Newly dx, hard to decide on Rx.

Hello everyone. I have been following the forum for a while now and finally signed up. I am 48 and was diagnosed with PC mid May of this year. Family hx , no symptoms but dad made me go get it done. Thanks Dad!! Initial psa 2.3, 1.5 yrs later 5.8, 5.6 then biopsy. 4 Cores positive, 2 at a 6 and 2 at a 4 plus 3. Both higher grades on the left side, mid medial and mid lateral. 2-3 mm. Overall graded as T1C. I have done my research but I am still having a hard time deciding between surgery and brachytherapy. I live in Vancouver BC and both good options with good surgeons and a very good brachy team. I just cant seem to pull the trigger. Leaning towards brachy but some nagging thoughts about long term radiation(placed in my head by surgeon). Also the question as a younger guy about what happens if a local occurrence happens in the future. Lots of great experience out there. Hope to get some comments or opinions. thanks in advance. Steve

Sorry you are here. There is good news. Based on your numbers there is every reason to believe that you can be totally cured.

As already stated, both chooses are good. I can only talk about surgery. The advantage of surgery is that you physically remove the source of the cancer. However, the side effects of surgery for someone young may be an issue. It can not be overstated, if you go with surgery, get someone that has done thousands of operations. Experience does matter. Please know that wit a good surgeon most (in the upper 90%) regain bladder control (many in less then a month) as well as being able to be intimate. Please know that the long term results for DaVinci surgery is the same as that for traditional. It is better to do with the most experienced surgeon, not the one who uses the fancy equipment.

Good luck! Thank your dad again. Your cancer was cought earlier enough to be cured!

I was too high risk for surgery and chose HDRBT. Very happy with the results. I have experienced total remission with no negative side effects.

Regarding radiation problems down the line, first, listen to the RO, not the urologist. Second, the advances in radiation therapy in the last decade have greatly reduced the side effects. Third, radiation induced secondary cancer is a risk of about 1/3 the risk of dying from the surgery. Essentially non-existent. Fourth, don't be concerned about local salvage after radiation. Why do you think every urologist knows they will go to radiation to salvage a failed surgery? A large proportion of G7 surgeries also require salvage radiation. Remember the radiation treats a much greater area than the surgeon can cut. HDRBT also treats the seminal vesicles making it very effective. And if there is a local failure after radiation (rare) salvage radiation can still be done, especially if you start with brachytherapy, either permanent seeds or HDRBT.

Again, the urologist-surgeon is pushing his specialty and is not an expert outside his specialty. Go directly to the radiation oncologist concerning the radiation therapy with the risks and rewards. It has been very well documented that at your risk level both radiation and surgery have similar outcomes for cancer control. However, on average, surgery will cause more significant negative side effects than radiation. In your case I would pursue the treatment that presents less significant lifestyle side effects for most men regarding continence and sexual function. This is the advantage of radiation based therapy.

The research is the easier part of the process. The deciding not so much. It took me a year to decide. You've got time still....but don't wait a year.


I asked myself a couple of questions.....

1) "Once I am cured, would I rather be there with having had radiation done on my body or would I rather be there with having had no radiation done on my body?"

2) "If there's a recurrence, which salvage options do I find most or least attractive? Which ones am I most comfortable with?"

A part of it was my personal situation. I went through this alone....and I did not want to be out of town for treatment. I wanted to be in the security of my own home. Given that, I knew from speaking with them...I did not want the local radiation guys coming any where near me. So that leaned toward surgery. Also, just anecdotally, the men who I knew locally with whom I'd spoken....there were 3 radiation guys. Two of them had recurrent cancer about 9 years later. One rectal. One bladder. But the newer machines are supposed to have mostly taken that out of the equation....of so I'm told. The third had seeds and it had been 25 years with no problem. The surgery guys I'd spoken with were inversed. out of the three I spoke with, 2 had had no problems. One had become a hermit.

Also....you have a 4+3. I think that could have tipped the scales for me in the direction of radiation. With more 4's than 3's....I think I might have gone out of town for radiation....but I cannot know that.


But let's be clear....there's no silver bullet here. And you already have a gut feel for what you'd like to do. Most of us do.

I'm also a surgery veteran. My story is linked below in my signature.

I knew a number of people, including some friends, who had surgery. I didn't know anyone who had done radiation. So I was biased towards surgery. Since my surgery, I've been active on this forum and done more reading about the disease. I've learned that radiation is a very viable treatment option for patients like you. I urge you to ask around for the best RO's in your area and get opinions from them. Also, there is plenty of good information on this forum. One of our members, Tall Allen, is very well informed on radiation.

There is a lot of information about surgery here, or on the web. My best advice is choose an experienced surgeon. The more experience the better. The best guys give you the best chance to remove the cancer, get you continent quickly, and preserve the nerves needed for sexual function.

Take your time, and make the decision that is right for you.

Archer48-

The Vancouver Prostate Centre is excellent, so you have some very good choices there. Martin Gleave is on anyone's list of top urologists, and would be a great choice. You can fill out a nomogram like the one below to get a feeling for the odds that surgery would be successful:

/www.mskcc.org/nomograms/prostate/pre-op

So your expected 10-yr probability of being free from recurrence is 83% if you go with surgery.

I think they now offer both kinds of brachytherapy there - low dose rate (seeds) and high dose rate (temporary implants). Because of your relatively high grade cancer which is predominantly pattern 4 (4+3), there is a relatively high risk that it is outside of the area that seeds alone could cure. I think most seed ROs would also include external beam radiation to treat the parts that seeds can't reach effectively. In fact, the seminal study proving the efficacy of brachy boost therapy for intermediate risk guys like you was done in Vancouver (it was called the ASCENDE-RT trial). For men with intermediate risk PC, the 9 year probability of being free from recurrence was 94% for those who received the brachy boost therapy.

/pcnrv.blogspot.com/2017/03/brachy-boost-gold-standard-for.html

Because the side effects of brachy boost therapy are higher than brachy monotherapy, some ROs are using high dose rate brachytherapy (HDR-BT) as a monotherapy for intermediate risk men. HDR-BT, unlike LDR-BT, can treat an area outside of the prostate capsule. This seems to have equally excellent oncological outcomes with less toxicity.

The risk of second cancers due to radiation exposure is low:
/pcnrv.blogspot.com/2016/08/the-real-risk-of-secondary-malignancies.html

Salvage therapy is not much of an issue with cure rates of 94%, and for most of the remaining 6%, the recurrences were probably not local -- they were metastatic and could not have been cured. For the remainder, if they were local-only recurrences, they could potentially be cured with focal salvage radiation or focal salvage ablation. They have a better side effect profile than salvage surgery after radiation. All salvage therapies, after RP or RT, have a higher probability of side effects than either treatment alone. It is best to make the decision on what is most likely to cure you.