Could radiation leave some cancer cell indolent
Hi, agonizing over surgery or radiation. I am 64, healthy. Diagnosed Gleason 4+3 (4 cores targeting the two tumors shown on MRI are Gleason 7, all 4+3) with a MRI fusion biopsy. psma scan shown tumors completely localized inside of the prostate.
I was offered SBRT with 4 month ADT at UCSF. I am hesitating because I am afraid that radiation may not completely kill all cancer cells. Some cells may become just dormant and might come back active after 5,10,15 years, while prostatectomy is permanent. Any insight is highly appreciated!
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Sorry you find yourself here, @laojia
Are you categorized as Unfavorable Intermediate Risk? It appears so based on the 4+3 score.
It's all about the tradeoffs. Prostatectomy possibly offers a cure, but the idea that the prostatectomy guarantees a cure is incorrect unfortunately. There's a non-zero risk of recurrence that goes higher as you move up the risk ladder.
From a March 2024 paper, my bold font.
The 8-year risks of BCR in the post-2010 era were 21%, 25%, 41%, and 60% for low-, favorable intermediate-,unfavorable intermediate-, and high-risk disease, respectively.
The paper has some plots of biochemical recurrence rates for the different risk profiles.
https://www.sciencedirect.com/science/article/pii/S1078143924003442?via%3Dihub
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Unfortunately, no prostate cancer therapy is 100% perfect and recurrences do occur with both prostatectomy and radiation. Best to study the percentages and side effects and come to a conclusion. Based on your profile, you can take some time, but not forever.
More in general, UCSF is an excellent institution and their recommendation makes a lot of sense to me.
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Thank you @CentralPA for your input, however it seems to me the biochem recurrence post RP is due to undetectable micro spread before the surgery. And after many years, those micro cells become larger and detectable. My issues with radiation are whether the cancer cells inside the prostate which are detected by biopsy can be completely destroyed, and not come back alive after 10 or 15 years after being indolent. It seems possible that some cancer cells may escape the radiation
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For sure some may live, or since the prostate is still there some may emerge just as the original ones did. My attitude following radiation would be that you are on active surveillance.
The flip side is there is an ongoing line of research on how surgery can promote cancer growth, so its not just micro cells that eventually become detectable. The surgery can give them a solid nudge.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380551/
The good news is there is a continuing effort to understand how that happens and mitigate it. For example…
https://www.scopus.com/record/display.uri?eid=2-s2.0-85181241306&origin=resultslist&sort=plf-f&cite=2-s2.0-85017313238&src=s&nlo=&nlr=&nls=&imp=t&sid=4a3f53c417d91b3429f262e46853e4bd&sot=cite&sdt=a&sl=0&relpos=22&citeCnt=0&searchTerm=
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Hi,
Surgery will remove all of the Prostate and if done properly all of the Prostate cells. If the cancer has spread outside of the gland those could multiply and reoccur later. Radiation does not kill all the Prostate cells, just the cancerous ones plus a small margin of cells surrounding the cancerous ones. Could the non cancerous cells after radiation turn cancerous? Thats the question to ponder. That’s why I feel it’s important to know where the cancer has been detected inside your Prostate before you make a decision. The PMSA PET scan should give you a very good picture of where your cancer is located. As others have stated no procedure is foolproof but both surgery and radiation have good success results. It’s a choice you and your doctor team need to make based on the facts and remember the main goal should be to kill the cancer cells.
Dave 3+4
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laojia…I started this journey in 2009 at 53. I’m under the care of UCSF too. It sounds like your PCa is contained and that is good. I’ve had surgery, salvage radiation, SBRT and had Lupron two separate times for six months and still have the beast…Why is UCSF offering SBRT instead of surgery? Your SBRT treatment would be over a two-week period and probably 5 treatments. You would notice very little to nothing in the treatments…UCSF is a great place to be. Having choices of treatments is a good thing. Your treatment(s) are discussed with a panel of doctors and the best treatment options are offered to you. What I like about UCSF (or any teaching hospital) is that the doctor(s) you are meeting with are not pushing their specific craft benefiting their private practice (surgery, radiology, medical oncology….). My advice is to listen to the doctors you are meeting with at UCSF and go with what they feel is the best option…At the end of the day, it’s all the luck of the draw…
All the best-BD
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the fact that younger people and those have longer expected life span are more likely offered RP vs RT. Does that points to the assumption doctors believe RP offers longer lasting efficacy than RT. Otherwise, due to worse ED and incontinence profile, the younger people should be offered more RT instead because they are more sexually active and out there being the bread earner?
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The important point here is that there are no absolutes or 'cures' when discussing prostate cancer (PCa) and treatments. We only know what we can see or identify, and even then, there are no absolutes. The best scans available today, including PSMA, cannot see individual PCa cells, nor can they see minute clusters of PCa cells. Only when PCa cell clusters reach a certain size, they can be observed on scans. So, just because a scan did not see PCa, that does not guarantee that PCa does not exist.
Bottom line, each of us on our PCa journeys has to make our own treatment (or non-treatment) decisions, based upon the information that is available to us through our own research, data and advice received from medical professionals, and layperson experience-based suggestions, like the folks on this Discussion Board.
And, once you make your best available decision, you move forward and not not look back or second guess yourself, as that is wasted time, emotion, and effort. A PCa journey focuses on the present and the future, while always keeping quality of life as an important guiding factor.
Personally, I've had a fairly lengthy PCa journey, and over my journey, I've received most of the scans and treatments available today. And, while I am currently in remission (PSA undetectable), I have no illusions that I am cured, and my journey will continue. If interested, my PCa journey can be viewed here:
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Hi,
In my humble non medical opinion the reason younger men are offered surgery is due to the side effects & anesthesia. Urine leakage and ED are usually overcome with time to a manageable level. Also anesthesia is much better tolerated with men in their 40s-early 60s. More of a risk with men in their 70-80 range. With radiation usually there are low immediate side effects but things such as bladder and bowel problems a year + out from the last treatment. So if you have radiation in your 50s you could have rectum/bladder issues for a long time vs someone in their late 70s. Just my assumptions about age/treatment and you know what they say about assumptions.
Dave 3+4
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I speak from the horses mouth. I was 57 in the same boat. I chose radiation now six years later cancer still there I just got done having salvage surgery and I am pretty incontinent. First of all you need to have decipher testing done need to make sure that the grade 4 cancer is not Cribform Cribiform is radiation resistant you can believe me because that’s what’s going on with me. It killed the Gleason three but not the Gleason 4 so I removed my prostrate. I wish I would’ve done it the first time that’s just my opinion. Forgot to say five treatments in the radiation. I could not urinate. I had to take Flomax everday and it totally messed up my bowels for good. What’s the first thing you do when you find out you have cancer you try to get rid of it and how do you try to get rid of it by getting it out of your body radiation and all that other crap is no good the only true way to get rid of it is to get it out of you. That’s just my opinion. I wish I did it the first time Radiation is poison. Radiation can cause cancer radiation might not even get rid of it like with me. And now I have to worry about getting a secondary cancer from the radiation.
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