Where things stand
The biopsy confirmed prostate cancer. Grade Group 2 (Gleason 3+4=7), with intraductal carcinoma in one sample and cribriform pattern in two others. The adverse features push the case into unfavorable intermediate risk. Active surveillance is off the table.
Pathology came back faster than expected — one business day instead of five — and I met with Dr. Glickman this morning to walk through it.
Engaged in a little bit of retail therapy on 5th Ave on the way home ;]
This page is the gap between knowing the diagnosis and choosing a treatment.
What's on the table
Two primary treatment paths, both with well-established outcomes for this risk band:
- Robotic prostatectomy (RARP). Surgical removal of the whole prostate plus seminal vesicles, with neurovascular bundle preservation where the cancer allows. Done through small abdominal incisions on the da Vinci platform. One operation, then a recovery curve measured in weeks for the early phase and months for full continence and erectile function recovery.
- Radiation therapy. Treats the prostate in place. Multiple modalities — external beam over 4–8 weeks, SBRT/CyberKnife in five sessions, brachytherapy seeds in a single procedure, or combination approaches. At unfavorable intermediate risk, short-course ADT is typically added for 4–6 months.
Long-term cancer control between the two is broadly equivalent. The differences are everywhere else — side-effect profile, recovery shape, what gets monitored afterward, and which salvage doors stay open if anything fails.
What this does (and doesn't) mean
It means a treatment decision is the path forward, not surveillance. With the adverse features in the pathology, monitoring without treating is no longer the conservative choice — it's the riskier one.
It does not mean a single path is preordained. Surgery and radiation produce broadly equivalent long-term cancer-control outcomes for localized disease at this stage. The choice is about which side effects, when, and which doors stay open afterward — not about which path is more likely to cure.
Dr. Glickman's read on where I sit: at 66, with my baseline health and function, I'm “middle of the road” — strong arguments either way.
It also doesn't mean the decision needs to be made this week. Prostate cancer at this grade moves slowly. There's time to gather the inputs — genomic testing, a parallel radiation oncology consult, a possible second pathology read — before committing.
How I'm thinking about the choice
The two paths aren't symmetric — they don't fail in the same way, they don't follow up the same way, and they don't leave the same options open. The things that actually distinguish them for my case:
- Data clarity. Surgery yields full-gland pathology — the definitive answer on EPE, margins, seminal vesicle involvement, and lymph nodes. Radiation leaves the gland in place and the “was there microscopic spread?” question never gets a definitive answer; it gets inferred from PSA behavior over time. Given the capsular abutment on imaging, that asymmetry matters more than it would in cleaner cases.
- Salvage direction. If surgery fails first, salvage radiation is well-established and effective. If radiation fails first, salvage surgery is harder, with worse continence and potency outcomes. The doors don't swing both ways equally.
- Side-effect timing. Surgery: intense and short. Weeks of recovery, then a slow climb on continence and erectile function with most of the improvement landing in the first year. Radiation: gentle up front, but the erectile decline plays out over 1–3 years, and if ADT is added, you absorb a 4–6 month course of hormone side effects layered on top.
- Age curve. 66 is the right side of multiple curves. Surgical recovery is age-sensitive and only gets harder. ADT side effects also get harder with age. Doing either now is materially easier than doing it in five years.
- The capsular abutment. Broad capsular contact on the right means surgery may sacrifice the right neurovascular bundle for clean margins, and radiation needs to cover that area in its field. Both paths handle it — they just handle it differently.
The honest unknowns
Things that neither consult nor any test fully resolves:
- The cribriform / IDC-P radioresistance question. Mixed published evidence. No major guideline rules radiation out, but the question deserves to be asked of both the urologist and the radiation oncologist directly.
- Microscopic EPE. Probability above zero, exact probability unknown. Partin tables and Briganti nomograms sharpen but don't answer it; PSMA PET only catches it above a resolution threshold. Surgery would answer it; radiation would not.
- Neurovascular bundle preservation, right side. The surgeon's intra-operative judgement — not pre-decidable. Best estimate from imaging and biopsy is “at risk.”
- Long-term quality of life with each path. Outcome statistics are population-level. Individual experience varies more than any aggregate curve suggests. The honest answer is “you find out.”
Since this page (May 19): I gathered second opinions at Northwell and Memorial Sloan Kettering — two radiation oncologists, two surgeons, and a urology NP. Both radiation oncologists proposed short-course radiation; the surgeon who also does focal therapy ruled it out and leaned slightly toward surgery. A PSMA PET scan on June 13 came back clean — no spread beyond the prostate — though MSK's MRI re-read flagged a small, lower-suspicion spot on the left (a second cancer or just inflammation, still unconfirmed). The risk grade cited above is now contested — most read it favorable intermediate, MSK leans unfavorable — and that's what decides whether radiation comes paired with a few months of hormone therapy. Two genomic tests, Decipher and Artera, are the last inputs before I choose; the MSK surgeon visit on June 18 is the first time the full team weighs in on the PET.
Two paths drawn.