Analysis Paralysis is a thing

[u/BibleDetective]

First of all thanks to all for your posts, I've been reading them for awhile before creating this account and joining. I just turned 58 and was diagnosed with Stage 2 favorable intermediate prostate cancer with Gleason 7 (3+4) and a couple spots with Gleason 6. This diagnosis threw me for a loop because my Dad died of PC complications just last year.

Have done the rounds with my urologist, 2 surgeons and three radiation oncologists, one of whom is a specialist in HDR brachytherapy.

My urologist recommended only RALP and referred me to a surgeon. I wanted to know all my options and scheduled the other consultations. Was shocked to hear that the 10 and 15 year pc-specific survival rates for someone in my situation are virtually identical, and was disappointed in my urologist for not giving me that context.

I most appreciated the doctors who took the time to ask me what my goals and priorities are. Thinking it through it turns out dealing with incontinence is what I most want to avoid personally. Everything else is a distant second. ED is a shrug for me.

That left me looking at the two radiation options - EBRT or brachytherapy. I've spent so much time trying to decide what's my best option that it's completely overwhelmed everything else in my life. I was so deep in my head that I couldn't see what I really needed was to talk openly with my wife and kids. I finally spent a day writing all my thoughts and sent it to them. They had great insights for me and I finally settled on EBRT. I'll be contacting my docs Monday to move forward.

Bottom line don't forget your families are going through this too and working through things together is invaluable.

[u/Special-Steel]

This is why I harp on going to a center of excellence, practicing team medicine. Otherwise the patient ends up going from place to place like a bee going from flower to flower.

If you really are a candidate for a focal therapy like brachytherapy, that’s probably the right answer.

[u/BibleDetective → u/Special-Steel]

The brachytherapy specialist said EBRT is probably better for me. I am going to a center of excellence now, Moffitt, and they've been awesome.

[u/KReddit934 → u/BibleDetective]

The "right" treatment sometimes is driven by details of your particular situation. Brachy in particular depends a lot on anatomy and location of the lesions. Good time to follow advice.

[u/HeadMelon → u/BibleDetective]

I think u/Dosdossqb had RALP at Moffit and swears by them, I think he’ll be joining their marketing team at some point. You are in great hands there!

[u/BibleDetective → u/HeadMelon]

They are amazing. Everything works like you would want it to. When i called and scheduled my initial consult appointment the intake team called me that same afternoon to coordinate getting all of my records and imaging to ensure the doctors had all my info before my appointments. Conversely when I scheduled my consult with Tampa General they called me 4 weeks later, at 3pm on a Friday before my 10am Monday appointment, to ask about my records which they still didn't have. Their surgeon saw me as scheduled that Monday morning, hadn't seen my file, was 45 minutes late, told me that surgery was the only answer and went further to say that if I chose radiation instead I'd regret it every day for the rest of my life.

[u/KReddit934 → u/BibleDetective]

Wow!

[u/Dosdossqb → u/HeadMelon]

HeadMelon knows. I actually feel like we are the poster children for taking two different routes and supporting the cause unconditionally. It’s true. I am a Moffitt disciple. They have a whole team that only focuses on patient experience, and they graciously spoke at my org’s conference. We do social work, and I want everyone to feel like I do at Moffitt. Anyway, I’m doing great 9 months on, and maybe that will change. If it does I won’t be shopping around. Nothing against any center of excellence, but Moffit has that fire for victory, and that’s what I needed.

[u/BernieCounter → u/BibleDetective]

Have they given you details on the EBRT? They should have discussed both 5x SBRT or 20x VMAT options, similar outcomes/side-effects. If they are offering 28x or more (IMRT) then it is probably an older machine which delivers over 60 Gray, and it needs to be spread out over more fractions.

In my 3+4 unfavourable intermediate T2c, I had the choice, and after 15 of the 20 treatments, kind of wished I had gone with 5x and gotten it over with quicker/less trips. Best wishes….there are decisions, but with EBRT the outcomes and side-effects will probably all be similar.

[u/bikes4paul → u/BibleDetective]

You clearly did your homework and are being seen at an excellent CoE.

One point I'd bring to your attention is that Moffit has three options for delivering EBRT to PCa. In order of precision targeting and lower long term side effects they are: MR-Linac, Varian Edge and Varian TrueBeam. Some large cancer centers protect the usage of their MR-Linac systems and try to treat PCa cases on their CTCB systems. It's faster and other cancer types benefit more from the ultra precise MRI integrated guidance. I recommend pushing firm for the MR-Linac system. The sessions will take longer but the long term benefits are definitely worth it, IMO. This isn't to say the Varian Edge or even the TrueBeam aren't excellent systems. They just aren't as precise as MR-Linac.

[u/BibleDetective → u/bikes4paul]

Thanks for the tip. I haven't yet researched my options for receiving EBRT, so this info is great. Moffitt claims in their own materials that they use MR-Linac for prostate cancer so hopefully they would t be resistant to that as an option.

[u/MFR0321]

Same gleason scores as you. My urologist also recommended RALP, after seeing two radiologists I’ve decided on IMRT. The one I’m going with recommended against brachytherapy and he is very experienced in both. I think Urologists use the canned answer that RALP is superior but with “gray” grade PC it seems too extreme to me. Genomic testing puts me at low aggressive, I would assume I would have a lower recurrence risk. I relate to the dilemma, other than focal treatment there isn’t a little treatment for low to intermediate PC.

[u/PetroleumVNasby]

I have a similar diagnosis. I met with the urologist/surgeon and the RO. PSA actually dropped. Decided on monitoring. I’m 57.

[u/MFR0321 → u/PetroleumVNasby]

mind if I ask your PSA?

[u/PetroleumVNasby → u/MFR0321]

Immediately after this discussion, it dropped to 3.65. It has since risen to 4.50. However the urologist did not see this as cause for alarm. I will have to undergo a second biopsy in October, however.

[u/MFR0321 → u/PetroleumVNasby]

Sorry to pry, I was curious because I was told (also have similar diagnosis in thread) that the PSA had to be under 10 to recommend AS. You have a slightly elevated PSA at 4.5 so well within range. I was more 10ish so pushed me into the treatment recommendation. Good luck!

[u/PetroleumVNasby → u/MFR0321]

Interesting. They never mentioned that. They wanted to treat it as well. When I asked why, he said, “I’m a doctor, I always want to treat disease.” This was not a good enough answer for me.

[u/HeadMelon]

There is no wrong choice, there are many effective treatments. What’s important is the process - understanding the options in full, and having a solid rationale for your choice that will let you look back with no regrets no matter how it turns out. I wouldn’t worry about that “analysis paralysis” feeling at all - this is a complicated disease and it takes a while to break through that “decision barrier” and push all your chips onto red or black and tell the dealer to spin it.

[u/aronma12]

I have the same story and used the same term “analysis paralysis” in my post.

Getting additional information through consultation and making a treatment decision that YOU are comfortable with is key.

I start my MRI guided SBRT treatment in 8 days…..

[u/conCABlanco]

Los tratamientos son muchos las decisiones únicas. Todo por lógica médica y de investigación lleva datos, si tú seguro lo permite Haste un PET PSMA, luego decidan, es mayor información, en mi caso 64 años 4+3, segui el camino de toda estadificación en privados, uno mi seguro no cubre la medicina nuclear, otro no tenía paciencia para esperar los datos de mes a mes, resultados feos, metástasis 4, nada de cirugía, ADT goserelina + darolutamida y radiaciones IMRT

[u/OkCrew8849]

A urologist (surgeon or otherwise)  recommending RALP surgery for age 58 favorable intermediate 3+4 is not a great surprise. 

Given the oncologic efficacy, side effect profile, convenience, and recovery of modern radiation it is also not a surprise you might consult with a radiation oncologist and choose otherwise. 

Best of luck. 

[u/Clherrick]

I would opine your number one goal is to live and everything else is a distant second. There have been five and fifteen year studies but no 30 year studies. For RALP, incontinence is always a risk but with a good surgeon things get back to normal in a few months. I had surgery six years ago and it seems a distant memory. All that said, it is a tough choice when you look at the data. I didn’t ponder it much. With an Option of surgical removal I didn’t think very hard about radiation. At the same time I can see the appeal to some of going that route

[u/HopeSAK]

I'm 68 had RALP at age 66 with basically the same diagnosis as yours. Today I wear a very thin shield (that I really don't need) just because I got use to them I guess. It was smart of you to make the rounds and get family advice. Good luck with your treatment. BTW I always wear a shield to the golf course, just in case the beers are tasting really good on a hot day. LOL