Which treatment is better for a PSA value of 15 ng/ml?

Question

Hello doctor,

My father, who is 68 years old, was recently diagnosed with prostate cancer. His biopsy revealed a Gleason score of seven, which places him in the intermediate to high-risk category. His prostate-specific antigen (PSA) level is 15 nanograms per milliliter.

His MRI (magnetic resonance imaging) showed localized disease, but with extracapsular extension. The urologist recommended surgery, but a second opinion advised radiation plus hormone therapy.

How do we decide which is better?
What are the risks of long-term androgen deprivation? Does it lead to cognitive decline or cardiovascular issues?
Are there newer treatments like focal therapy worth exploring in his case?
His bone scan was clear. Should we still be worried about micrometastasis?

We are confused about the trade-offs between treatment choices.

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Your father’s diagnosis of intermediate-to-high-risk prostate cancer, indicated by a Gleason score of four+three=seven, PSA (prostate-specific antigen) of 15 nanograms per milliliter, and extracapsular extension on MRI (magnetic resonance imaging), places him in a group where both surgery and radiation therapy with hormone therapy are considered valid treatment options. The choice between them depends on several factors, including his general health, preferences, and how he weighs potential side effects.

Radical prostatectomy offers the advantage of physically removing the prostate and provides detailed post-operative pathology, which can guide further treatment if needed. However, it comes with potential risks such as urinary incontinence and erectile dysfunction. These side effects can impact quality of life and should be part of the decision-making discussion.

Radiation therapy combined with androgen deprivation therapy (ADT) is also highly effective, particularly in cases with extracapsular extension. It avoids the risks of surgery but introduces concerns related to hormone therapy. ADT side effects may include fatigue, hot flashes, decreased libido, bone density loss, increased cardiovascular risk, and, in some cases, mild cognitive changes.

Focal therapies like high-intensity focused ultrasound (HIFU) or cryotherapy are typically reserved for low-risk or select intermediate-risk patients. In cases with extracapsular extension, these therapies are generally not considered adequate as stand-alone treatments. They may not effectively address the full extent of the disease.

Although the bone scan did not show any metastasis, micrometastatic disease cannot be completely ruled out. This is why systemic hormone therapy is often included in treatment plans for higher-risk prostate cancers. Close monitoring and personalized follow-up are essential to ensure optimal outcomes.

I hope this information helps you.

Thank you.