You are right that PSA over 20 puts you into the high risk category, especially with your small prostate, but I think a bit more scrutiny is required. Getting a second read from Epstein is a great idea.
The fact that you had hematospermia may be an indicator of prostatitis, or perhaps some kind of urinary tract obstruction. Did the MRI identify any obstruction in the transition zone ? Was a cystoscopy done to check for obstruction or bladder stones? Are you suffering from significant urinary retention? I'm asking these questions to try to understand if there are possibly other causes for the very high PSA. This is important because it may change your treatment options change.
ADT has never been found to be a useful adjunct to radiation in intermediate risk patients when the Gleason score is 3+4 or less, and when cancer is unilateral. So if you can attribute the high PSA to obstructive causes, you can probably do just as well without ADT.www.redjournal.org/article/S0360-3016(12)00856-5/abstractwww.redjournal.org/article/S0360-3016(11)03443-2/abstract
I think surgery can be problematic for prostates that small, because they are sometimes difficult to remove cleanly from the prostate bed. That may have been shown on your MRI.
As for your radiation options, I think you can eliminate low dose rate brachytherapy (seeds) because your prostate is too small:www.brachyjournal.com/article/S1538-4721(11)00323-0/abstract
The other one I'd eliminate is conventionally fractionated IMRT (the one you are leaning towards). In the last couple of years, a series of clinical trials have shown that there is no advantage in going for the conventionally fractionated treatment schedule (40-44 treatments). Hypofractionated IMRT can accomplish the same thing in much less time.
If you are indeed high risk, the best option may be a combination therapy of 25 IMRT treatments with a brachytherapy boost to the prostate. SBRT and HDR brachytherapy as monotherapies have been used experimentally for high risk patients, but are excellent choices for intermediate risk patients.
Where are you located?
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
•SBRT 9 yr onc. results
•SBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEsmy PC blog