Factors influencing my choice of RP after my G10 (5+5) biopsy:
1. My uro/surgeon told me RP and RT were equally valid treatment options
for my situtation and that I would have to make a choice. He offered to set me up with an RO. The literature I looked at seemed to confirm this for high-grade men. Only when I specifically pressed him did he offer that he would counsel a brother with my PCa status
towards surgery. We discussed treatment options for me at two post-biopsy office visits.
2. I was satisfied with his good RP outcome stats regarding continence and potency. I had had an excellent outcome with him for a previous TURP operation for my BPH. Since I saw him for years and every 6 months since my TURP, I got to know him through our chats and respected his knowledge. (He also mentioned procedures that are possible if continence was not sufficient post-op).
3. I had reason to believe my PCa had been caught early or very early and had a good chance of being prostate-confined: (a) relatively low PSA; (b) clean bone scan and CTs; (c) nine previous negative biopsies; (d) I was having 6-monthly uro visits after my TURP for BPH; (e) the nodule he felt on DRE was new.
4. As I was leaning toward surgery, I also preferred an
open procedure rather than RALP, and, by chance, my uro did only
5. I preferred to deal with any negative RP outcomes soon after surgery rather than any negative RT sequalae years after treatment. Since I was willing to bet on my PCa being prostate-confined, I saw no oncological advantage to having radiation act over time on my cancer cells versus having all the PCa removed by surgery, especially regarding met potential.
6. There seem to be no studies on the effect of RT on BPH.
7. For my high-grade PCa I was looking at a long course of ADT if I chose RT.
8. The possibility of needing only surgery (without RT and ADT) was very attractive
-- was was knowing RT and ADT were there for any needed adjuvant treatment and still are for any salvage treatment.Thoughts on my RP choice with hindsight:
1. From my outcome, it appears my PCa was, in fact, prostate-confined (path stage pT2 R0, G9 (4+5). I've learned that this fact correlates well with good oncological outcomes, whereas Gleason score does not appear to matter much with prostate-confined disease. I was already experimenting with sildenafil because of BPH-related ED before surgery, and still use it, but only sometimes, now. I am 99.99% continent.
2. Recent studies have leaned in favor of RP (+ RT/ADT if needed) having better overall survival (OS) than EBRT + ADT for localized disease (i.e. not necessarily even prostate-confined) in high-grade men. A study just published by D'Amico et al. calculated 93% vs 87%, and 76% vs 60%, respectively for 5- and 10- year OS.
Results for EBRT + brachy boost + ADT (vs. RP) have been varied and may or may not yield better BCR statistics, but expert RO's point out that good BCR stats do not guarantee better overall survival. It takes a long time to have OS stats for new RT treatments. Optimal RT doses for the newer hypofractionated regimes are still being worked out.
3. It turned out that my prostate had grown back half of the weight that was removed during my previous TURP, and if I hadn't had a RP, I may have been needed a second BPH procedure in a few years. Again, studies on the effect of RT on BPH are, AFAIK, non-existent.
4. My Decipher score was low-risk for the chances of metastases within 5 years (August will be my 4-year mark).
5. I don't think my "let's have it out now" reasoning above was unfounded: studies of 2-year post-treatment biopsies on men who chose RT show there can be viable PCa cells remaining that give rise to recurrence. In other words, all recurrence in these men may not be caused my micromets that are there before RT. IMO this isn't an insignificant consideration with high-grade disease.
5. My post-op uPSA was 0.010; it was 0.020 approaching 4 years post-op.
6. Since my RP, the issues of impaired mental cognition and cardiovascular risk with ADT have become of greater interest and study.
7. If you go the surgery route: overall stats for continence and potency outcomes with RP don't matter as much as the stats of the surgeon who is doing your
RP! Not all surgeons are equal. When interviewing surgeons asking about
their stats for these outcomes is just as important as asking the number of RALP procedures they have performed. Looking back, I would have gone with my surgeon even if he did only RALP; however, I do think an
open procedure can have advantages over robotic for high-grade disease, better access to lymph nodes being one of them.