By Ankit Agarwal, MD

I regularly meet men from across San Francisco – from the Richmond and Sunset to Pacific Heights, Noe Valley, and SoMa – who are trying to sort through a new prostate cancer diagnosis without getting lost in conflicting recommendations.

San Francisco patients have access to excellent medical centers. That is a strength. But many men still choose to come south for a focused radiation oncology opinion because they want to understand whether brachytherapy, SBRT, or a combined approach may fit their case better than a one-size-fits-all recommendation.

That is really the purpose of this page: not to suggest there is only one good path, but to explain why some city patients decide that a 30 to 40 minute trip for a specialized opinion is worth it before committing to treatment they will live with for years.

Making Sense of Your Diagnosis

When you are first diagnosed, you will hear a lot of numbers very quickly: PSA, Gleason Grade Group, MRI findings, stage, and risk category. Those details are not paperwork – they are what determine whether active surveillance, surgery, brachytherapy, SBRT, or combination therapy should even be on the table.

My first advice is simple: slow the process down enough to understand those numbers. A careful review of your biopsy, imaging, urinary symptoms, and goals often changes the tone of the whole conversation.

Why some San Francisco patients seek a specialized radiation opinion

Many men in the city are balancing a demanding job, family logistics, and a reasonable desire to avoid unnecessary disruption. They are not only asking, “Which treatment works?” They are also asking, “How many visits will this take? What will recovery look like? What are the odds I will regret this choice five years from now?”

Those are good questions. For some patients, the answer may still be surgery or a standard external beam course. For others, brachytherapy or a shorter-course radiation plan may offer a better mix of cancer control, convenience, and quality of life. That is why I think a second opinion is valuable before treatment starts.

Brachytherapy: why I think it belongs in the discussion

Brachytherapy is a form of radiation in which small radioactive seeds are placed directly into the prostate under ultrasound guidance. It is typically an outpatient procedure, and for the right patient it can provide excellent long-term cancer control in a very short treatment timeline.

I focus much of my practice on brachytherapy because I believe it remains under-discussed relative to how effective it can be. It is not appropriate for every man, but for selected patients it can be one of the most efficient and durable prostate radiation options we have.

One reason is that the literature is not vague. In the ASCENDE-RT randomized trial, men treated with a low-dose-rate brachytherapy boost had 9-year biochemical progression-free survival of 83%, compared with 62% for men treated with a dose-escalated external beam boost. Put simply, that is a meaningful difference in long-term disease control.

For intermediate-risk disease, brachytherapy alone can be an excellent option in carefully selected patients. For higher-risk disease, brachytherapy can also be used as a boost together with external beam radiation and hormone therapy.

There is also informative monotherapy data. In a large international multi-institutional analysis of 9,101 men treated with low-dose-rate brachytherapy alone, Pd-103 was associated with a 7-year freedom from biochemical failure rate of 96.2% versus 87.6% with I-125. That does not mean every patient should get Pd-103 monotherapy, but it does show how specific technical choices inside brachytherapy can matter.

Just as important, a treatment discussion should include quality of life. Men often want to know about urinary function, bowel effects, time away from work, and sexual side effects – and those questions should be part of the decision from the beginning.

Reducing treatment burden for some higher-risk patients

One of the most meaningful developments in modern prostate radiation has been the move toward more individualized treatment intensity. In selected higher-risk cases, combining a brachytherapy boost with radiation can support a shorter or more tailored hormone therapy course than older one-size-fits-all approaches.

That does not mean every high-risk patient should automatically receive the same plan. It does mean that men with more aggressive disease may benefit from meeting with a team that is comfortable discussing brachytherapy, external beam radiation, and ADT together instead of treating each piece in isolation.

The TRIP/TRIGU0907 phase 3 trial is part of why. In 332 men treated with brachytherapy plus external beam radiation, the 7-year cumulative incidence of biochemical progression was 9.0% with shorter-course ADT and 8.0% with longer-course ADT, without a significant difference between the groups. For some San Francisco patients who are trying to balance excellent cancer control with fewer months of hormone-related fatigue, hot flashes, and sexual side effects, that is a very meaningful conversation.

I also think patients respond to hearing what treatment feels like in real life. Many men I see after brachytherapy tell me that the temporary urinary irritation was manageable and that they were glad the treatment did not consume weeks of daily appointments.

SBRT and external beam options

Not every patient is a brachytherapy candidate, and some men simply prefer an external beam approach. SBRT allows us to deliver a focused radiation course in just a handful of treatments for appropriate patients, which can be especially attractive for men commuting from the city.

We also use modern image guidance and rectal spacing techniques when appropriate to help protect surrounding tissues. In other words, a consultation should not be about pushing one treatment on everyone – it should be about matching the treatment to the patient.

What the trip from San Francisco actually looks like

For many city patients, the first visit is simply a consultation in San Mateo or Mountain View with review of PSA history, biopsy, MRI, urinary function, and goals. From there, we talk through whether active surveillance, surgery consultation, brachytherapy, SBRT, or combination treatment makes the most sense.

If treatment moves forward, we try to keep the process practical. Some patients drive via 101 or 280, some prefer Caltrain, and some combine visits with work on the Peninsula or in the South Bay. For men considering brachytherapy or SBRT, the reduced number of treatment days can matter a great deal.

What to bring to your consultation

San Francisco patients usually get the most out of the first visit when they bring:

  • PSA history and the date of diagnosis
  • Biopsy pathology report and MRI report
  • Any PET, CT, or bone scan reports
  • A summary of urinary symptoms and current medications
  • Questions about side effects, recovery time, and whether a second opinion changes the plan

Our physician team

At Western Radiation Oncology, Dr. Steven Kurtzman, Dr. John Shumway, and I focus heavily on prostate cancer radiation and brachytherapy. That experience matters because candidacy decisions are nuanced – prostate size, urinary symptoms, prior procedures, MRI findings, and cancer risk all influence the recommendation.

My goal in a consultation is not to pressure a patient into one path. It is to make sure he leaves understanding what the realistic options are, what the tradeoffs look like, and why one approach may fit his case better than another.

Your next step

If you live in San Francisco and have been diagnosed with prostate cancer, I think it is reasonable to get a specialized radiation oncology opinion before choosing treatment. Bring the records, bring the questions, and make the decision from a position of clarity rather than urgency.

Second opinions are welcome. Whether you ultimately choose treatment with us or elsewhere, the goal should be the same: excellent cancer control, thoughtful quality-of-life planning, and a treatment plan that makes sense for your actual life.

About the Author

Dr. Ankit Agarwal is a radiation oncologist at Western Radiation Oncology specializing in prostate cancer treatment, including brachytherapy, SBRT, and combined-modality care for selected higher-risk patients. He serves patients from San Francisco, the Peninsula, and across the Bay Area.