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Time to decide on surgery or radiation, any thoughts?

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Posted 5/28/2022 3:07 PM (GMT 0)
After mri and mri targeted biopsy determined I had one lesion in left side of prostate. Gleason score came back 4 + 4. Biopsy 2 cores with cancer, and other 14 cores none. I am 69 years old (almost 70) and in good health. The prostate size in normal. Radiation oncologist order a PSMA PET scan. Scan results were good, only area of cancer was the expected area. Nothing outside the prostate. My urologist doctor says he felt comfortable with doing surgery to remove the prostate, since I was in good shape with no issues. He also said if I was 10 years younger he would recommend surgery over radiation. Also he stated that how well radiation results is showing, it is now equal to surgery. He is leaving up to me to decide. This coming week I have appts with radiation oncologist and a urologist oncologist. The radiation oncologist stated in my first appt that he would plan on doing 3 months of ADT and than start imrt radiation for 28 sessions and than 12 months of ADT. I am at lost which way to go. The potential of incontinence for long term with surgery scares me. And for radiation path all of its downsides.
Any thoughts and opinions would be greatly appreciated
Posted 5/28/2022 3:20 PM (GMT 0)
You're asking what is one of the main questions that come to this Forum. I would say the Forum generally leans towards one of the many forms of radiation. The debates can be contentious.

It seems you are doing your research, which is the most important thing. Then you will be equipped to decide what is best for you.

Good luck in your journey!
Posted 5/28/2022 3:43 PM (GMT 0)
PS, I should have added that what your doctors are telling you sounds about right and the chances for a good outcome are about equal for the various treatments. Choices, choices, choices. 🙂
Posted 5/28/2022 3:51 PM (GMT 0)

mattam said...
PS, I should have added that what your doctors are telling you sounds about right and the chances for a good outcome are about equal for the various treatments. Choices, choices, choices. 🙂

really? what does this even mean:

"He also said if I was 10 years younger he would recommend surgery over radiation. Also he stated that how well radiation results is showing, it is now equal to surgery."

OP, my opinion is in my signature. please note that i am in my 12th year of remission with no serious side effects.
Posted 5/28/2022 4:05 PM (GMT 0)
Like I said, it can be contentious. 😉
Posted 5/28/2022 5:59 PM (GMT 0)
CF:

With a G8 diagnosis, even if it appears to be organ-contained, I would lean towards Radiation--especially one of the 'short run' varieties like HDR Bracy or SBRT (cyberknife). The reason is with G8, there is a not inconsiderable possibility that the little buggers HAVE gotten out, they just haven't grown big enough yet to be visible. RT will hit a wider base in your pelvis than surgery, and have better chance of knocking it out on the first try.

This is actually the hardest part of the process: You have choices, all of them have advantages and disadvantages, and you have to choose one. And, IMO, there is a lot more involved that 'just' cancer control and 'just' potential side effects. Here's a few more things to consider, in no particular order:

Time and Place: Where do you live relative to where treatment will happen? If you're a long distance away, the amount of time you'll spend going back and forth--especially with today's gas prices--becomes a factor. How much time do you want to be out of commission? Surgery is a day or two in hospital generally, and then a recovery period that can last a while--4-6 weeks isn't uncommon to get 'mostly' back to where you are today. Radiation is a lot more variable--some guys basically do the treatment and are right back at 'life' immediately. Others, not so much.

Cost: Ok, at your age, you're on Medicare--what do they cover, look into approvals and so on. In some cases, out of pocket costs can be significant. Lots of people poo-poo this aspect, but it is very, very real for many.

Comfort zone: Do you want to KNOW your full pathology? The only way you'll know that for sure is surgery--IMO, it's not that important...but some guys find that really important. How comfortable and trusting are you of your treatment team--either surgical or radiation. It's important.

Other factors: Do you currently have issues with urination--either difficulty or leaking? How about ED? How important is future ED to you? If you're having BPH symptoms, such as difficulty emptying your bladder, RT can make it worse. ED can be an issue with surgery.

One thing that is sure: When guys take their time to really consider their options before treatment starts, they tend to be happier with the results, regardless of what happens. The guys with the greatest regrets are the guys who went from diagnosis to treatment in a few days based only on what their diagnosing doctors tell them to do.
Posted 5/28/2022 6:26 PM (GMT 0)
I recently had surgery (May 17th) and am still recovering, and the catheter is still in (until this coming Thursday). In my own exploration, I found that there are so many reasons for or against surgery or radiation, the choice came down to some of the things that Halbert mentioned. And it's all very personal -- I'd never want to tell someone what's "better" or "worse". Every situation is different. Here's how it came down for me (in no specific order of importance):
- Daily drives to the RO for treatment would have been a) long, and b) destructive to my work.
- I wanted to know exactly what the hell was going on and how bad this really is. Having the prostate removed and then sent to a lab was more comforting to me. I'm a worry-wart. YMMV.
- I have immense trust in the surgeon, who has done over 2,000 RALP procedures and if anyone could do this and spare the nerves, he could. And he did -- the surgery went perfect, according to him.

So -- to the OP, I wish you well, and agree with others here that once you make your decision you'll be happier.
Posted 5/28/2022 9:04 PM (GMT 0)
With a G8 diagnosis I would suggest that radiation with an ADT kicker offers the best chance for a complete cure and the least long term side effects. I liked the convenience of SBRT and also HDBT although depending on your location you may have to travel to find a medical team who specializes in those procedures. With SBRT we had to make a total of eight trips to Cleveland Clinic for the entire treatment including the preliminary evaluation. Also, with G8 I would recommend find the very best team you can and worry more about the success rather than the length of travel. I found modern radiation to be very safe and effective w/o long term side effects. Good luck and keep us posted. Terry
Posted 5/28/2022 9:30 PM (GMT 0)
Cancerfight, as you can see everyone has their opinions. The most useful comment in my humble opinion is when Halbert stated: "One thing that is sure: When guys take their time to really consider their options before treatment starts, they tend to be happier with the results, regardless of what happens. The guys with the greatest regrets are the guys who went from diagnosis to treatment in a few days based only on what their diagnosing doctors tell them to do."
This is a decision only you can make. Just be sure you are educated in the pros and cons of each. And while Halberts comment is correct in that you should not rush into anything, i would not take a ton of tme with a G8, grade 4 cells tend to not act nice.

It's interesting that your urologic oncologist whom i assume is a surgeon, stated that your chance of cure is the same with either approach.
And despite some of the strong "opinions" regarding surgery, many men here, and many that i know of elsewhere, have had great results with surgery, after taking care to choose a very experienced surgeon.

With that said, with a g8 there is, as halbert stated a more than small chance that there are cells that have escaped the prostate capsule and just are too small to be picked up on a scan. So its possible that radiation + ADT might be your best bet.

As you can see, there are too many variables and its too personal a decision, so only you can make the right one. And whats right for other men here, may or may not be right for you, in terms of the variables, the priorities and the emotional aspect.

Lots to think about. Sorry.
Posted 5/28/2022 9:33 PM (GMT 0)
You get to pick the side effects! The most important part is you caught it early and regardless it will soon be in the rear view mirror.

Some odd things to think about/consider

1) With surgery they get their hot little hands on your cancer, can examine it under a microscope, test its genetics….even years later. It provides definitive information and is superior to grainy images.

2) surgery will require them poking holes in your abdominal wall. in my case (i am overweight) that has led to ventral hernias afterwards. So additional trips to the surgeon.

3) if you get it removed and your psa steadily increases afterwards, you know its back and you know relatively quickly.

4) If you radiate an area and something else pops up near that area (say another type of cancer) that needs radiation you have to consider overlapping fields.

I try and avoid the “you should do it this way because…” type of food fights on these kinds of posts, and am perpetually thankful we as a group have choices for eliminating the problem.

It comes down to, what is your personal worst case.
Posted 5/28/2022 10:04 PM (GMT 0)
well the OP's title is:

"Time to decide on surgery or radiation, any thoughts?"

he's asking for opinions

and i'm sure as hell not going to recommend surgery when i think it's the worst possible choice in most cases!

if you've spent any time on this forum you'd realize most permanent SEs are a result of surgery, and surgery followed by radiation is even worse
Posted 5/28/2022 11:05 PM (GMT 0)
Only you can make the decision. If it fails of course you wished you made a different decision.

I had robotic surgery and two years later I had to get radiation treatment because PSA became detectable. It has been 7 years since then and recently my PSA became detectable (0.02ng/ml) using the ultra-sensitive test. I can tell you I had zero problems with my surgery and radiation treatment, and zero side effects afterward except very minor stress incontinence.

My only regret was I wished I would have added one or two radiation treatments. At that time my IMRT/IGRT was 39 treatments at 1.8 grays for a total of 70.2 grays. Maybe a couple more grays or radiation would have prevented the recent increase in PSA.
Posted 5/29/2022 12:08 AM (GMT 0)
I honestly believe prostate cancer will not be your demise regardless of the treatment modality.
Posted 5/29/2022 1:51 AM (GMT 0)
4 4 is serious, the fact that only 2 cores were found doesn’t mean it’s nowhere else lurking in the prostate. The biopsy is very limited as only a tiny fraction is sampled.
I was diagnosed in 2012 and from my experience with this disease since then, I believe radiation has a better cure rate for higher risk cases with less of a chance or permanent side effects and or recurrences.
Whatever you decide find the most experienced practitioner who specializes in prostate cancer even if you have to travel.
Posted 5/29/2022 2:43 AM (GMT 0)
RT is certainly one good option (as is surgery), but I would do research about SBRT as the sole RT modality for high-risk disease: it does not have a long track record for judging oncological and toxicity outcomes.

High dose Stereotactic Body Radiotherapy (SBRT) (2022, medical news article)

"High-risk Early Stage Prostate Cancer

An analysis of data from a consortium of seven institutional phase 2 studies and registries was published in International Journal of Radiation Oncology, Biology, Physics in February 2021.

Analysis of 344 men (median age, 72.3 years) with high-risk prostate cancer treated with SBRT reported a 4-year cure rate of 82% with the 5-day regimen of high dose SBRT. Overall, 72% of men did receive ADT (median duration, 9 months) and 19% received elective nodal radiotherapy. Eighteen percent of men experienced grade 2 or worse genitourinary toxicities and 5% experienced grade 2 or worse gastrointestinal toxicities.

The 4-year PSA free recurrence rate is similar to the 5-year rates among men in the ASCENDE-RT trial of brachytherapy boost (85.5%) or dose-escalated conventionally fractionated radiotherapy alone (83.6%) along with 12 months of ADT, despite that some men in the current trial received no or shorter courses of ADT."
Posted 5/29/2022 2:45 AM (GMT 0)
I would opt for Brachy with ADT and external beam. No just external beam.
Posted 5/29/2022 2:48 AM (GMT 0)

halbert said...
CF:

With a G8 diagnosis, even if it appears to be organ-contained, I would lean towards Radiation--especially one of the 'short run' varieties like HDR Bracy or SBRT (cyberknife). The reason is with G8, there is a not inconsiderable possibility that the little buggers HAVE gotten out, they just haven't grown big enough yet to be visible. RT will hit a wider base in your pelvis than surgery, and have better chance of knocking it out on the first try.

This is actually the hardest part of the process: You have choices, all of them have advantages and disadvantages, and you have to choose one. And, IMO, there is a lot more involved that 'just' cancer control and 'just' potential side effects. Here's a few more things to consider, in no particular order:

Time and Place: Where do you live relative to where treatment will happen? If you're a long distance away, the amount of time you'll spend going back and forth--especially with today's gas prices--becomes a factor. How much time do you want to be out of commission? Surgery is a day or two in hospital generally, and then a recovery period that can last a while--4-6 weeks isn't uncommon to get 'mostly' back to where you are today. Radiation is a lot more variable--some guys basically do the treatment and are right back at 'life' immediately. Others, not so much.

Cost: Ok, at your age, you're on Medicare--what do they cover, look into approvals and so on. In some cases, out of pocket costs can be significant. Lots of people poo-poo this aspect, but it is very, very real for many.

Comfort zone: Do you want to KNOW your full pathology? The only way you'll know that for sure is surgery--IMO, it's not that important...but some guys find that really important. How comfortable and trusting are you of your treatment team--either surgical or radiation. It's important.

Other factors: Do you currently have issues with urination--either difficulty or leaking? How about ED? How important is future ED to you? If you're having BPH symptoms, such as difficulty emptying your bladder, RT can make it worse. ED can be an issue with surgery.

One thing that is sure: When guys take their time to really consider their options before treatment starts, they tend to be happier with the results, regardless of what happens. The guys with the greatest regrets are the guys who went from diagnosis to treatment in a few days based only on what their diagnosing doctors tell them to do.

If he is on advantage, he may soon see the disadvantages of an HMO.

Post Edited (Duck2) : 5/28/2022 8:55:05 PM (GMT-6)

Posted 5/29/2022 5:23 AM (GMT 0)
You have gotten lots of good advice. I'd like to add that in thinking about your choice you should focus on two things. First, what treatment option has the best chance of curing you? Second, what will be the side effects of each treatment option. The first consideration is more important, of course. A 4+4 might incline me toward radiation as offering the best chance of a cure. And radiation has fewer side effects. I've had both surgery and, when that failed, radiation. The side effects of the surgery have been much more serious and life-changing. It's good to avoid having both surgery and radiation, as the side effects cumulate.
Posted 5/29/2022 2:07 PM (GMT 0)
Cancerfight, as you can see, there is not a definitive answer to your question. My suggestion is that after you make your choice, don’t look back. Regret and “if only” is it’s own form of punishment and who needs that when dealing with any health issue.

BTW, I am active on several motorcycle forums and the answers here about what form of treatment is best almost mirrors the answers I see there about “what’s the best tire” or “what’s the best oil.” On those queries, I rely on what the manufacturer suggests or recommends as they, supposedly, know something about the machine they designed and manufactured, at least more than people on social media.
Posted 5/29/2022 3:58 PM (GMT 0)

Cancerfight said...
After mri and mri targeted biopsy determined I had one lesion in left side of prostate. Gleason score came back 4 + 4. Biopsy 2 cores with cancer, and other 14 cores none. I am 69 years old (almost 70) and in good health. The prostate size in normal. Radiation oncologist order a PSMA PET scan. Scan results were good, only area of cancer was the expected area. Nothing outside the prostate.


It sounds like you fall in the High Risk category, with your G8 but not T3a and PSA < 20 (is this true?)

So I think if I were you (but I’m not, so “grain of salt”, etc.) I would choose HDR Brachytherapy to directly zap the offending lesion, EBRT because you don’t just do brachy with high risk PCa, and as little ADT as they’d let me get away with (one year?). It’s a recommended standard of care in the NCCN guidelines.

I would not choose surgery due to concerns of side effects, incontinence more than ED, and also due to the effectiveness data summarized in the site link below. But I tend to be OK with uncertainty such as would come with not having a full pathology of the prostate.

https://www.prostatecancerfree.org/compare-prostate-cancer-treatments-high-risk/

I also know that what I think I would do with high risk PCa and actually having high risk PCa are two different things.

Best of luck!
Posted 5/30/2022 12:01 AM (GMT 0)
Cancerfight

As you are approaching 70, I would recommend that you avoid surgery. Your urologist said that if you were 10 years younger, he'd recommend surgery. What he said was, I think You’re too old for surgery.

ADT for 12 months, Beam radiation and HDR will take care of you.


Good luck

Al
Posted 5/30/2022 12:39 AM (GMT 0)
Cancerfight - I was 66 and had surgery with adjuvant radiation 5 months after surgery based on the results of the prostate pathology. ED is the only lasting side effect at age 70.

Surgery can be tougher than you might think. I was on my way home in 24 hours and some are doing it as day surgery now. I thought the recovery was worse than advertised and I have had a fair number of previous surgeries to compare against. On the other hand, the treatment is over quickly but the recovery is longer than you might think.

Adjuvant radiation was time consuming with a handful of oddities but everything resolved during or after treatments within a few months. I did not have the full prostate radiation treatment so I suspect mine was a little easier than primary treatment.

At 70, I might be more inclined to go the RT route as the physical demands are not as great. G8(4+4) is up there on the risk scale so there are no shortcuts and you will have to do something that is not a whole lot of fun. You just pick the one that you think you will be at peace with in a year from now regardless of results and move on with confidence.
Posted 5/30/2022 1:02 AM (GMT 0)
IF you believe there is a good chance your cancer is truly prostate-confined and that your cancer was diagnosed early (I don't remember your last PSA), surgery has the advantage that it is done with curative intent: if no adverse pathology is found when the whole prostate is examined and if your post-op PSA is "undetectable," no further treatment is needed until/unless you encounter a rise in PSA in the future.

I avoided both RT (IMRT plus a brachy or SBRT boost) and a long haul (perhaps 2 years!) of ADT by choosing surgery for my very high risk PCa. I'm close to 100% continent and can get by without sildenafil (which I do sometimes use)--I was already experimenting with it for a few years before my RP anyway.

My uro/surgeon told me at the start of our treatment conversations that RP and RT were both valid options for me and that I would have to make the decision. I was bolstered in my choice of surgery by my strong feeling that my PCa was diagnosed very early, my PSA was not that high, my G10--downgraded to G9 (4+5)--cancer was prostate-confined, my imaging was good, and my tumor burden appeared to be low. It was 5 weeks between my PCa diagnosis and surgery, my sole treatment. I have my 5-year post-RP visit in two months.

Only after my treatment did I learn of studies showing (1) ADT (especially long-term) can have deleterious effects on cognition and (2) high-grade cancer can remain viable in some men after primary radiation as demonstrated by 2-yr post-RT biopsies. IMO cases of RT failure are attributable nor only to micro-metastases that formed before treatment, but also the the formation of mets after RT at a time when malignant cells are dying, but can retain the ability to metastasize.

The RT vs RP choice can be a difficult one precisely because it is a choice.

Djin
Posted 5/30/2022 3:29 PM (GMT 0)
Mumbo and Manfred, I hear what you are saying regarding surgery at 70 but it depends on what kind of 70 one is. I turned 70 yesterday and feel as good as I did when I had RALP 4 years ago with which I had zero issues related to age or fitness.

I keep myself in pretty good shape, running 20-25 miles per week, lap swimming 3-4 days per week, hit the cardio machines on occasion, eat a very health diet, keep a healthy weight, and don’t smoke and only drink occasionally in moderation. I just got back from 2-weeks in Italy on a study abroad with some 20-something fellow students where we walked over 11,000 steps a day and I wasn’t the one lagging.
Posted 5/30/2022 3:47 PM (GMT 0)

VinceInMT said...
Mumbo and Manfred, I hear what you are saying regarding surgery at 70 but it depends on what kind of 70 one is. I turned 70 yesterday and feel as good as I did when I had RALP 4 years ago with which I had zero issues related to age or fitness.

I keep myself in pretty good shape, running 20-25 miles per week, lap swimming 3-4 days per week, hit the cardio machines on occasion, eat a very health diet, keep a healthy weight, and don’t smoke and only drink occasionally in moderation. I just got back from 2-weeks in Italy on a study abroad with some 20-something fellow students where we walked over 11,000 steps a day and I wasn’t the one lagging.

i can't recall a radiation guy on this forum having an AUS installed. i think most men would consider incontinence a major side effect
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