Decision made 👉 five zaps, zero hormones

Where things stand

It's decided. Longer version below.

Two things happened first. I collected one more opinion — a third read of the slides, this time by a pathologist trained at MD Anderson. I sent him the three slides where the scary features had originally been called. His conclusion matched the re-reads: no cribriform. At this point the count is three expert pathologists, one genetic test, one AI, and one PET scan, all pointing the same way.

Then on Tuesday Dr. Setton — my radiation oncologist at Memorial Sloan Kettering — called. With the third read in hand, he put it plainly: this is favorable intermediate-risk disease (the risk category where treatment works best and hormones aren't part of the deal). That's not just a category. It's permission to choose.

What I picked

Five sessions of radiation — SBRT on the MR-Linac — no hormones. Translation: SBRT (stereotactic body radiation therapy) is high-precision radiation delivered in five outpatient visits instead of the old several-weeks routine. The MR-Linac is the machine that does it — it takes an MRI of the prostate before every single session and re-aims to wherever things actually sit that day. If you want the full homework trail, the radiation deep dive is on the site.

It's also what Dr. Setton said he would pick in my shoes. The reasons stack up: statistically the best odds of keeping erectile function, short and long term. No OR, no catheter, no recovery weeks — about ten days start to finish, life continuing as normal around it. And no hormone therapy, the dealbreaker that started this whole second-opinion odyssey.

One prep step first: a hydrogel spacer — a soft gel placed between the prostate and the rectum to push the rectum out of the radiation field. Twenty-minute procedure under sedation, done ahead of the planning session. The gel starts dissolving around three months, is essentially gone by six, and — in a detail I did not need but you now have too — exits in my urine.

What to expect

Urinary. About 90% of patients get a temporary increase in frequency and urgency. It peaks around a month after treatment, improves by eight weeks, and is mostly resolved by three months. Roughly 20% get a rebound flare later in the first year — treated with anti-inflammatories, more annoyance than problem.

Bowel. Not guaranteed, unlike the urinary stuff. Maybe a 20% chance of mild effects; a low chance of anything significant long-term.

The rare stuff. A roughly 1-in-300 chance of a radiation-caused second cancer after ten years. Serious bowel or bladder injury: theoretically possible, essentially never seen in his practice.

And the number that matters most. For favorable intermediate-risk disease, the odds the cancer never spreads are about 98% at ten years. In nearly 1,000 patients Dr. Setton has treated, not one favorable intermediate-risk patient has needed a second round of local treatment. (If it ever came to that, backup options exist.) He gave me his personal digits, unprompted, which I'm choosing to read as a good sign.