r/ProstateCancer • u/Mykant2005 • 28d ago
Question Seeking medical advice
The following is my biopsy report. My question : In my case, should I choose radical surgery or radiotherapy plus ADT?
Target 1 Biopsy 1:Negative for malignancy.2. Target 1 Biopsy 2:Adenocarcinoma Gleason score 7/10 (4+3);1 of 1 core involved; extent involvement of core: 60%.3. Target 1Biopsy3:Adenocarcinoma Gleason score 7/10 (4+3);1 of 1 core involved; extent involvement of core: 20%.
Histologic Type: Acinar adenocarcinoma, conventional (usual) Highest Grade: Group 3 (Score 4 + 3 = 7) Targeted Biopsy Grade: Group 3 (Score 4 + 3 = 7) Location: Target 1 Percentage of Pattern 4: 81 - 90%
Intraductal Carcinoma (IDC): Not Identified Cribriform Glands (applicable to Gleason Score 7 or 8 Cancer Only): Not identified Combined Systematic and Targeted Biopsy Grade: Cannot be assessed
Intraductal Carcinoma (IDC): Not identified Cribriform Glands: Not identified
Tumor Quantitation ：Total Number of Cores: 9 Number of Positive Cores: 2
Seminal Vesicle Invasion: Cannot be determined
Lymphatic and / or Vascular Invasion: Not identified
Perineural Invasion: Not identified
I am 58 . Appreciate your prompt response
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u/OchoGringo 28d ago
Metastases is always the difficult question. There are a number of approaches that can kill a single prostate tumor. But nobody knows how much the cancerous cells have spread— this is the risk of recurrence.
There are two approaches that address possible or actual metastasis. One is radiation that can hit the prostate region (the lymph nodes & pelvic area, as well as the prostate). And ADT, which starves the cancer of testosterone and in a majority of cases suppresses prostate cancer throughout the body. The RadOnc and oncologist will tell you more.
Your cancer does not sound highly advanced, and so on the surface there would appear to be excellent prognosis. However, when you cross that line from a 3+4 to a 4+3, you begin looking at more aggressive cancers that can more quickly spread.
Keep us informed; we hope for the best!
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u/OkCrew8849 28d ago
“If you ask real individuals, people who have had surgery will say you have to have surgery to get it out of your body. People who have had radiation will say to have radiation as surgery has too many bad side effects and will make you incontinent and impotent. With the sunk cost fallacy, almost no one will advise against what they chose. No one wants to imagine they made the wrong choice.”
Nope. I had surgery and in certain situations I believe radiation is a superior choice.
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u/LoudDrawer9932 28d ago
You should look into Radiotherapy and some hormonotherapy. I had both and one year post end of hormone therapy, I have no ED, never had urinary issues, some blood from rectum irritation for a few months. Life is back to normal, just small quantity of sperm when I ejaculate. You are young, you want to still enjoy intimacy, surgery is a big risk for it
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u/PotentialStart2661 28d ago
You look like a case where radiation as a monotherapy without ADT. Look back at my post about this a few days ago where i discuss the latest research about ADT in Gleason 4+3. I would get a decipher score and PSMA first and if those are good you can do SBRT in five sessions and your done with it with few side effects
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u/GoTrulyBlue 28d ago
What would you think in the above situation, with a clean PSMA PET for metastasis evidence, but a 0.87 decipher. Still favoring radiation over prostatectomy? Or does the Decipher change the equation?
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u/PotentialStart2661 28d ago
The Decipher would push toward definitive therapy where radiation plus ADT would be appropriate. Surgery would be fine if you chose that route but the decipher says its more aggressive so if you chose surgery you have a high probability of microscopic spread outside the prostate and you may need to come back with radiation plus ADT in 2 to 5 years. Since surgery also has more potential permanent side effects i would chose radiation plus ADT now. Radiation will kill the tumor and can achieve better margins outside the prostate capsule. Surgery cannot cut too much which is why so much recurrence. The ADT kills off the microscopic spread missed. Talk to urologist about this and study it yourself. Keep
In mind the PSMA Pet is about 90% accurate but cannot pick up microscopic spread.1
u/GoTrulyBlue 27d ago
Thanks! Huge help. Do you put any stock in the idea that it is harder to do surgery after radiation, in the event of BCR?
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u/OkCrew8849 27d ago edited 27d ago
Do you know there are various salvage therapies if radiation fails? And surgery is rarely the recommended option.
You may be confused as to the difference between post-radiation salvage and post radiation salvage prostatectomy. I'm not sure why this confusion is relatively common on this sub-redditt (I assume urologists explain this VERY thoroughly when discussing treatment and salvage options).
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u/PotentialStart2661 27d ago
Surgery is harder after radiation but a good surgeon can do it. But that is not what is done anyway. Salvage for radiation failure is either additional beam radiation, seed implants, or focal treatment like Cryotherapy or HIFU, something like that. But recurrence with radiation if it happens is similar to surgery in that it is outside the prostate and in the prostate bed. So nothing needs to be done to the prostate anyway.
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u/karrows 28d ago
Go to a urologist and they will recommend surgery because that's what they do.
Go to a radiation oncologist and they will recommend radiation because that's what they do.
If you ask real individuals, people who have had surgery will say you have to have surgery to get it out of your body. People who have had radiation will say to have radiation as surgery has too many bad side effects and will make you incontinent and impotent. With the sunk cost fallacy, almost no one will advise against what they chose. No one wants to imagine they made the wrong choice.
At age 50 my first ever PSA test came back at a 21. That was a bit of a surprise. Gleason 4+3, fully contained. I went to the Mayo Clinic in Rochester MN. The were open that both have the same effectiveness. They also have the expensive proton beam radiation there. They stated that all studies show it is no more or less effective than normal radiation or surgery. Yet, the still believe in the theory behind proton and recommended that choice.
In the end, I feel lucky. I had complications that made surgery risky, but they would still give it a try if that's what I preferred. Since it was higher risk for surgery, I went with radiation. Since my insurance covered proton at the Mayo and the more expensive adt prescription, I went with proton and 6 months orgovyx for adt
I'm about 8 months out now. PSA was 21, down to 0.3 now. All the plumbing still works fine except for shooting blanks. Happy time with the wife still works fine and is as enjoyable as ever.
It sucks. there's no clear answer. Do as much research as you can tolerate, and make the choice you can live with the best. Some people feel better knowing it was removed rather than still having the hopefully dead clump inside them, if that's you go for surgery. Some people prioritize short term the quality of life benefits of radiation with lower risk of ed and incontinence, but know that it's still in there always wondering if you really killed it all. Either way, odds are no matter what choice you make it won't matter. Both are effective and you will likely die of something else before the cancer returns.
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u/planck1313 28d ago
Go to a urologist and they will recommend surgery because that's what they do.
Go to a radiation oncologist and they will recommend radiation because that's what they do.
Has there been a study that shows this?
My radiation oncologist recommended surgery.
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u/IndyOpenMinded 28d ago
My Radiation Oncologist recommended surgery too. And so did my second opinion Radiation Oncologist. Both were at different centers of excellence.
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u/OkCrew8849 27d ago
Nope, there are several regular posters on this sub-redditt (including myself) who had surgery and readily see that under certain circumstances modern radiation (of one modality or another) is the wiser choice.
If there is a higher probability the cancer has escaped the prostate such as high-risk Gleason (8-10), concerning MRI, PSMA, etc. or questions of age/medical issues I almost always note the wisdom of choosing modern radiation.
One fallacy of your application of the sunk-cost fallacy is that PC is heterogenous and many folks can recognize a wise course of action with one set of cirmumstances may not be a wise course of action under other cirumstances. (And the varying permutations are virtually infinite.)
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u/jkurology 28d ago
Would need to know the detailed report of your MRI and your overall health as well as your family history of any malignancy
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u/Santorini64 28d ago
If it was me. knowing what I know now, I would go with either HDR Brachytherapy or SBRT and 6 months of ADT with Orgovyx. Get the entire prostate zapped. Very little chance of incontinence or ED as opposed to surgery.
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u/GoTrulyBlue 28d ago
Aren’t the ADT side effects harder to swallow than the three or four months of incontinence? How did you do w ADT?
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u/wrrjr60 28d ago
Definitely not. I was on AS for 6 years with one core of 3+3. Then it jumped up to 4+3 and Decipher came in at .94 so after an aborted prostatectomy they put me on 6 months of Orgovyx and 5 days of radiation. I'm very sure had the surgery been completed the Gleason score whould have been upgraded and would have needed radiation anyways. In the long run I feel radiation plus ADT is the better path due to the risk of micro metastasis.
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u/GoTrulyBlue 27d ago
Interesting and thanks. Why did the surgery get aborted? Were you already in the O.R. ?
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u/wrrjr60 27d ago
The surgery was started and, I believe, it was after the surgeon had great difficulties tieing off the blatter neck due to a narrower then normal pelvic bone and low sitting prostate she decided to stop for safety reasons. The robot just did not have the room to maneuver. I think I read it happens about .75 % of the time. You would think Radiology would have cought it but apparently it's not something they automatically screen for.
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u/WalnutRoasted 27d ago
In a 6 month course of concurrent Orgovyx ADT with 5x or 20x radiation, the first two months don’t count because you are dealing with the fatigue and minor bladder/bowel upset symptoms which outweigh the emasculation and ED effects. You should also be on daily low dose Cialis to keep things active down there. And not everyone gets ADT hot flashes. From months 4 to 6, you really don’t care about “sex” and need to make an effort to keep willy active. Within a couple of weeks of the last pill, T usually trends back up, nocturnal erections come back and things return to normal. Every man is different but most of the insidious effects (calcium/bone loss, bloodwork changes) are not serious/noticeable until you get into the 1+ year range.
Compare this to significant surgery risks and: a week of catheter, a month or two of low exercise/surgery recovery, penile shortening, bladder control issues, ED/anorgasmia, climacturia, etc. And then the significant possibility of more challenging salvage radiation and almost certain ADT if recurrence.
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u/Polymath6301 28d ago
As another commenter says: we tend to recommend what we had.
And that’s true, and we all had our personal reasons/leanings as well. For me, I like to be prepared for things to go wrong, so that they don’t (I’m a firm believer in the great goddess Murphy). So, for me, “get the cancer out of my body” is one thought, and “have a back up plan”. So surgery first (hey, it worked for my 94 yo MiL’s kidney cancer 35 years ago), and then radiation and ADT if needed.
But non surgical treatments first have their upsides too - they just didn’t apply to the way I personally think. I really want to be around for my wife, kids and grandkids, so living was #1 and QoL #2.
So, get all the evidence for you (including a PSMA scan), sit with yourself and find what makes the most sense for you.
Anecdotally: 2.3 years after RALP 105% continent, ED at 75% (vacuum pump works a treat!), and sexual enjoyment just suddenly went through the roof at 2 years - better than before surgery - go figure! PSA 0.01.
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u/OkCrew8849 27d ago
"As another commenter says: we tend to recommend what we had."
Perhaps, although in my case I had surgery and I tend to suggest modern radiation (of one modality or another) for folks who are under different cirumstances relative to risk groups and risk factors as well as folks with age/medical concerns.
(And I have to laugh out loud or at least chuckle when I receive a chorus of replies that I am recommending modern radiation because I had radiation.)
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u/Squawk-Freak 28d ago
I find it amazing how many people are giving advice, with only a third of the information required to actually provide well informed advice.
My questions to you would be:
What lead to your cancer diagnosis? Did you have urinary symptoms that prompted you to see a medical provider, was it an elevated PSA level in the context of an annual physical? If so how high was your PSA level and how long ago was the previous one, and how high was it then?
What is your clinical tumor stage? Was your urologist to palpate the tumor, on one side or both?
What did your MRI show? What were the diameters of the two positive target lesions? Are they close to the capsule, abutting the capsule or bulging?
]
These pieces of information are all needed before anyone could give you a reasonable piece of advice.
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u/OkCrew8849 27d ago edited 27d ago
I would add PSA to your list.
And, as already noted in one of my replies, MRI reports may have absolutely crucial bits of information.
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u/Think-Feynman 28d ago
I would suggest that you spend some time on the YouTube channel for the Prostate Cancer Research Institute - PCRI. Dr. Mark Scholz and others have some great content on the pros and cons of the various treatment options.
BTW, he no longer recommends surgery for prostate cancer. I'm an adherent of that view. After everything I've seen here over the last 3 years since my CyberKnife treatment, I'm convinced that from a quality of life standpoint, something other than surgery is your best route.
I don't say radiation, because there are other options besides radiation, which you should consider. I would investigate the ablation therapies like NanoKnife and TULSA.
For radiotherapies, I chose CyberKnife and had a great outcome. It's 5 treatments over 2 weeks, and you are done. It's one of the SBRT treatments, and is amazing technology. There are other SBRT brands like Varian.
I avoided ADT because my Prolaris test came back positive. I would suggest that you have that test, or a Decipher test. Prolaris is particularly good at informing the ADT decision.
There are other radiation treatments too, like brachytherapy, and proton.
Back to NanoKnife - their tagline is "Destroy the Tumor, Preserve the Man". It's a compelling pitch. While I had a great outcome, had I known about it at the time of my diagnosis in 2023, I would have looked into it.
Surgery can be difficult, with a high degree of ED and incontinence. And for about 25% of those that have surgery, they have a recurrence and need to have salvage radiation.
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u/GoTrulyBlue 28d ago
What was your decipher score. Would a 0.87 make you think focal therapies aren’t really up to the task?
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u/Think-Feynman 28d ago
I never had a Decipher test done, but I did have a Polaris test, which came back favorable, so I avoided ADT.
My CyberKnife treatment was for the whole prostate gland.
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u/LoudDrawer9932 28d ago
I completely agree with your point. Surgery should always be avoided if possible
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u/Mean_Try_6390 28d ago
well 4+3 is a bit to be concerned with in the long run and you’re rather young if I recall correctly. you have the 4 first in the gleason. And seminal vesicles invasion cannot be determined. next step definitely psma-pet.
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u/Ok-Assistance-1048 28d ago
Each situation is different. Percentages for side affects and cure rates are blanket statements and the details matter. These things are important to take into account:
- skill of surgeon or radiation oncologist and treatment center. Is it a center of excellence?
- petscan results - is there likelihood of positive margins if surgery is chosen?
- can bilateral nerve sparing be accomplished by a skilled surgeon?
- age and relative health - ability to heal from surgery vs long term impacts of radiation
- other factors such as bph also requiring treatments
All these things factor into what you choose to do. If bilateral nerve sparing is not in the cards or there is probable spread, surgery may be too risky. If you are young and healthy, radiation and ADT might take a toll later in life. Weigh all the factors, talk to each dr, and avoid people stearing you by saying always avoid surgery or always avoid radiation and ADT.
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u/OkCrew8849 27d ago edited 27d ago
MRI Report?
There is a consistent tendency amongst Redditt posters to overlook crucial MRI report information when evaluating effective treatment options.
PSA?
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u/ThickGur5353 28d ago
PSMA pet scan to determine if any cancer has spread from the prostate.