T3a locally advanced prostatectomy?

Hi John, I am nearly the same age as you with a near identical diagnosis, but 24 months ahead of you in the treatment. G4+5 T3N0M0 PSA 25ish (it was different on 3 tests), 95% cancer on biopsy. I don't know if I was T3a, T3b they never said.

After the first MRI, but before full diagnosis, surgery was mentioned, and I was warned that adjuvant RT would almost certainly be required to deal with local advanced spread, so two lots of side effects to deal with. After biopsy I had the formal diagnosis meeting when I was given the gleason, percent cancer etc. I said "oh dear, I was expecting G6 and something trivial like active surveillance" he replied "that is not a sensible option, sensible treatment for you is two years ADT, HDR brachy, 15 fractions EBRT.". I mentioned that I sort of liked the idea of surgery (to just be rid of it), he said we will have an MDT meeting and see what happens.

Next meeting the treatment offered was as above. I am rather cynical, so my thoughts are that my prognosis (and sadly yours too) is not good, and no surgeon would want to operate on someone where the chance of clear margins is probably zero so the chance of recurrence is high, we would just make their statistics look bad.

I didn't push for surgery I can see that the treatment offered has as good an outcome as surgery, and my initial thoughts about surgery was based on an emotional desire to have the cancer cut out.

Anyway I had the treatment they recommended. As it happens today is the day the zoladex finally leaves my system, so hopefully I will start to recover from the side effects. 

As I have said in numerous posts I was lucky that I was not troubled much by side effects, but do miss my labido and will be glad to get my mojo back.

I haven't noticed much in the way of side effects from RT (there are some to do with the bowels but they are not severe). 

I can still get a hard on, with a lot of effort, and an orgasm which is dry, but OK. (remember I am still on zero testosterone, I'm hoping things will improve in the coming months)

I would say I am happy with the treatment I have had, I think if I had RP which would almost certainly be non nerve sparing, I would have regretted it.

One advantage of RP is that post treatment monitoring, if psa is not zero, you've still got cancer; so they can put you through some more unpleasant treatments. Whereas with RT until psa >2 the assumption is you haven't got cancer (even though you may have).

I would say my character is phlegmatic as are several posters on this forum. I am not that bothered that my life expectancy is now 70 rather than 85 as it was before diagnosis. If you are an anxious person then this disease is probably hell. 

Edit ****************

See Lyn's post below for clarification on following paragraph

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So I would say, make a decision about side effects and which are the least bad. If the oncologists are recommending that treatment go for it, if not then... I don't know, I was not in that position.

If you have anxiety problems (which is quite normal after a cancer diagnosis) , try and manage them, that will make a big change to your quality of life.

Edited by member 28 Apr 2020 at 00:43  | Reason: To refer to Lyn's later post about treatment decision.

Thanks Lyn, you've said that a lot better than me. I think in my case the outcomes were equivalent so I didn't think to add to my post the rather important point of, consider the outcomes first and then move on to think about side effects. 

Edited by member 28 Apr 2020 at 00:30  | Reason: Not specified

You and many others may never be certain you made the right choice.   I thought about it a lot flipping between the two.  Although it was partly fear of having an op and worry at having 3months hormones, 6 weeks daily RT, 3 - 6 months RT.   I'd had surgery for 2 skin cancers and everyone said cutting it out is the gold standard which for that condition it is and that influenced my thinking.

I was very keen to get it out.  Dave's phlegmatism doesn't enter my vocabulary, perhaps it should.  When the surgeon offered me an op in 10 days my decision was made and 120% certainty and enthusiasm arrived.   After reading on here for about 12 months I became less certain it was as cut and dried and it took a long time for me to accept RT could be as good as RP.  I now think if you have spread RT is probably better in some cases otherwise in from things I've read it's not quite as good.  You say the surgeon mentioned a wide margin and he was confident.  Some might say he would say that but did you trust him? Trust is a great thing.

For me side effects were hardly an issue they could cut the lot off.  I would be sorry to see the old lad go but being here longer is a higher priority.  

The op is quite an easy route I found.  Go to sleep and wake up hopefully without a cancer and I had no pain at all.  There is a month of messing about but it soon passes.

Mine was upgraded from 4+3 to 4+4.  But also downgraded from T3 possible to T2a.   I also wouldn't have feared RT as secondary treatment and the ability to use that route seemed a plus.  I've absolutely no regrets but if it had been 5+4 it would likely have been RT only at my hospital.  From the stats I've seen I don't think my surgeon does ops on people of that grade.  So you could count yourself fortunate to be offered it.

I wonder what Stephen Fry had, his was a high Gleason 9 I think.  Actually I answered it myself, surgery and he said something about it being 4+4 originally upgraded to 9 which could either be 4+5 or 5+4.     https://www.youtube.com/watch?v=jetCGj44kq8

I'd be interested in when will the op take place.  Being on hormones means you've got a start towards RT and if the op takes a few weeks it narrows the time gap even more.  In my opinion people with high Gleason should be given priority and perhaps you could push that one.

I just re-read the above and it doesn't come out clear but perhaps some bits will add something to your pondering.   It's a tough one and many write on here of the same.   All the best.  Peter

If you are a high risk patient (PSA >= 20, or gleason >= 8, or stage >= T3a), I was told they treat the seminal vesicles and pelvic lymph nodes even if there's no spread identified there (sometimes called "whole pelvis" by oncologists, but that means something completely different to radiographers). This was done with 75% dose in my case (46Gy), which minimises any risk of lymphodema and limits other collateral damage. The prostate was topped up to 100% (61Gy) with HDR brachy. This was at Mount Vernon - I don't know how widespread this protocol is. The treatment is called HDR Boost.