As a T3a, you are locally advanced which means the cancer has (or high chance it has) broken through the prostate capsule. This reduces the chance of radical prostatectomy (RP, surgery) being able to remove it all, and you would quite likely need radiotherapy (RT) anyway afterwards. So one line of thought is go with just RT, and avoid having side effects from both procedures. This may depend exactly where the break through the prostate capsule is, and how near the capsule is in the rest of the prostate (the "margin").
With a PSA > 20, you are just in to the high risk category. A currently popular treatment for this, following on from trials starting well over 10 years ago and 10 year survival data now being available, is Brachytherapy combined with whole pelvis RT (WPRT) - sometimes referred to as Whole Pelvis and HDR boost. The WPRT is a lower than normal dose (75%) to the whole pelvis to mop up spread outside the prostate, and the Brachytherapy tops that up locally inside the prostate to full dose. RT is preceded with 3-6 months on Hormone Therapy (HT) because that makes the RT significantly more effective, and the HT usually continues afterwards to make a total of 18-36 months. (This is the path I'm on.)
Another factor is your overall health and fitness. A RP is quite a significant operation with a long recovery time from the abuse the body gets in the process, even keyhole. This means it's less suitable for less fit people and as people get older. RT is not such an assault on the body, and you may be in better shape immediately afterwards. RT does bring risk of causing bowel and bladder cancers many years later on - not an issue if you are elderly, but more of a lifetime risk if you are younger.
This covers outcomes, but another important issue is quality of life (QoL). No PCa treatment is without impact on sexual function, at least temporarily, and often permanently too, and this impacts relationship with a partner, often very significantly so. Different people have differing priorities with regards outcomes or QoL, and this has to be factored in to your treatment decisions.
Nerves that control erection are on the rear and lower surface of the prostate. If the cancer doesn't reach or extend through the capsule in those locations, the nerves can be spared during a RP, giving you a chance for erections to work afterwards. Sometimes, partial sparing can be done even if full sparing isn't possible. Even in the case of nerve sparing, erections don't always work again afterwards, and conversely, when not spared, there is a tiny chance erections will recover after some years (one member has experienced this). Almost no one can achieve erections immediately after RP - even with nerve sparing, it typically takes 6-24 months for the nerves to recover to the full extent that they are going to. With RT, the situation is the other way around. It usually doesn't impact the nerves immediately, but RT carries on "cooking" the area for some years after treatment, and erections can be lost some years down line. The HT that goes along with RT also has a temporary impact on libido while you are on it, and no libido has the secondary effect of causing erection problems.
So it's not a simple decision which path to take - some of it depends on what your multi-disciplinary team (MDT) recommends with regards to survival rates and ability to handle the treatment, but it may not be clear cut (in many cases, the survival statistics are almost identical). Then you have to factor in what's important to you in terms of QoL. We do have members here who have ceased treatment because QoL in terms of sexual function is more important to them than longevity, but for most people, longevity is pretty high up the priority list.
As Johntheprint said, if you give us more details of your precise diagnosis, and PSA scores with dates in your bio, it helps to give advice more targeted to your situation.
Anyway, sorry you're here, but welcome, and you'll get lots of advice if you reach out for it.
Edited by member 21 Jun 2019 at 15:16
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