So this conflict of observation is interesting. Gfunk and Ramses would say not much more morbidity with salvage brachy or sbrt. Urologist says lots of morbidity.
Not really. Its understandable bias. For a lot of these guys urology won't get involved until they have an issue and hence their experience is biased towards the times it didn't work. Same for us and surgery for very high risk patients. A lot of them will do fine with surgery. We see them when they fail and our perception is not representative of the whole population.
I also think the key here is patient selection. Notice the first thing I asked about was LUTS. Then also said I would really need to look at the imaging to decide. There is very clear potential to cause a lot of problems if you are not careful. I personally wouldn't consider SBRT or brachy in someone in this situation who was already having issues. In that case, I think ADT would probably be the way to go.
If the disease was not systemically threatening, not sure how you can justify risks of full dose definitive treatment here.
I can see where you are coming from but I think perspective matters. For those of us who did this in training and then continue to do a fair bit of it in practice and have not seen the dreaded toxicities its a different equation. There are 3 predominant reasons other than systemic spread to consider treating the primary: chance of cure, preventing symptomatic progression (aka, outlet obstruction), and avoiding hormones. These are hard discussions that require a lot of nuances. If the patients main goal is preventing progression and they don't care about sexual function, ADT (or even continued observation) all the way. Hands down (can always radiate later if ADT isn't going well or they start showing evidence of castration resistance). Way more often than not I am trying to talk patients or referring providers OUT of doing anything too aggressive. But, if the patient is super anxious about having cancer and sex is super important to them then aggressive treatment to the primary may honestly give them the best chance at QOL that balances all of their concerns.
If after going through all of the options the patient opted to radiate the primary I would base the decision to do hormones or not on the same variables as the definitive setting judging the risk of systemic spread: absolute PSA, doubling time, GS, etc. We all know the normograms are probably not exact for these situations but still, if absolutely all of the traditional variables are low risk for distant disease at the time of treatment, I don't know what ADT would be adding other than side effects. If the biopsy showed GG4, that would be a different situation...
I also don't love focal therapy because in the definitive setting the overall message is that our current imaging is not adequate and in-gland control is modest. Reading these scans post-treatment is more, not less difficult. You really don't get a 3rd crack at it. A focal boost is not risk free and I personally feel like if you are going to use a "definitive" therapy, give it the best shot you can. GFunk said something similar in the last thread he linked above.
One last thing that is probably worth distinguishing. People always ask if I do a DIL boost. The answer is yes and no. I don't purposely do it in a prescribed way. That said, I am not going to do brachy if I don't think I can get adequate coverage of the GTV. What would be the point? I don't do MR/US fusions during treatment so I can't tell you the D90 to the GTV but that being said, I am very cognizant of what part of the prostate had disease and I would wager >90% of the time its probably >130% of the RX dose because of how I select patients. So while I am not formally contouring out the GTV and giving a prescribed DIL, in practice, they at least a modest DIL boost.
