All I might add at this stage is to hold off on actually receiving any
adjuvant/second treatment until the post-op pathology results are in, if you
choose surgery (first (which I did and would). You and your docs will know
much more at that point about the nature and extent of your disease and
which/whether follow-up treatment may work best. I wouldn't agree to all
three treatments up front, before pathological assessment, if I had a PSA of
200, a Gleason 10 in all 12 cores, and a 25-year-old wife. I want a doc or
team of docs willing to THINK, not just fire a triple-barreled shotgun at
me.

Advising firing all three silver bullets at a partially-defined case of
cancer tells me two things, both alarming:
1. The doc cares ONLY about maximizing your heartbeat duration, regardless
of the time you gain from it or your QOL in the meantime. (Whether that's
for your benefit or his statistics rermains to be seen.)
2. S/he doesn't seem interested in YOUR priorities, unless YOU discussed
them at great length with the doc and you both arrived jointly at this
blitzkreig approach.

Presuming you plan surgery first, there's no post-op hurry to start adjuvant
treatment the next day -- or month. You'll have plenty of time to assess the
pathology and its implications AFTER you're out of the hospital, off any
narcotics, and sufficiently clear-headed to assimilate the results and
render a valid, well-considered decision. You are not capable of those
actions while under the influenceof narcotics, no matter how clear-headed
you THINK you are, and you flat don't KNOW enough about your cancer to make
adjuvant treatment choices at present.

Then unless your post-op pathology clearly dictates adjuvant treatment (and
which one), I'd want to wait AT LEAST until my first post-op PSA completes
the picture. Surgery, at worst, may leave you dribbling and pointing south
for months or even a lifetime. Big Deal! The OTHER treatments can actually
have some SERIOUS side effects, temporary or permanent., with likelihoods
ranging from low to almost certain. Besides that, the likelihood they will
significantly extend your life span will vary significantly based on your
post-op pathology and lab tests. (Your PRESENT urinary/bowel/sexual health
also strongly influence which initial and adjuvant treatments to choose.)

Take it one step at a time.
1. Begin right now identifying and weighing your life's priorities (e.g.,
all the QOL factors, the many SE impacts and likelihoods, the quantity and
likelihoods of life extension any adjuvant treatments may add). You can't
make a valid first-treatment choice until you've researched those.
2. Consider surgery first because it doesn't preclude radiation later and
provides far more decision-making data than the alternatives. (OTOH, some
circumstances favor seeds as a first treatment. Your research and additional
facts will reveal those.)
3. Assess the pathology and blood chemistry assessment after surgery, with
new facts and a clear head.
4. Do more research specifically based on your options remaining after your
initial treatment. Maybe no decisions will NEED to be made after your first
treatment, either because it's clearly successful (in which case you wait
and watch) or is clearly unsuccessful (in which case the next treatment
could be a no-brainer). The initial treatment most likely to answer to those
implied questions is surgery.

I.P.

Michael,

It is usual practice, after surgery, for a pathologist to evaluate the
excised prostate.  If the "margins" are clear, then radiation and
hormone therapy are generally not recommended.

"Clear margins" means that no cancer was found on the outer
part of the removed tissue.  If there is no cancer there, then there
is an excellent chance that the cancer has not spread beyond the
prostate and was entirely contained in the removed gland.  In such
a case, there would be no reason to subject the patient to the
additional side effects of radiation and/or hormone therapy.  If
the margins are not clear, patients are often referred for follow up
radiation to try to get any cancer that extended outside the
prostate.  In many cases, the "extra-prostatic extensions" of
the tumor are still within a few millimeters of the prostate bed.
Some doctors always make such referrals when margins are not
clear.  Others wait to see what the PSA looks like after surgery.

As others have said, surgery is often recommended over radiation
for younger men (e.g., below 60) on the theory that, if the prostate
is gone, the cancer is gone.  There's no worry about whether some
of the cancer survived radiation, or whether it could crop up again.
On the other hand, radiation is sometimes recommended over
surgery for cases where there is some reason to believe in
advance that the cancer is already at or beyond the margins
of the prostate since radiation can also treat the area
immediately around the prostate.

I think it's an excellent idea to try to find the best surgeon you can
and the best radiation oncologist you can, and get advice from
each of them.  Unfortunately, I don't think there's a slam dunk case
for the superiority of either treatment.

It is important to get the best specialist you can find.  Horror
stories exist about surgeons who took out most, but not all of the
prostate, or radiation oncologists who used insufficient or badly
aimed doses, or who used obsolete equipment.  Treating prostate
cancer is a real specialty - one that not every urologist or every
radiation oncologist really possesses.

Best of luck.

   Alan

<... lots of of good information elided ...>

Yes, but don't panic Mike.  It hasn't necessarily "spread" outside
the prostate and so is still very likely treatable.

The words "fall apart" here may be a bit more alarming than KH
intended.  "terra incognita" is accurate.  We don't know that
radiation is no good after 15 years.  What we do know is that
relatively modern radiation techniques are only 15 years old
so we don't have empirical data beyond that.

KH clearly meant that but I wanted to be sure that his
statement was not misinterpreted.

My experience was pretty much the same as KH's.  Same side
effects.  I also attributed my tiredness at least as much to Lupron
as to radiation - though radiation does make you tired and you too,
Mike, may need Lupron - if radiation is the route you take.

One cautionary note.  The side effects KH describes are by far
the most common ones, but radiation does do a lot of internal
damage and there are no guarantees.  Rates of impotence are said
to be comparable to the rates for surgery.  Some other effects like
long term proctitis, long term urinary difficulties and, it is said by
some researchers, slightly (but not zero) increased chances of
secondary cancers, are all possible.

I chose radiation in part because I believed the effectiveness
was equal to, and the side effects less, than with surgery.
But there are no guarantees with any treatment.  Your best
bet for reducing side effects is to get the most skilled, most
dedicated, most experienced doctor you can find.  Whether
he's a surgeon or a radiation oncologist, he'll have better than
average results with fewer than average side effects.

   Alan