RP Surgery or SBRT Radiation - Decision Time

New member seeking advice. Diagnosed in November (2017) and still in the learning phase. Have talked to my original urologist, a radiation oncologist and two surgeons. All good information but no clear cut direction on the optimal treatment.

Surgery option sounds valid as the Sloan Kettering prediction model suggests with my data there would be 72% progression-free probability 5 year after RP and 58% progression-free probability 10 year after RP. Net, pretty good chance that radiation would be required some time in the future and the radiation after surgery approach makes sense.

The downside of surgery for me is that the lesion is close to the capsule on one side of the gland and the nerves on that side probably couldn't be spared. So, not a good ED prognosis.

I have learned a lot about SBRT and have found a radiation oncologist who has had good success with it via the CyberKnife instrumentation. We've had much discussion with the 3+4=7 versus the 4+3=7 situation and he feels I'm still in the Intermediate camp and that SBRT is a viable approach. My concern is that if I go with the SBRT approach and it fails, am I in worse shape than if I had the surgery and then followed-up with radiation if it failed.

Everyone says that "it's your call" but it sure sounds like an extremely important decision for a lay person.

Since many of you have gone through this same conundrum, I'd greatly appreciate any help or advise you might have.

DOB 11/1949, Age @ DX 68
DRE - enlarged but normal
PSA - 4.2 on 4/2016, 4.2 on 6/2017, 5.3 on 9/2017, 4.4 on 12/2017 (15% free)
MRI 8/2017 - 1 lesion, 8mm, PI-RAD 5, prostate volume 66mL
Biopsy 11-2017 - normal 12 core, 3 cores Gleason 3+4=7 (10% 4, 10% 4, 40% 4)
Biopsy 11-2017 - focused on MRI lesion, 5 of 5 cores 4+3=7, 55% 4, PI-RAD 4
Stage T1c, Intermediate Risk Category

Welcome, T.S.! I don't have any advice for you -- it would be thoughts of a dry brain in a dry season -- but just wanted to know: Mind if I call you Gerontion?
As tough as the decision is for a layperson, you should feel fortunate you've found a group of doctors who are supplying you with hard information and not pushing their personal treatment agendas.

Sorry about your diagnosis, but glad you're here. Hope we can be of help!

First off, you might want to consider a second opinion on your biopsy slides from Epstein at JHU. Given the amount of positive G7 cores you had, I'm not sure how likely it is that you would get a different reading. That said, it's cheap and easy to do, so why not go ahead and get more info? If for some reason, one of your 4+3 cores was really a 4+4, that could change your thinking. (I'm not saying that would happen, of course. But it would be good to confirm.)

Assuming that everything is confirmed as a G7, either surgery or SBRT have similar chances of curing you. The main difference is the side effect profile, so that's really worth considering. Regarding your concern about recurrence, both surgery and radiation have salvage options. For example, if you did have SBRT and there was a recurrence, they would likely do additional radiation.

Other things to think about: surgery gives you pretty quick feedback on whether it was successful or not. Radiation is a much slower drop in PSA...that didn't bother me, but I do know that for some people that's difficult.

I agonized over the treatment decision, but eventually one made sense to me, particularly as I learned more and got more comfortable with my options. Good luck to you and let us know how we can help!

TS: I can't weigh in on the technical aspects of various treatments as I am just not that knowledgeable about all of them. You have already received some good advice, particularly from TA.

You will see in my signature that I have just recently finished 5 fractions of SBRT at Swedish Medical in Seattle with Dr. Robert Meiers, one of the leading SBRT/Cyberknife RO's. He has some very impressive "non recurrence" stats for intermediate risk guys. something like 97% at 8 years follow up.

I was DX in early August this year and by late August I had scheduled surgery. I then started really listening to what I was hearing here at HW. I went back to the decision process, talked to a few more Dr's and ended up doing SBRT. I am very happy with my decision. The treatment was a breeze. As I had some minor urinary issues pre TX due to an enlarged prostate and am now having moderate issues. They consist of low pressure/slow flow and some pain sometimes when I pee. Under good control with a couple of pills a day. The main reason I went with SBRT and not surgery was over the SE/QoL issues. For me it looked like guaranteed SE's right now and maybe well into the future with surgery and less SE's right now and maybe non now and into the future. I will say this...I may have a little trouble peeing right now but I can pee or not pee, that is my choice. After surgery MOST often you don't have that choice.

I am biased towards RT and specifically SBRT. I have as yet to find out if the TX was successful but as far as where I am today I am VERY pleased.

My advice........Take a little time, get in touch with yourself, determine what is most important in your life concerning quality of life issues. Then with those thoughts, feelings and ideas in hand research ALL of the mainline treatments and see which most closely fit with who you are and who you WANT to be on into the future.

May you be well.

Roger

TS, good advice from people who have walked the road you’re starting on. I chose surgery to get definite pathology, eliminate the mother tumor, and with a view to adjuvant/salvage later. Don’t know where you are but mine was done by Dr. Touijer at MSKCC.
Pretty well recovered at ten weeks, carried 40-pound bag of salt to the basement water softener today.
Unfortunately, at 6 weeks I had persistent psa at 0.10; not good but hoping it’s on the way down rather than up.
Well played Saipan! Listen for the mermaids sining each to each.

I had RARP at City of Hope in LA. A very respected cancer hospital. my URO told me that I may need to use Cialis or Viagra after to treat side effects. I did not know about this site and went with rp without much study. All the stuff I saw talked about nerve sparing robotic surgery. Just get it over, I thought. The URO took all my nerves, 13 lymph nodes and a wide margin. ( He said it was worse than biopsy indicated) I am <.1 PSA now. BUT..Still partially incontinent. Sex life is 0. No ejaculate. very light feeling of climax when I use injections to get hard. Also hard is painful. 50% of the time injections fail, and when they don't fail they are a real pain if your wife is waiting for you. No blood flow to the glans area of my penis. Stone cold. Last weekend I was judging a dog trial in cool weather. The combination of leakage and the cold, by the end of the day my penis felt like a frozen popsicle. My physical therapist has me on vacuum device to get blood flow every day and injections every 4-5 days just to keep things alive in case I ever do want to have sex. I think I am clear of cancer and I am very thankful for that but you need to weigh the sexual side effects. Be sure you know ALL the side effects. Also if URO does not cut wide enough, you will be back in salvage radiation. TA does not even talk about the severity of the SE"s of surgery. If I had met him before the RP, I would have followed his advice.

T.S. - I can't add much from the medical/technical viewpoint. The others, more qualified than I, have done an admirable job for you there.

What I can do, though, is reinforce for you that your treatment decision should be made from your own viewpoint. What is important to YOU? There are both surgical and radiologic treatments that have high odds of effecting a cure for you, BUT their side effects profiles are quite different. Whichever treatment you choose, at your age, you will live with any side effects for many years. Learn about the side effects, then weigh them heavily in making your choice. BTW - You will only learn the real truth about any treatment by consulting with a practitioner in THAT particular treatment. A surgeon will not know the latest about radiology. An RO who specializes in IMRT will not be current about brachytherapy, nor will an IMRT specialist be up to date about SBRT. Look around and meet with the right docs.

With your stats, I believe that you need not be in a big rush to get to treatment. You can take a month or two to learn about potential treatments and make your choice. Once you have chosen your treatment path, you can interview prospective docs and choose who best to administer your treatment. Both the treatment and the doctor are your choices to make. Take your time. Do it right. You shouldn't need to do it a second time, but if you do, the process will be the same.

Well T.S. as you can see from the posts you have received already it pretty much lines up on who had what TX as to what they will advise. That is natural for one to advocate what route they took. The important thing is to be knowledgeable. The Doctors although well meaning and dedicated most usually suggest their specialty as the answer. Also I have found, in my limited experience, and from what I have read here at HW that more often than not each Dr. also fails to really lay out the severity of the SE's from the TX they are proposing. So....................again I say. Become very knowledgeable of the technical data and of the anecdotal from other people here at HW Then armed with that info talk with the various Docs.

It seems to me that one of the biggest positives put forth by the surgery guys is that you WILL know the EXACT extent of your PCa. Well.......IMHO that is not really true. I have read case studies of men who had excellent post op results, with clear everything and still had recurrence down the road. The same holds true for RO. A steadily declining PSA for a number of years just to have it jump well down the road. All I am getting at is that for ME the decision is much more about today, right now, immediately following treatment......what will my life be like. I look at it like this because I believe all mainline treatments seem to be about the same, statistically, as far as recurrence.

May all beings be well.

Roger

TS- I also feel you have received good advice to your question.

Let me add my own story. After my diagnosis, I became aware of this forum when searching for information about possible surgeons. Yes, I was biased towards surgery. I saw one RO, a member of my urologist's group, and was briefed on the 40+ radiation treatment protocol. I ended up deciding surgery.

I'm comfortable with my choice. My PSA is still undetectable, and I regained continence right away. ED is still an issue, but I expected that. I became active on this forum after my surgery.

However, I know there would have been a benefit to joining this forum upon diagnosis. I've learned about the other forms of radiation treatment. That additional information could have helped me make a more informed decision. SBRT is very interesting! I'm a person who appreciates knowing as much as possible. Perhaps you are too.

So pay attention to what fellow PC veterans are telling you. Become educated, and ask your providers more questions. My guess is you'll make the choice that answers your specific needs.

Good luck.

Yes that's true BB. I have read a number of posts from the surgery guys who wish their choice had been different. I did not really want to go there for fear of being dubbed "anti" surgery. You know how it can get going sometimes. I do feel that surgery "CAN" be a viable option given certain circumstances.

May all beings live happily always free from animosity.

Roger

Dear TS, I am glad to read your note and the various responses as it feels similar to my dilemma starting about 6 weeks ago. I still go back and forth on surgery vs. RT. Within either one I go back and forth on who is the right surgeon or who is the right RO or what is the right kind of RT. I go back and forth on the advantages of finding someone local who you can easily follow up with versus going and finding the one you feel best about.

The decision seems so important in my life that even moving somewhere for 5 weeks of RT might be worth it if it were the "just right" RO, or "just right" medical center. I hope your process is moving along well, Manticore
_________
PSA 17.3, Gleason 7 (4 +3) and four 7's (3 + 4) out of 16, lesion along the capsule

Sorry, Manticore, didn’t notice you’d already started another thread and gotten responses. Good on you, that’s the right way to do it. Good luck.

MARK: I am happy to see that you have come to the decision point and made it. I am biased, of course, but am glad to see you chose SBRT. Outcomes are great, statistically, and I can vouch for the SE's being minimal.

Suggestions: Talk to the RO or RO nurse about starting flowmax and something to help with the mild to moderate pain with urination you may encounter about the 3 rd treatment. I would suggest at least having it with you as these drugs take effect within a few hours.

I woke in the night after #3 needing to pee, I couldn't get it started and it was fairly painful trying. I finally did get it going a few hours later but still painful. Spoke to the nurse the next morning at treatment, got a script, got the flowmax and 3 hours later all was well, not great but well. Also to be on the safe side get a bottle of Aleve as it works way better than Ibuprofen for pain.

I had trouble staying awake during treatment as I wanted to watch the Robot work.

Be well and please let us know when TX is and how it goes.

Roger