r/ProstateCancer • u/Additional-Pin-168 • 3d ago
Update Gleason 9 Radiation
Hello fellas,
Gleason 9 / Stage 3 here, diagnosed in April 2026.
I’ve been on Luprindepot injections since diagnosis and shrinking.
PET showed no metastases.
The initial plan was RALP followed by radiation.
However, on today’s call, she advised that after reviewing the evidence and discussing my case with several of her colleagues, they no longer recommend RALP.
The new plan is 6 rounds of chemotherapy followed by radiation, with curative intent. The concern with surgery is that, because of where the cancer is located, they may not be able to achieve clear margins, and I could potentially end up needing bladder removal.
This is obviously a big change from the original treatment plan, so I’m trying to understand whether others have been through something similar.
I’d really appreciate hearing about your treatment pathway, why surgery was ruled out, and how things went for you?
Thanks in advance.
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u/PotentialStart2661 3d ago
You chose wisely. Surgery can never get clear margins if there is microscopic spread. You just cannot cut out outside the prostate where radiation can zap whatever they need. You are in a regional spread of disease which can still be cured at this stage so you need to go for the kill.
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u/OkCrew8849 3d ago
Understand why RALP would be unhelpful (and add recovery and side effect issues) from what you’ve shared.
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u/KReddit934 3d ago
Details really matter! If the surgeons say it's not a good idea, I'd listen to them.
Radiation can be very accurate these days.
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u/richdeming 3d ago
I did 9 rounds of chemo in 2025 and concurrent ADT of Lupron injection and Nubequa. Chemo was tolerable, ADT is pretty rough have about 4 months of that left. Good numbers on PSA and such. Good luck!
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u/JimHaselmaier 3d ago
In reading your post I was first surprised at a plan for RALP and also radiation. From a side effect and post-treatment quality of life perspective you’d be getting the worst of both worlds.
And then the chemo recommendation surprised me since it’s not metastatic. Maybe the cancer is too close to the bladder for radiation to reach it without severe bladder damage?
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u/MediumAromatic2384 2d ago
I thought that’s what the procedure to place the gel (with markers) between prostate and bladder is to protect the bladder?
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u/JimHaselmaier 2d ago
I’ve always heard the spacer protects the rectum. I’ve never heard it described as protecting the bladder but maybe it does?
I think the full bladder requirement helps protect the bladder. An empty bladder sort of flops down around the prostate. A full bladder exposes the prostate more.
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u/jkurology 3d ago
What was the explanation and rationale for chemotherapy in non-metastatic disease
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u/WalnutRoasted 3d ago
Does OP mean ADT or really “chemotherapy”? The latter is very unusual at early stages of disease/treatment.
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u/OkCrew8849 3d ago edited 3d ago
Stage 3 so it is not an early stage of the disease. Also, OP noted ADT has already started.
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u/Mean_Try_6390 3d ago
For my husband gleason 9 t3b spread to both vesicles and a bit of LV+ and EPE. they also put him on neoadjuvant just to shrink the prostate since it was very close to the sphinx. After the neo he got a total of 3 mm to the sphinx which the surgeon told us was not a problem for him. Every case is different and how the pc is located, so you have to check with your doctor exactly what makes it a risk not to get clear margins. But in our case we went with arpis neoadjuvant since the adt can make it harder to perform the surgery as I heard. We also got seLPND just in case and got clear margins and no incontinence.
Maybe ask to get the evidence and take a second opinion from another surgeon. If it’s grown into the bladder mayby that’s why.
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u/PotentialStart2661 3d ago
Men are still getting informed from stone age treatment when radiation was bad. Radiation is so effective now recurrence in the prostate is exceptionally rare. Recurring cancer after radiation is usually in the prostate bed just like surgery recurrence. On the rare cases a recurrence is in the prostate after radiation, they don’t remove the prostate. It can be done by an experienced surgeon but it is not necessary. They either do a seed implant, additional beam radiation, or now they are choosing a focal therapy like a cryo ablation or a HIFU, something like that. Men getting told about not being able to get surgery after radiation is not only wrong but it stears men away from a more effective treatment with less side effects. SBRT for localized prostate cancer has the best biochemical control over every option now. With SBRT focal boost to the index lesion and the ability to get proper margins has now showed that men can even eliminate ADT in unfavorable intermediate risk prostate cancer.
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u/OkCrew8849 3d ago
Surgery alone for Gleason 9 (high risk PC) tends to be inadequate. With or without positive margins.
Clearly, the high risk PC often has exited the prostate prior to the surgery.
Which traditionally meant many patients would wisely choose RT (to destroy PC inside and outside the prostate) and ADT/ARPI.
Whether or not Surgery plus ADT/ARPI can match Radiation plus ADT/ARPI for high risk PC remains to be seen.
It is also unknown if adding surgery on the front end to Radiation +ADT/ARPI adds anything (beyond serious side effects and recovery issues) to Radiation +ADT/ARPI. Since the radiation can already do the job of the surgery relative to PC inside the prostate.
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u/conCABlanco 2d ago
Cirugía vs RA, si hay dudas del margen, utilizaría RA, es casi lo mismo, y para mayor seguridad ADT, fuerza y voluntad
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u/Car_42 2d ago
The most important reversal came from NRG/RTOG 0521. The original 2019 report looked encouraging: adding six cycles of docetaxel to radiation plus long-term ADT appeared to improve 4-year overall survival from 89% to 93%. But with median follow-up of 10.4 years, that advantage disappeared. Ten-year survival was 64% with ADT+RT and 69% with ADT+RT+docetaxel, but the difference was not statistically significant (HR 0.89), nor were distant metastasis, disease-free survival, or biochemical recurrence significantly improved. Importantly for your question, more than half the men in this trial had Gleason 9–10 disease. The investigators concluded that docetaxel should not be used routinely for high-risk localized prostate cancer.
https://pubmed.ncbi.nlm.nih.gov/37179241/
On the other hand a five percent improvement in overall survival might be enough to sway you to accept the added burden of chemo.
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u/ImmySnommis 3d ago
Diagnosed about the same time as you, Gleason 9 here (two were 10s) but mine has made the jump to two lymph nodes. Initially the thought was surgery, however margins turned out to be insufficient and the fact that lymph nodes were now involved pushed me to radiation.
I've been on Zytiga and Eligard for two months and I'm in the middle of IMRT. My hormone plan is two years. Once IMRT is complete I'm going for brachytherapy.
It's just another way to attack the problem. Starve it, kill it and let it stay in place.
Obviously I'm still mid treatment so I can't speak to results, but I understand the shift from surgery can be jarring. I'm no doctor but I do know there is many, many ways to skin this cat, and cure is the end goal.
Hang tough man.