LDR Brachytherapy - 1 rollercoaster year later!

So, although it's still too early to tell categorically (is there ever a categoric?) at least it's still possible that I could be one of the minority of people who have LDR Brachy and go on to experience this 'bounce' phenomenon.

Obviously it would be more reassuring to just see a straightforward downward trajectory but I'm not losing hope at this stage - bounce can definitely occur, especially in younger men so I'm keeping fingers (and everything else) crossed!

Next PSA September and weirdly I'm not expecting it to fall by then so will probably remain wondering 'is it or isn't it'? Will cross that bridge when I come to it!

PSA in mid September was up to 7.91 from 4.64 in June. As I'd said in a previous post, I was expecting it to have increased since June even if this is bounce.

Onco and Urologist ordered a contrast MRI which came back completely clear with no sign of locally recurrent or metastatic disease but 3 weeks after the September PSA test, it had risen again to 9.09 in October on retest.

Now, despite the very reassuring MRI and mostly reassuring PSMA PET (which did note some 'patchy uptake in both lobes most noticeably at the apex') the onco and urologist have decided they want to biopsy :( The understandable rationale is because of the scale of the rise (nearly 7ng/ml) and the duration (10 months now on an upwards only trajectory).

I can't say I'm delighted at the prospect because although with each result it looks less likely to be a bounce, it still could be!

I've read numerous publications stating bounces can last up to a couple of years and 10 or even more months on an upward trajectory as part of the overall bounce duration isn't unheard of. Throw in the whole 'younger men are more likely to have bounces and they're more likely to occur earlier and bigger' and I want to continue to cling to the hope it is a bounce.

The question is, am I in denial?!

The uro has been wanting to biopsy now since June and reading his body language, he appears to think this is treatment failure. The onco on the other hand still acknowledges it could be bounce but is losing confidence with each PSA result and I'm also not sure he's ever personally seen anyone bounce with these numbers.

Some friends have questioned why I'm resistant to having the biopsy (they've obviously never had to deal with the side effects!!) but the main reason is actually not because of the biopsy itself but because I've read in a few places that biopsying within 3 years of LDR BT can often or even mostly be inconclusive because of the time it takes for the radiation to kill the cancer cells. One of the studies recalled how 3 patients with rising PSA post LDR BT all had biopsies which came back positive. They were all offered savage RP, all 3 refused and subsequently, all 3 eventually had their PSA fall to below pre rise nadir without further intervention. So although all 3#s rises were the result of bounce and not failure, they all could have chosen to have an unnecessary salvage RP based on the biopsy results! Scary!

Now the consultants have sought to reassure me that pathology can tell between cancer that has been radiation affected (and so should die) and cancer that hasn't been radiation affected and would therefore require further (undefined) treatment.

Despite that, I keep thinking about those 3 guys who could have had those unnecessary salvage RP's though and wonder why they got those cases wrong? I'm also aware that I'm still (just) within the parameters of a bounce and I desperately don't want to be overtreated too soon.

Equally, I don't want to be behind the curve if this is indeed failure....

Nothing's ever simple huh? :(

Yes I went backwards and forwards trying to decide whether to go RARP or Brachy and I don't think there's a right or wrong answer because both options have pretty much identical success rates.

Ultimately it was the equal chance of success with almost certainly fewer risks that steered me towards BT.

My urology consultant does both RARP and LDR BT and he said it would be a toin coss as to which would be the better option but he also came down (just) on the side of RARP. But when he went on to say he'd done probably 2000 LDR BT procedures and only seen failure in about 20 of those, I decided they sounded like pretty good odds!

Also, my Dad was diagnosed with PCa when he was 60 and he had LDR BT. He's now 80 and still has an undetectable PSA which probably influenced me too.

As I said here or in another thread, the only problem I've had with LDR BT is this period of uncertainty where you just have to wait and wait to judge how effective it's been, every PSA test brings quite a lot of anxiety with it! But I suppose that's probably the same post RARP as well in fairness.

Other than the testing anxiety though, the BT procedure is so straightforward and easy to tolerate. In and out of hospital in half a day, no worse side effects post procedure than having a biopsy really. A little more urinary urgency for the first few months but that's about it. I would say by 6 months post op my urinary and sexual function was as good as pre op.

I also remember discussing my options with a Dr friend I've known since school. He's one of the brightest people I've ever met and a hugely well regarded consultant in a different medical field. He'd just had robotic kidney surgery but said to me, 'why would you choose to have major surgery (RARP) when you could have a minimally invasive procedure (BT) that's just as likely to be succesful?'

Pretty straightforward on the face of it you would think but like many on here, I still didn't find it that easy to make the final decision despite his matter of fact advice!