

I would encourage you though totHoroughly consider all options, as I did.

FrackMe said...
John T, How can you say that "secondary cancers are not an issue anymore" with radiation? I spoke with top radiation oncologists when I was deciding on a treatment and that isn't what I was told. If you are assuming that better targeting will lead eliminate secondary cancers, wouldn't you need to wait many more years to say that?

I hope you and JohnT will forgive my inserting myself in this, but I recently looked into this and wrote an article about it:

Risk for radiation-induced second primary cancer (RTSPC) is low and may differ by radiation technique

As you can see, it's on the order of 3-5 per 1000 man-years. If I had to guess, it's probably about the same risk that surgery will spread the cancer.

Can invasive procedures spread prostate cancer?

There are a lot bigger SEs worth worrying about.

- Allen

Hobster, I may be a good example of how effective salvage RT is.  I had a radical prostatectomy 9 years ago last November and start Radiation treatment tomorrow.

Frack, Best of luck with whatever treatment you chose. I was 53 at DX and was given the "younger men heal better/faster" talk by my urologist at the time, who happened to be a surgeon. I did a lot of research and talked to a lot of doctors before I landed on SBRT as a treatment and I couldn't be happier. I would have done BT, with surgery being my last option, if I had not chosen SBRT. My decision was based on fear of the side effects of surgery. I totally get the arguments FOR surgery, but it just wasn't the path I was comfortable with. You will need to chose your own path and it's one of the hardest parts of this journey. Good Luck.
Mike