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Choosing surgery or radiotherapy?

Posted 10 Mar 2019 at 18:03

I'm 64 and I've been recently diagnosed. My biopsy showed G9 and subsequent MRI and PET scans suggest T2/N0. 

Given the aggressive form I've asked for and received testosterone-suppressing tablets (Bicalutamide) while I decide which treatment to take.

I've spoken to the surgeon who is keen to try his skills on me and he was pretty persuasive - until he said that he wouldn't be able to nerve spare in my case, so would leave me permanently impotent!

I've asked for and await a meeting with the radiotherapist, and meanwhile reading mostly good things about narrow beam and about high dose brachytherapy, which I can have in nearby Exeter (I live in Taunton). 

Given that surgery and radio seem to have comparable success rates, why would I choose surgery? Especially as many operees (is that a word?) go on to need radio anyway?

Posted 10 Mar 2019 at 18:57
Have you ordered or downloaded the ‘Toolkit’ information pack from this website?

Surgeons tend to want to surge....

With a high-risk G9 cancer such as yours there is a good chance that if you had surgery you would have to undergo adjuvant hormone and radiotherapies subsequently anyway.

You are on the right track consulting an oncologist, and you are entitled to second opinions from each speciality.

Best of luck whichever path you choose.

Cheers, John.

Posted 10 Mar 2019 at 19:11

Did the surgeon say how big the tumour is and exactly where it's located. If it's not too large and away from the edge perhaps you can take time over the decision.

It seems nerve sparing is why you may go for radiotherapy.  Although time could be a factor with a Gleason 9 and cutting it out gets rid of the main driver immediately and if it did recur there is some research that says not having the main driver slows development.

I can't advise at all on RT as I was keen to have surgery even though  there is a lot of reading claiming parity.  A surgeon and a Urologist said to me I made the right choice although perhaps for my case.

I'm impressed you asked for testosterone reducing tablets.  You've obviously done some homework. All the best Peter

Posted 10 Mar 2019 at 19:23

If the surgeon is saying no nerve sparing then it suggests that the % of each core is quite high and / or the cores show that the cancer is already close to the edge. Radiotherapy (assuming it is IMRT and even better if it is IGRT) can target those edges and the adjacent nerve bundles while hopefully leaving other nerves intact.

It varies a bit by area / region but where I live, you would not be offered brachytherapy. Common criteria are a Gleason of 7 or below, a PSA of 10 or below and a small gland; although the bicalutimide may have a dual effect of reducing your prostate volume, it is not going to reduce your G9.

If by ’narrow beam’ RT you mean proton beam therapy, you are unlikely to get that for prostate cancer in this country although you might wish to travel to Germany, USA or other countries as a very small number of other members here have. Proton beam has excellent results as a salvage treatment but trial data was very disappointing as a radical treatment so the couple of proton machines are reserved for hard to reach tumour such as optical myeloma, some head / brain tumours and very small children who would not be able to cope with normal RT. 

What was your PSA at diagnosis?

Edited by member 10 Mar 2019 at 19:31  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

Posted 10 Mar 2019 at 19:34
PS Is there any reason given for you not having a bone scan? With a G9, I am not sure I would want to go ahead with radical treatment without the full set of diagnostics.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

Posted 10 Mar 2019 at 20:51
I wonder by 'narrow beam' whether BikerBaz has in mind Cyberknife , which a few people have had in the UK although this is not suitable for everybody. It's helpful if a definite RT procedure proposed is named as there are several ways of administering RT.
Posted 10 Mar 2019 at 21:20
“Wide beam” RT is where the prostate and the surrounding lymph nodes are irradiated - that’s what I’m having at the moment. Presumably, therefore, “narrow beam” is targetting just the prostate.


Posted 10 Mar 2019 at 22:18
If you Google 'narrow beam' you get proton beam therapy.

IMRT is by nature a multitude of very narrow beams targeted to the area of need via a computer programme - your target area may be wide to include the lymph nodes, John's was wide in that it included the bottom of his bladder - but the beams were narrow.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

Posted 11 Mar 2019 at 02:32

Sometimes a wider beam is helpful to allow for a greater margin. Cyberknife works on a much tighter and more intense beams with greater accuracy so is a narrow beam but unusual to give to a G9. The Royal Marsden (among others) advocate it for suitable candidates :- https://www.royalmarsden.org/difference-you-make/cyberknife-state-art-radiotherapy?gclid=EAIaIQobChMI-rLNh4L54AIVzZ3tCh1JvQ3yEAAYAiAAEgIUfPD_BwE.

Hadron treatment (which includes protons and carbon ions), operates these days using 'pencil beam' delivery but as has been said, this means having to go abroad for it as a private patient for PCa. https://www.protominternational.com/2017/11/advantages-of-pencil-beam-scanning/


Edited by member 11 Mar 2019 at 02:36  | Reason: to highlight links

Posted 11 Mar 2019 at 08:15

Thanks for the feedback folks!

My terminology is probably inaccurate. I'm learning fast though.

My Macmillan nurse describes the Musgrove's therapy as "somewhere between IMRT and 3D", and I will find out more when I meet the oncologist. No I'm not talking proton beam and in any case can't see any evidence that's any better.

My biopsy showed 3/12 cores positive - 2 in a palpable lump near the surface but also 1 in the body of the organ. All G4+G5.

The organ is large, around 100ml in volume, and this has been cited as making me unsuitable for low dose seeds. I am having some retention and flow problems, which is why I was PSA tested in the first place. My PSA was just over 4 in 2016, now just over 11.

I'm hoping I can go the high dose brachytherapy route, but being obese and with Type 2 diabetes the risks with any general anaesthetic are higher, as with the surgical option. I'll ask about an epidural.

I know I'm jumping the gun asking you kind folk for opinions before I've spoken to the oncologist. Naturally enough I'm worried, and keen to get on with it!

Edited by member 11 Mar 2019 at 08:17  | Reason: mis spelling

Posted 11 Mar 2019 at 08:34
Entirely understandable, Baz. It is a worrying time - we've all been through it and we're happy to help in any way we can.

All the best,


Posted 11 Mar 2019 at 09:55
Thanks for that.

I missed the question about the bone scan. My first MRI did show a couple of suspicious lesions in my pelvis, so in the new year I had a PET-CT scan using 18F-labelled cytosine* and looking for it's rather prostate-specific uptake, and that showed no "hotspots" either in the bone or anywhere outside of the organ.

Touch wood it's been caught early...

*as a former scientist I was fascinated by both the MRI and PET-CT scans. The quantum theory explanation of positron emission is completely mind-blowing!

Posted 11 Mar 2019 at 13:48
Great news about the bone scan results. That should mean that you're on a curative pathway.


Posted 12 Mar 2019 at 09:55

As well as learning about the treatments and their side effects, do think long and hard about your lifestyle: you'd have trouble getting a razor blade between treatment options in terms of survival - but they are oceans apart in how they affect your life.

Also, there is a little more gambling involved with surgery: they can predict likely outcomes but the range is pretty big. Radiotherapy is less exciting in that sense. 

Finally, it's vital to hear from both consultants: and remember that the surgeon is much more likely to emphasise the best possible outcome and tend to gloss a little over the worst. And that isn't just my experience: surgeon optimism is well researched. Though I must say mine was so one-sided that I credit him with my eventual choice of RT, which (in my case) was probably very much the best option.

But my point is that we're all different. Think long term / big picture and think about what will be best for the unique set of circumstances that is you.


-- Andrew --

"I intend to live forever, or die trying" - Groucho Marx

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