Surgery vs radiotherapy

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Hi, my numbers are T2c NO MO. Like many others, I am currently reviewing treatment options. I've seen the oncologist and will see the surgeon in a few days. Until seeing the oncologist, I had thought that surgery was the most likely route for me, partly because I had been told (by someone whose views I respect) that my relative youth and fitness (I'm 61) would probably make this the best option for me, because radiotherapy has more side effects in the very long term. The oncologist didnt challenge the view directly, but did say that so far as external beam radiotherapy is concerned, the view that younger people may eventually experience more significant side effects is a bit outdated. Has anyone else come across this debate? Any views?

  • Hi H.  This is such an individual decision and I wouldn't want to influence you either way.  I can only share my personal experience.  I'm 63.  I had been on active surveillance for about 2.5 years.  During that time, I had some pretty bad urinary retention problems, with an 80g prostate. A disastrous biopsy left me daily self-catharising for several months before HoLEP surgery changed my life, opening up my waterworks. Just as things were getting back to 'normal' my PSA creeped up, MRI and another biopsy confirmed I needed treatment.  The tumour was contained within the capsule, but due to HoLEP my prostate was significantly smaller and 'sticky' which meant that surgery would be 'tricky.'  Also the tumour was also located very close to a nerve bundle, which would unlikely be saved, so there was a higher propensity of ED and incontinence.  Even before that discussion with the surgeon, I had decided on RT.  Firstly, I am lucky to have BUPA, which means I have a few more choices.  Secondly, the Royal Marsden Hospital is about 20 minutes downs the road.  I had done a lot of research - the videos D described are very informative.  I found that the incident of relapse is about the same with either option, but ED and incontinence is far greater with surgery.  I was fortunate to have MRI LINAC - MRI guided stereotactic radiotherapy.  To my knowledge, there are only three centres that offer this treatment.  I had 5 sessions over two weeks.  Week 2, I was pretty tired.  The week after treatment, I was exhausted.  I worked from home on week 4 and week 5 I returned to work.  If I'm honest, I should have taken a little more time off...I just felt I 'needed' to get back to it, for my own mental health.  I have no other side effects.  MRI LINAC has a 94% cure rate.  I was offered 6 months of HT, but this would only increase the cure rate to 96//98%, but the side effects of HT were daunting considering the possible gains, so I declined it.  With surgery, recovery can be up to 12 weeks!  With conventional radiotherapy, you have 20 to 30 sessions over 4 to 6 weeks.  There can be long term side effects from either types of radiotherapy, but they don't materialise for 1 to 2 years.  Incontinence is rare, 40% of men will have ED, but this can be treated with viagra or other ED drugs.  I have no regrets.  But I want to stress here...one thing I've learned about prostate cancer is that now two cases are identical.  What was right for me may not be right for you.  Everyone says it, but it is soooo true - do research.

  • An excellent post.  AW

  • Joe2005.  If I had the option in RT I too would have opted for MRI LINAC.  From my research I found that there was a similarity in efficacy of the different modes of RT.  The difference is in the toxicity.  MRI LINAC helps to improve targetting and focus, thus minimising the toxicity and concentrating the efficacy.

    As you say it is difficult to give categoric advice due to nuances.  It is best that we provide pointers and the individual does their own research such that they reach a level of confidence, because they will have to live with their choice.  I hope you subsequently make the right choice for you Higher1.

    It is very early days but thus far I have no regrets.  Like you I am T2c.  I too have had HOLEP, and I declined HT.

    I finished the last of my 7 UHF fractions on Friday.  It was only at my second last fraction that I was compelled to get up once in the night.  To my surprise I did not get up last night.  My bowels are also returning to normal.

    Dedalus.

  • Hi D and Higher1.  Once my final decision to go with RT was made - this was mid December 2023 - I kind of dropped out the forums and didn't do much more research. I had done what I believe was very thorough investigations, including the latest peer-reviewed university studies (I have access to some very good medical libraries). It was exhausting at times, and frankly a little overwhelming.  While general 'patterns' of information exist, there is still a lot of conflicting information out there, particularly from the US where treatment providers are in competition with each other.   There is also a bias that surgeons will often nudge you towards surgery and oncologists will often nudge you towards radio therapy.  In the end, it is YOUR decision.

    However, I trust my oncologist completely.  She is tops in her field at the Royal Marsden.  But that is only part of the reason for my trust in her.  More importantly, everything she said made sense for me.  Yes, she corroborated much of my own research, but she treated me - and treats me - as an individual.  In my opinion, this kind of trust is as important as the therapy you receive.  My treatment began on Jan 2, finished two weeks later and, as I mentioned, I was back in work at the beginning of Feb.  Two days ago I had my first blood test as a check up.  I'll receive results shortly, but as far as I'm concerned, I'm cured until I'm told otherwise.

    Finally, D, I am happy for your update and that you are doing well.  I felt I left the forums abruptly but at the time, it was what I needed to do.  Really, in the end, Higher1, that's what we all must do.

    Good luck in your next chapter.

  • Joe 2005.  In view of us both being T2c, and also opting solely for higher dose - reduced fraction RT sans HT, I am interested in your first PSA result, if you care to share it.  I can't recall what your psa was at the time of diagnosis.  I was 13.1 and it surprisingly dropped slightly a few weeks after my TP biopsy.           

    My prostate volume was 36cc at MRI and 42cc at the RT planning stage.  Like yours it was 80+ prior to HOLEP, but that was 12 years ago.

    In view of our similarities, it would be interesting to compare numbers.

    Thanks for your well wishes, and the same to you, going forward.

    Dedalus

  • Thanks all for your comments and contributions, they all help with my understanding of the issues. I’ve done some more reading over the last few days, and for those who are interested, I have found the following presentation to be a good summary of the treatment options and in particular it addresses the question I raised in my original query. 

    https://www.google.com/gasearch?q=robotic%20radical%20prostatectomy%20vs%20radiation%20therapy&tbm=&source=sh/x/gs/m2/5

  • Hi Higher 1

    There are so many variables and nuances to consider and we basically need an individualised approach to our PCa treatment.  The following is a small taster of my experience.

    I am also classed as T2c.  I find this classification a bit of a grey classification and confusing in terms of whether you are high risk or intermediate risk.  Some papers consider T2c as high risk, others intermediate risk.  After much reading and consideration of all my stats, I opted for intermediate risk.  The urologist classified me as T2b because I had a tiny amount of cancer on the right side of my prostate.  Most of the focus and a large tumour was on the left side.  I argued that I should be T2c because I had Pca on both sides of my prostate.  He conceded.

    It is very important to know as precisely as possible what your classification is, because it informs treatment decisions both by the medical profession and the patient.  The following links may add to your knowledge and assist with your decision making.

    Age is an important factor as it is in your case.  Age essentially excluded me from surgery, but it obviously does not exclude you.  However, a piece of research that helped me was aided by diagrams and it takes robotic and standard surgery into consideration in the analysis.  You have to persevere to get to grips with the diags and paper.  Please see the link here:

    https://www.prostatecancerfree.org/compare-prostate-cancer-treatments-intermediate-risk/

    https://ascopubs.org/doi/10.1200/jco.2014.32.4_suppl.110#:~:text=According%20to%20the%20D'Amico,classify%20cT2c%20as%20intermediate%E2%88%92risk.

    and here:   https://gmcancer.org.uk/wp-content/uploads/2021/10/paper-3_gm-active-surveillance-protcol-v7.pdf 

    As I said up thread, I would not want to direct you towards any specific mode of treatment. My final piece of advice remains the same ie to keep reading, unless of course you feel you have sufficient information and have arrived at a decision.  Initially, I considered having private RP, then it was private Tulsa Pro in Germany, then brachytherapy.  Whilst I waited for tests on the NHS it gave me sufficient time to do a great deal of research.  I eventually arrived at a decision I was comfortable with.  I am sure, you will do the same, if you have not already done so.

    Dedalus

  • Hi D

    I think as long as T2 and not T3 doesn't matter that much if ab or c but obviously the lower the better.

    T2 anything is considered confined to the gland and not spread to nodes or vesicles.

    Suppose the only concern would be if a Gleeson  9 or  10  which means obviously more likely to spread faster so  perhaps  b or c more worrying there especially if near the gland edge.

    Best wishes 

    Steve 

  • Hi Steve.  Thanks for your reply and reassurance.  However, the b or c does seem to make a difference with regard to 'potential' progression.  The quote I include below relates to A.S. but still appears to be relevant.

    In my reply to Higher1 I mentioned that I found T2c to be a somewhat grey classification area.  Something seemed to get muddied when they moved over from the NICE to the Cambridge Group classification system in terms of classifying T2c as high or intermediate 'risk for progression'.

    Eg from the Manchester NHS reference I posted:

    "The Cambridge Group proposed 5 prognostic risk groups to further expand and define the risk of
    progression for patients at diagnosis (with the primary end point being mortality). Cambridge
    Prognostic Group (CPG) 3 show clearly worse outcomes than CPG 2 patients, yet NICE
    intermediate group patients could fall into either group 2 or 3. For example, a patient with a Gleason 3+4 tumour and a PSA of 17 would be intermediate group in NICE NG131, whereas this patient would be CPG 3 and as such would have a much higher risk of progression than some other intermediate risk disease patients. It is therefore suggested that CPG 3 patients should not be considered for Active Surveillance without discussion at the SMDT and appropriate modification of the surveillance programme, along with full counselling of the patient as to the risks of progression".

    There also appears to be confusion at the international level regarding T2c risk classification.  IIRC D'Amico and AUA still classify T2c as 'high risk for progression'.  

    I read a discussion on Reddit where the PCa patient contacted NICE for clarification on the T2c risk classification and was not given a definitive answer.  He was referred back to his consultant and told that it was an individualised decision matter.  Perhaps that is the correct answer because as I said we bring our individual variables to the process.  However, it does not help when we look at one UK classification system and it is now at variance with the other, as well as being different from international classification systems.

    Dedalus