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Trying to decide

Hello and thanks for the help and information on this forum. I am 64 and recently diagnosed with PCa. My Gleason score is 3/4 (7) with 5 out of 12 biopsy cores showing cancer and one of those rated as a 4. PSA is 4.9 So I am a low level.
Because of the 4 rating it was recommended that I enter treatment and I am all for that since I don't want this to spread.

I am trying to decide between beam radiation treatment or prostate removal. My oncologist recommended the beam radiation treatment over surgery because of my weight and possible incontinence issues after surgery. I am 5'8" and weigh 276# but overall health is good with no other issues. Sexual activity is not an issue for me.

I believe both treatments have about the same results in mitigating the effects of the cancer but I am concerned with some of the side effects of the radiation on the bowel. Part of the procedure is an out patient surgery that places markers into the prostate and the insertion of a polymer (?) shield between the prostate and the rectum to protect the rectum from the radiation.

Any one have similar experiences?

Thanks and best wishes to all going through this and other medical issues.

  1. If you don't already have one, buy Dr Patrick Walsh's book 'Guide to Surviving Prostate Cancer". Chapter 7 discusses options and includes some guidelines, pros and cons. It also says, on p.251, "Educating yourself is half the battle - the half you can control. The other half involves a leap of faith. You must find a doctor you can believe in, and then you must be able to accept that doctor's advice".
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    Underlying health factors are always an important factor when considering a major surgery under general anesthetic. So it comes as no surprise that your oncologist commented on your weight, given your BMI of 42. A 2005 study (Ahlering et al) concluded "obese patients had significantly worse baseline urinary and sexual function, had complications, and did not recover urinary function as quickly or as well as nonobese patients. Obese patients also demonstrated a strong trend toward a delay in recovery time."
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    Clinical assessment (T, GS) may be different from actual pathology. For example, after an MRI and a fusion biopsy, I was assessed as cT1, tumor only in left side of prostate with 7 out of 8 biopsies as 3+4, and 1 of 4+3. The 6 biopsies in the right side were all labeled benign. Based on the MRI I was N0, and based on a nuclear bone scan I was M0. In actuality I was pT3b, GS3+4. (I reserve judgement on the M score till after an ultra sensitive PSA test scheduled for later this month). The difference between the clinical assessment and the pathology was not all that surprising, given a 2012 study I had read, (Cooke et al) involving 56,446 patients which concluded: "Pathologic staging results in higher risk stratification than that predicted by clinical criteria in the majority of patients."
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    At age 72, I was a couple of years older than suggested by Walsh as an ideal candidate for RP, but I figured I was fit and healthy, and chose a DaVinci single port robotic prostatectomy, with an acknowledged leader in robotics as my surgeon. I am 5'10" and the morning of surgery I was 145.8lbs (BMI 20.9). The surgery went well despite the cancer having spread beyond the gland, which required removal of the seminal vesicles, part of left nerve bundle, and part of the bladder neck. Clear margins were obtained. The BPLND realized pN0. Apart from minor leakage the afternoon that the catheter was removed I have had zero issues with incontinence. Dry from the get-go. Based on the pathology I have a 35% risk of recurrence - but I prerfer to think that I have a 65% chance of being cancer free. I did not relish the idea of radiation, even less the idea of ADT, and am happy with my decision.
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    I hope these comments are of value. Good luck on your journey.

    1. P.S. I forgot to mention that the pathology showed the cancer was throughout the whole of the prostate, not limited to just the left side as indicated by biopsy.

      1. Thanks for the feed back. I am now learning what all the abbreviations mean and issues associated with this disease. I am under the impression that a biopsy is not accurate when determining the extent of the disease in the prostate. My biopsy came back showing no cancer on the left side and 5/12 positive cores on the right side. So I am concerned that radiation may not eliminate all the cancer. My doctor said they monitor PSA for any reoccurrence after treatment and that reoccurrence can happen with either treatment.
        I just ordered the Walsh book. When you first hear the "cancer" it causes alot of anxiety but I am learning that given my stage I do have time to make an informed decision.
        I hope the best for you also thanks for sharing.

        1. , First of all, I am really glad you have the ability to take some time to consider your treatment options. The initial shock of a cancer diagnosis can lead to making snap decisions, which may not end up being the best ones. By taking more of a "turtle" approach, you will hopefully end up making the best, most informed decisions for your personal situation. In my search for options, I ultimately learned about proton therapy, and selected it due to its extreme precision, and low incidence of negative side effects. Proton therapy is a specialized form of radiation in which an accerated beam of protons is used to treat the cancer as oppsosed to the usual powerful X-Ray or "photon" radiation. I was Gleason 6, with 4 positve cores, all on the left side, diagnosed at age 57. I am now 10 months post treatment, and just received new PSA results from a 10/8/2021 blood test -- it is now 1.25! And as advertised, the therapy, so far, has not caused any bad side effects. The main barriers to selecting proton therapy are typically accessibility (How close is the nearest center to me, or could it be possible to relocate for several months for treatment) and will my insurance cover it? As you do your research, I would certainly recommend learning about proton therapy before making your final decision, keeping those caveats in mind. And if it was not already ordered, it might be useful to look into myriad "prolaris" genetic testing on your biopsy samples for additional information on the cancer. Finally, has an MRI been ordered? When I went to the proton center, before admitting me as a patient, they did a 3 Tesla MRI to better understand the extent and location of the cancer. The MRI actually revealed two separate lesions (we did not knw that from the biopsy alone), and all indications were that both were still local to the gland. The additional information from these tests might be quite helpful in guiding you toward the best decision.

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