I also asked the doctor what percentage of post surgical path reports result in a Gleason upgrade. He said it is as high as 25% in some locations, which is a higher number than I’ve found so far. I feel the worst for those that choose surgery as their one and done, only to have to go to radiation right away based on post surgical findings.
Enoont, I've been lurking on this thread as others have already given very good advice, but I thought I would just chime in on one of your observations, noting that you are keen on SBRT vs surgery. It's true that there are a high level of Gleason upgrades after surgery (and a significant but lower number of downgrades). Many of these upgrades result in secondary radiation. Biopsies are by their nature imprecise.
If a pre-treatment diagnosis such as yours (MRI, DRE etc) indicates that focal treatment would be curative, both surgery and SBRT are excellent and equivalent choices in terms of cure. In surgery, because a pathologist examines the prostate, immediate adjuvant radiation can be applied if there is averse pathology that indicates high risk disease such as EPE or higher gleason grades.
For low/intermediate risk disease SBRT is a focal therapy
and radiation is not normally aimed at the prostate bed. This results in the lower level of rectal and urinary side effects compared to IMRT. However, since you don't have a prostate to examine after SBRT, you have to assume that the initial diagnosis through biopsy was accurate. If there were higher gleason grades or EPE you would be non the wiser and would not know that focal radiation is not enough
. Hence those 25% of surgery patients you mention who had upgrades or EPE would go unnoticed in SBRT and reirradiation of the prostate bed would not occur until biochemical recurrence (BCR), which may be a long time. BCR for radiation is defined as nadir PSA + 2.0, which could take a considerable amount of time.
So, while you may feel for those 25% of surgery patients who required adjuvant or salvage radiation after a pathology upgrade, it is possibly even worse or too late for those who had focal radiation and didn't seek secondary treatment until a delayed BCR, whereby the cancer had gone from local to metastatic.
Higher intermediate risk patients e.g., Gleason 4+3, can choose combination therapy which even more spread out than the surgeon cutting wide, such as Brachy Boost, Surgery & adjuvant or even SBRT Boost.https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5879839/
Not that I'm suggesting it would be useful in your case
Now 58 Dx Dec '16, PSA 4.313
Jan '17 MP MRI PR 5, Bn Scan -ve; Fusion BX 4 of 12 +ve G7 (3+4)
RALP Feb 2, 2017
Path: G7 (3+4), PT2c No ECE, margins, LN or SV all -ve
2017-2018: 0.019-0.059(Siemens); <0.008(Abbott); <0.03(NCCS); < 0.01(Bck Coulter); <0.006(Labcorp)
2019: 0.033(Siemens); <0.008(Abbott); <0.03(NCCS); <0.006(Labcorp)