Weighing up longer term risks of surgery vs Radiotherapy

I have recently been diagnosed with 2TCN0M0 prostate cancer, I met the surgeon yesterday who outlined three of the choices that I am sure many in a similar situation to me have faced, active surveillance, radiotherapy or surgery. I will meet the oncologist in a months time where we will discuss radiotherapy further. My Gleason score is 7 (3+4) The surgeon indicated to me that my Gleason was 7 in the left part of the prostate but only 6 in the right hand side. Whilst I understand that 15 year survivability is broadly the same with the three options that were shared with me, I am interested in better understanding the longer term side effect risks of surgery vs radiotherapy, having heard that about 5% of men having had surgery will still be incontinent after a year and that there is a risk in the long term of bladder cancer or bowel cancer with radiotherapy. If anyone has any information about these longer term risks that can help me make an informed decision, I would be grateful to hear from them.

Hi Pilgrim 

The way I looked at this was to concentrate on , in theory, the  easiest  option.  I Def didn't want major surgery so had 4 years on  AS which u have also been offered.

Then 20 sessions of radiotherapy, a few side effects during treatment but they soon finished and everything ok now.

Having surgery can certainly produce issues like ED and urinary problems. Obviously not everyone has them it has to be said.

Only downside to Radiotherapy is no surgery if cancer returns whereas radiotherapy after surgery ok.

So do think it through, time on your side and see what others say

Best wishes 

Steve 

Whilst looking for something else I came across this information. In particular section 1.3.7 gives some indication of short and long term effects of active surveillance, Prostatectomy and Radiotherapy.

https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#localised-and-locally-advanced-prostate-cancer

This information does have limitations in that techniques have improved since this information was produced and it doesn't include things like Brachytherapy or the focal therapies. With radiotherapy modern machines provide a more targeted dose so that there is less collateral damage to adjacent structures.

I have looked at this information a few times, in part because it is encouraging for people with my diagnosis undergoing radiotherapy.

However, as you mentioned, treatment has moved on even from this. During my recent radiotherapy stint I met 3 men on salvage radiotherapy after comparatively recent surgery. There is another gentleman at my church just going down the same path.

It leads me to wonder whether men are being lead down the wrong path by suggestions that surgery and radiotherapy are equally effective?

It is a difficult decision for men to decide what treatment route to choose. Besides the statistics there is also the emotional side to consider when making that choice. Some men just want it out, others are surgery averse. Those who have surgery often do it because they feel they have a fallback of salvage radiotherapy and dismiss the not insignificant statistical risk of needing it. I doubt that many ask their surgeon what their track record is in that field. There is more and more data coming out which suggests that the risk of needing salvage radiotherapy is related to the initial risk factors of the patient so it is not a one size fits all. Radiotherapy and focal therapies have come on in leaps and bounds over recent years and give equivalent results but with a different set of side effects compared to surgery. For low risk patients the success rates in terms of a cure are similar. For higher risk patients I think more guidance should be given to the potential side effects of the different treatments and the risk of needing salvage treatment and what that salvage treatment involves after the different initial radical treatments. The UK falls behind other countries in terms of offering focal therapies unless the patient pushes for them or has private medical insurance.

Dr Mark Scholz has an informative video on the subject. 

https://youtu.be/ryR6ieRoVFg?si=uE54QYOkxByzeLtK

Hi Pilgrim2 and welcome to the forum. It would help us to help you if you could fill in your profile with some details. You can see any member's profile by clicking on their username or avatar.

I was 71 when diagnosed with T3A N0 M0, a Gleason score of 4+5=9 and a PSA of 11. So an aggressive cancer but with low PSA secretion. I was offered a choice of surgery or HT/RT. With the help of my son (who is a consultant anesthetist with the NHS) I made a list of all the pros and cons of each treatment path (there aren't really any pros, just cons and not-so-cons!) and decided on the HT/RT route.

The reasons for my choice:

1. I am very active and was told that surgery could leave me with long-term stress incontinence.
2. The surgery is a major operation and, at 71, how long would my recovery take and how long before I could get out rowing again?
3. Yes, there is the possibility of long-term bladder and bowel problems following RT, but again, at 71, is this going to affect my lifestyle?
4. How would my body cope with three years of HT?

I actually managed the side effects of HT very well by taking Evening Primrose Oil, Sage capsules and an occasional Homeopathic remedy of Sepia (cuttlefish ink). The fatigue following the RT was a bit more difficult but with a programme of exercise organised by my friends from the coastal rowing club, I overcame that in a few months and was soon back to pre-PC levels of exercise.

I am now 77 and walk at least 35 miles every week, swim a mile twice a week and go rowing as often as possible.

Everyone is different and this is just my personal take on my treatment path. I hope that helps and good luck with your choice.

Hi Seamus, thanks for this and sharing your reflections and the reasons for your decision.  I'm 59, T2CN0M0. Gleason 7 (3+4) (Also enjoy walking!) I have updated my profile with details of how I came to be here, including some worrying  MRI conclusions that that turned out to be a false alarm. 

Thanks Always Hope - the Scholz video was interesting and seemed to plat down the risk of secondary tumours from radiotherapy which was interesting (and reassuring)

Hi Pilgrim 

I've read your profile, and can very much relate to your situation as my stats (details in profile) are very similar to yours, although I am about a decade older.   

Question: have you received a MDT (multi-disciplinary team) recommendation, and supporting rationale if known, on which of your three options is the best way forward ?

Suggestion: if the AS option is under consideration by you, you may wish to consider requesting a copy of the full histology report, which I gather is not routinely issued.  This may be helpful in assessing if you are close to a tipping point between the current G3+4 and G4+3.  

Regards. Peroni.

Hi Seamus47. 

Interesting post that you put up, Your symptoms/numbers were an almost perfect copy of mine, apart from age. I was 78 when diagnosed last July.  I too was offered surgery or HT/RT – I was “borderline” (age wise) for the surgical route, but it was there if I insisted.

My reasons for choosing HT/RT were exactly the same as yours. Surgery just seemed to pose too much risk regarding incontinence and other “mechanical” problems. The more I read/heard about it the less I fancied it (if "fancied" is the right word).

I have been very lucky as far as side effects of the HT and the RT are concerned – almost zero. I have put on a bit of weight and certainly feel a bit more weary. I get hot ears now and again and had a slightly dicky tummy during the RT, but that may equally have been caused by my 95 mile round trip on public transport every day.

I was originally told 3 years on HT, but following the RT and the first follow up that has been reduced to 2 years. Have got my 2nd follow up in 10 days............must remember to get the PSA done before then ! 

Now the weather is improving I can get out and do some serious walking myself………..not sure if I can get up to your 35 miles per week though !

I am 100% convinced that I made the right decision. However, reading this forum shows that everyone is different and that only one person has to make the decision.