As always, the disclaimer: I’m just a guy sharing his experience dealing with prostate cancer. I am not a medical professional. If you are at the prostate cancer treatment decision junction, you should be talking with your urologist and other medical professionals. My treatment choice may not be ideal for your cancer, my risk profile may not work for you, and you may not have the flexibility to travel for treatment, as I will do in the next six weeks.
Is Active Surveillance an Option?
As you might expect, the preferred prostate cancer treatment option for most men is no treatment. After all, who would sign up for surgery or radiation if it wasn’t necessary? Doctors typically call this post-biopsy outcome “watchful waiting” or “active surveillance,” the latter if the monitoring is more rigorous with routine PSA testing, MRI scans, and biopsies. It’s a viable option if your cancer is low-grade and you are staged at a low risk of rapid cancer progression.
After my biopsy results came in, the Denver urologist who performed the biopsy indicated he felt that treatment was the order of the day. I could wait a few months, but much longer introduced the risk of the cancer spreading. I needed to decide which treatment option was best for me—surgery, one of several flavors of radiation, or perhaps one of the newer, less-proven focal therapies.
An Important Book
I revisited my prostate cancer research, focusing on learning as much as I could about treatment choices. I spent days collecting links, reading research reports, and making notes. I ended my research when a physician friend recommended the book Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer. I could have saved myself a ton of online work. This book is comprehensive and dives into more detail than many men might want. For a fully informed treatment decision, read the chapters in this book about treatment options. When you are done, your head may spin, but you will be well prepared for your post-biopsy treatment discussion with your urologist.
As an aside, during my research on treatments, I discovered the last 20 years have seen incredible progress in treatments for prostate cancer. I am enormously grateful for today’s options that are much more effective at treating prostate cancer with lower rates of serious side effects. I feel fortunate to be receiving treatment in 2024 rather than in 2004.
A Treatment Decision…Twice
Back to my decision, after my post-biopsy telehealth visit with the Denver urologist, my initial decision was to proceed with a radical prostatectomy (surgery). He had performed over 900 of these procedures and asserted a commitment to avoiding quality-of-life side effects (urinary incontinence and sexual dysfunction). Honestly, my first, quick decision was driven to a large degree by a strong desire to get it over with. I just wanted prostate cancer in my rearview mirror. Over. Done.
Fortunately, the first opening on the Denver urologist’s surgical schedule was two months out (if I were lucky), and he also recommended a consultation with a radiation oncologist. This gave me more time to research my choices and make a second decision. I discovered solid evidence that external beam radiation therapy was equivalent to surgery for five-year disease-free survival rates, and stereotactic body radiation therapy (SBRT), my preferred choice for radiation treatment, offered better results than surgery when comparing side effects. Amazingly, the machines delivering these precise doses of radiation are accurate within a millimeter or less, less than the thickness of a dime.
My next step was to find a radiation oncologist for a consultation and to schedule treatment. Unsurprisingly, the SBRT form of radiation is not performed in Santa Fe. To make a long story short, I was able to schedule a consultation with a radiation oncologist at the University of California health system in San Francisco. UCSF is a top prostate cancer research and treatment center in the U.S.
My UCSF telehealth visit with the doctor confirmed I was a good candidate for SBRT treatment. However, unlike the Denver urologist, the radiation oncologist gave me the option of active surveillance since he staged my cancer at a lower “favorable intermediate risk.” After a brief exchange about deferring treatment, we concluded that the steady increase in my PSA scores over the last 18 months meant that treatment was unavoidable at some point in the next few years. I decided to proceed with treatment now while the cancer was local and easier to treat.
I started down the long and winding road to arrange my treatment. Scheduling multiple visits in a facility 1200 miles away was challenging. I would need several separate visits to UCSF. The first was to insert gold fiducial markers in my prostate to guide the delivery of the treatment radiation. During this visit, they would also inject a rectal spacer hydrogel to reduce the risk of radiation damage to adjacent organs. A week later, I needed to appear for CT and MRI scans that would be used to prepare the treatment plan. Finally, two weeks after the planning session, I would begin a series of five treatments over ten days. Seven trips to UCSF. It’s not a big problem if you live in the Bay Area. It is more challenging if you are coming in from New Mexico. As hard as I pressed, I could not consolidate any sessions, necessitating three separate trips to San Francisco.
As a closing note, I should add there are other non-surgical treatment options that I didn’t seriously consider. In the realm of external beam radiation, IMRT is the tried-and-true protocol, but research shows that SBRT is just as effective and can be delivered in five sessions rather than 25-35 visits. Proton beam radiation (versus photon beam in IMRT and SBRT) is an option, but the evidence for its efficacy over other radiation treatments isn’t well proven. Brachytherapy (placing radioactive seeds in the prostate) has been widely used with good results. Still, my assessment of the evidence is that the significantly improved targeting of SBRT and IMRT makes external beam radiation therapy a better option. Finally, there are the emerging focal treatments using laser and ultrasound ablation. These options might be suitable for small, well-defined tumors. The evidence is not strong that they are any more effective than the mainstream treatment options, and, for many of us, a $40,000 out-of-pocket price tag for an unproven therapy can be a problem. Anecdotal evidence I have personally heard about these treatment options is not encouraging.
Placing A Wager at the Healthcare Casino
Finally, after months of diagnostic testing and interminable scheduling delays, my sojourn into the prostate zone is almost over. My last radiation treatment is scheduled for October 31. Hooray! In the final analysis, my choice is a wager that successful radiation treatment using the SBRT protocol would offer me the same outcome as surgery but with a reduced risk of quality-of-life side effects. Could surgery or focal therapy have had similar results? Perhaps, but I’m betting that choosing SBRT with a highly experienced oncologist in a practice focused on prostate cancer treatment will be a winner.